Intake Forms

Attention clients:

FMLA / Short Term Disability documents can be completed for clients who have participated in counseling consistently for a minimum of 3 months.

Please be advised that effective immediately, M & M Counseling LLC will charge a fee of $150 to complete any requested documentation (for example: leave request, SSI disability, letters, etc). A fee of $1.00 per page is charged for any copies of your mental health record. Please submit your request via email along with your release of information authorization form obtained from the requesting party (for example: your employer) to w ellnessandempowerment@gmail.com. We will notify you upon receipt of your request to discuss payment and delivery. Your request will be completed within 7-10 business days.

Adult clients

Biopsychosocial History Form
Intake Questionnaire
Drivers License & Insurance Card
Consent For Treatment and Limits of Liability
Credit Card Payment Authorization Form

Child clients (under 18 years of age)

Child Consent Form
Child Intake Questionnaire
Cancellation Policy
Drivers License, Child ID, and Insurance Card
Credit Card Payment Authorization Form