Affordable
Care Act

Deer Valley Counseling

Compassionate, Caring Counseling

Offices in Phoenix, Chandler and Scottsdale

We answer the phones 7 days a week!

602.750.8051

Forms

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

Notices

The intake packets refer to these notices, which includes our Payment Policy, Consent to Treat, Privacy Policy, Clinicians Notice, and Fees. Please read these before downloading and filling out your intake packet.

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 person 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.

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. If you are not the child's parent, you must bring legal proof

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

If you are coming in to see the psychiatric nurse practitioner to be evaluated for attention deficit hyperactivity disorder (ADHD), formerly called attention deficit disorder (ADD), please be aware that prior to possibly prescribing a psychostimulant, additional testing is required.

Authorization for Release of Confidential Information

Letters and Paperwork

Before requesting a letter, please download and read our Letters Policy. In addition, for both letters and other forms of paperwork, please see our Paperwork Policy.

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— 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. 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.

When Someone Besides the Client Is Paying

If you are guaranteeing someone else's sessions at Deer Valley Counseling, you will need to to read our payment policy (included in our notices packet) and then sign and return an Authorization to Charge Card. In addition, the client will need to sign an Authorization for Release of Payment Information.

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.