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.
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.