Forms

Referral Form - San Angelo and rural communities

If you would like to refer a client, you may use the Referral Form and fax it to 325-653-4218.

Authorization to Disclose Protected Health Information- HIPAA Release

If you would like for WTCG to share information about your treatment or condition, or if you would like another provider to share information about your treatment or condition with WTCG, you may use this form to authorize the release of the information you choose.

Español - Autorizacion Para Divulgar Informacion de Salud Protegida

Any and all forms must be sent to [email protected]

Please Note: New clients must return any and all intake forms prior to their scheduled appointment.

INTAKE FORMS (Make sure that you bring all of your completed forms with you on your initial visit):

If you would like to complete your new client forms prior to your initial appointment, this will save you some time of completing these forms in the waiting room.

Please click the links below to print the appropriate forms. Each client will download 2 files. Select between forms for adult clients and minor clients. Be sure to bring these forms.

Adobe Acrobat Reader DC (PFD Viewer & Editor)

Click the text below to install Adobe Acrobat Reader DC for free so that you are able to view, edit, and save the fillable documents below. If you already have Adobe Acrobat DC, please disregard.

Adobe Acrobat Reader DC Download

Make sure to save the PDF file before you edit it and check the PDF file after you have edited and saved it to make sure the information you filled out is still there.

Crisis

Crisis Intake Packet Adult-Minor

2nd Appt Packet

Payment Policy Informed Consent (For Minors Only)

Español - Paquete de Admisión para Crisis, Adultos y Menores

Español - Paquete para la 2da Cita

Adult Clients (18 years old and older)

Explanation of Services and Privacy Practices

Adult Intake Packet

EMDR Consent Form

Español - Paquete de Admisión para Adultos

Minor Clients (younger than 18 years old)

Explanation of Services and Privacy Practices