Forms

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Consent to Release of Confidential Information
  • I understand that this information will be used solely for the professional purposes, will remain confidential, and will not be disclosed to third parties.

    I understand that I have no obligation to disclose the above information and that I may revoke this consent at any time by informing any of the above noted individuals in writing. A copy of this release shall be as valid as the original. This consent remains valid for a period not to exceed one year

    .
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HIPPA form LMC Corp
  • HIPPA Text
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New Intake form for Adults
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  • We are always grateful for referrals.
  • Employment Information

  • Education

  • Relationship Information

    Past and Present marriages/significant intimate relationships
Adult Symptom Checklist
  • This field is for validation purposes and should be left unchanged.
Child symptom checklist