Family Circle Counseling
Family Circle Counseling
  • Home
  • Counselors
  • Services
  • Forms
  • Locations
  • Contact us
  • More
    • Home
    • Counselors
    • Services
    • Forms
    • Locations
    • Contact us

  • Home
  • Counselors
  • Services
  • Forms
  • Locations
  • Contact us

FCC Forms

Please download, print and complete the forms below, as instructed in your confirmation email. When you arrive for your appointment you'll sign an acknowledgment indicating your receipt and understanding of these documents. If you don’t have the ability to do this, we will provide you with paper copies of all documents.  

Roberta Gold

HIPAA Privacy Statement (pdf)

Download

Patient Information Form (pdf)

Download

PHI Release Authorization (pdf)

Download

Informed Consent (pdf)

Download

NAOMI STUART

HIPAA Privacy Statement (pdf)

Download

Patient Information Form (pdf)

Download

Informed Consent (pdf)

Download

Maureen tirella

HIPAA Privacy Statement (pdf)

Download

Patient Information Form (pdf)

Download

PHI Release Authorization (pdf)

Download

Informed Consent (pdf)

Download

Copyright © 2021 Family Circle Counseling, LLC - All Rights Reserved.