[Skip to Content]
West Texas Counseling & Guidance - Homepage

Forms

Referral Form - San Angelo

Referral Form - Del Rio

If you would like to refer a client, you may use the Referral Form and fax 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.

Any and all forms must be sent to reception@sanangelocounseling.org

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 Acrobate Reader DC (PFD Viewer & Editor)

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

Adobe Acrobat Reader DC Download

 

Adult Clients (18 years old and older)

Explanation of Services and Privacy Practices

Adult Intake Packet

Informed Consent for Telecounseling

Español Paquete de admisión para adultos

Español - Formulario de Admisión para Adultos

 

Minor Clients (younger than 18 years old)

Explanation of Services and Privacy Practices

Minor Intake Packet

Informed Consent for Telecounseling

Español - Consentimiento Informado para Servicios de Terapia en Línea

Español Paquete de admisión para menores

Español - Formulario de Admisión para Menores 

 

Telecounseling Guide

            Prompting and Steps for Telecounseling Service