Distance Counseling Forms

Please download, print and complete the following forms:

  1. Distance Counseling Terms of Service
  2. Client Information Sheet
  3. Client Service Agreement
  4. Client Fee Agreement
  5. Insurance Information Form
  6. Client History Form
  7. Primary Care Physician Communication Form
  8. Client Bill of Rights
  9. Receipt & Notice of Privacy Practices of Protected Health Information
  10. Statement of Understanding of No Court Testimony

You can either scan and email forms back to: [email protected]

Or mail forms to: 6200 Aurora Avenue, Suite 410W, Urbandale, IA 50322

CONFIDENTIALITY NOTICE: Email is not a secure form of communication for Protected Health Information. By choosing to use email for your Protected Health Information, you are accepting liability for and acknowledge the potential risks for interception of your email transmissions.