Motivations Counseling – Client Forms

Click on the icon below to print a form and bring the completed form with you to your therapy session, or

Click on the icon below to complete online and have the form automatically routed to your therapist:

New Clients:

Online Client Intake Forms (All Therapists)

Therapists: Susan Baker, Carolina Roman, Cathy Hein, Olivia Pudlo, and Belinda L.:

Individual Adult (18+) Forms
Child/Teen Forms
Couples Forms

Therapists: Ruba Afifi, Kelsey Engdorf, and Carissa Ferguson:

Individual Adult (18+)
Child/Teen Forms
Couples Forms


Click for instructions on how to use PDFescape online PDF editor.

Additional forms to fill out if your therapist requests you to do so:
Adult Symptom Screener

Please review the following document covering our privacy practicies regarding your Protected Health Information (PHI) before completing the new client paperwork:
Notice of Privacy Practices Form

New or Existing Clients:

In-Person Informed Consent (for COVID-19)

Existing Clients:

If you need us to release your therapy/treatment information to a third party, please complete the following form authorizing us to do so:
Authorization to Release Information

For EMDR Therapy sessions, please complete the following informed consent form prior to the first treatment:
EMDR Informed Consent

If you need to change the credit card information we keep on file for you:
Credit Card On File

For clients needing Telehealth Counseling, please complete an informed consent form prior to the first treatment:
Telehealth Informed Consent - Individuals/Teens
Telehealth Informed Consent - Couples

Please print, fill out the required forms, and bring them with you to your next scheduled appointment
or, where applicable, complete the form online.

Download Adobe Acrobat Reader DC for free.