Forms

Here are some useful forms. You will need the Adobe Reader to view these files.

Adult Intake Packets

If you like, you can download, print, fill out, and bring an intake packet with you to your first session to save time. If more than one adult is attending, each must fill out their own packet. If you are attending just to support the other person, not for treatment for yourself, fill out your packet (including the treatment plan) from the point of view that you are there to help the other person.

• Adult Intake Packet - Self-Pay Clients
• Adult Intake Packet - Insurance Clients

Child Intake Packet

If you have made an appointment for your child (under age 18), you can download, print, fill out, and bring these forms with you to your child's first session to save time. You must bring your child to the office the first time. If the counseling is just for your child, then you just need to fill out a packet for them. If the counseling is for you and your child, then you must fill out a packet for both of you and anyone else who will be included in the counseling.

• Child Intake Packet - Self-Pay Clients
• Child Intake Packet - Insurance Clients

Psychiatric Visit

If you have an appointment with our psychiatric nurse practitioner, then in addition to one of the above intake packets, you must fill out a prepsychiatric visit history

• Prepsychiatric Visit History

Authorization for Release of Confidential Information

From Deer Valley Counseling

If you would like for Deer Valley Counseling to release confidential information about you or your child to someone else, you must authorize us to do so in writing using this form—Authorization for Release of Confidential Information. Download the form, print it out, fill it out, and then fax it to Deer Valley Counseling. You will have to call 602.750.8051 for the fax number since we do not put that number on the internet. More information about the Deer Valley Counseling privacy policy can be found at Privacy.

To Deer Valley Counseling

If you would like another agency to release information to Deer Valley Counseling, you must authorize that agency to do so in writing using this form—Authorization for Release of Confidential Information To Deer Valley Counseling. Download the form, print it out, fill it out, and then fax it to Deer Valley Counseling. You will have to call 602.750.8051 for the fax number since we do not put that number on the internet.

Request for Copies

If you would like for Deer Valley Counseling to send you a copy of your file, you must request us to do so in writing using this form—Request for Copies. Download the form, print it out, fill it out, and then fax it to Deer Valley Counseling. You will have to call 602.750.8051 for the fax number since we do not put that number on the internet. Please note that if more than one person was present at a session, then we will have to receive an Authorization for Release of Confidential Information from each of the other persons present at the session before we can release the information for that session.

Privacy Policy

Deer Valley Counseling respects your privacy. You can read about our privacy policies in Deer Valley Counseling Notice of Privacy Practices.

Clinicians Notice

Important information about the Deer Valley Counseling clinicians can be found in the Clinicians Notice.

Authorization to Charge Card

If you are guaranteeing someone else's sessions at Deer Valley Counseling, you will need to read our Payment Policy and then sign and return an Authorization to Charge Card.

Additional Form for New Mexico Clients

For clients who are located in New Mexico at the time services are provided, we must also give you our Professional Disclosure Statement.