Consent & Authorizations

General consents for all new clients to complete at intake

Referral Form

To be completed by referral source (i.e. client, parent/guardian, physician, etc.)

Student Consent

Consent form to provide treatment to students at schools

Release of Information Consent

Consent to release information from client records to a designated source

Registration Form

(For Continuing Education – Suicide Assessment, Treatment, & Management – 10-28-16.) Course approved by LPC board for 6 continuing education hours to meet regulatory requirements established in 201 KAR 36:030 for LPCCs and LPCAs

We're here to help

Call us now at (606) 451-1936 or fill out this secure form to request an appointment. One of our team members will be in touch ASAP.