Child & Family Counseling Center

13649 Office Place, Ste. 102                      Phone: 703-670-5738

Woodbridge, VA 22192                                  Fax: 703-670-8213

Home Services Offered New Patient/Intake Insurance Staff Directions Handouts Resources Parenting Teen Page Notices/Upcoming Events

Intake Forms Instructions

Please print out and complete the following intake forms.  They are all in PDF format.  This will save you time at the initial appointment.  Complete the Child and Adolescent History Form if you are bringing your child or teen in for treatment.  Complete the Adult History Form if  you are an adult coming in for treatment.

Be sure to print out our Office Procedures, which will help you understand how we operate and help make your experience with us a positive one.

For the Release of Information form, please print one out for each person you would like us to contact.  Insurance companies require us to ask that you sign a release for your primary care physician, though you can check the "do not authorize" line if you do not want your therapist to contact your physician.

Financial Agreement                                

Patient Registration Form                                 

Lifetime Payment Agreement                                           

HIPAA 2019 Policy (please read and keep)

Acknowledgement 0f HIPAA Policy (please sign and return to us)                           

Release of Information Form     

Child and Adolescent History Form  OR Adult History Form

Office Procedures (Please read and keep for your records.)  

Adolescent Confidentiality Form (for teenage patients, parents should read this first, then have their teenager read it; parents and the teenager both need to sign it)

DSM-V Symptom Checklists   (Choose one)

Adult      Child/Teen