Forms

 

Below are the most recent forms for download.  These include our HIPAA notice, intake forms, referral forms, and release forms.  MOST OF THESE FORMS ARE FILLABLE PDF'S THAT CAN BE COMPLETED ON THE COMPUTER.  DOWNLOAD THEM FIRST - DO NOT COMPLETE ON THE BROWSER.  YOU MAY THEN EMAIL THEM.

Agency Referral Form

 

Use this form to make a referral to either agency.

Evaluation Referral Form

 

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

Intake Forms

 

If you are a new client, you may download these forms to prepare for your intake.

Evaluation Intake Forms

 

If you are a new client seeking an evaluation, you may download these forms to prepare for your intake.

Release of Information - Valliere & Counseling Associates/FTS

 

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

Consent for Telehealth Session
Required for all clients seeking Telehealth services
Valliere & Counseling Associates, Inc. Social Media Policy

 

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

Pennsylvania HIPAA Notice
 

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

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.

© 2020 Veronique N. Valliere, Psy.D.