© 2019 Veronique N. Valliere, Psy.D.

Parental Consent to Treatment

 

Use this form if you are indicating your consent or lack of consent for your child's treatment at the agency.

Forms

 

Below are the most recent forms for download.  These include our HIPAA notice, intake forms, referral forms, and release forms.  

Agency Referral Form

 

Use this form to make a referral to either agency.

Release of Information - Forensic Treatment Services

 

Convenient download for agencies or others requiring an exchange of information about clients.

Valliere & Counseling Associates Intake Forms

 

If you are a new client at Valliere & Counseling Associates in Fogelsville, PA, you may download these forms to prepare for your intake.

Pennsylvania HIPAA Notice
 

Valliere & Counseling Associates, Inc.'s HIPAA Notice Form

Valliere & Counseling Associates, Inc. Social Media Policy

 

This policy outlines the social media practices of staff of the agency.

Release of Information - Valliere & Counseling Associates

 

Convenient download for agencies or others requiring an exchange of information about clients.

Forensic Treatment Services Intake Forms

 

If you are a new client at Forensic Treatment Services in Allentown, PA, you may download these forms to prepare for your intake.

Evaluation Referral Form

 

Use this form to make a referral for an evaluation for a client, regardless of the type of evaluation.