Anne Toles Counseling
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New Client Forms

NEW CLIENTS: Please print "Adult Intake Form" and "Informed Consent", fill out and bring with you to your first appointment.  If the client is under 18 years old, please print out "Child/Adolescent Intake Form" and "Informed Consent", fill out and bring with you to your child's first appointment.  HIPAA is in the list below for your information. You do not need to print out HIPAA unless you would like to.  Also, bring your insurance card, if applicable (only BCBS insurance and Mississippi Physicians care network accepted), and ID.  Your therapist will be happy to answer any questions you may have regarding forms.
Adult Intake Form
File Size: 211 kb
File Type: pdf
Download File

Child/Adolescent Intake Form
File Size: 451 kb
File Type: pdf
Download File

Informed Consent
File Size: 694 kb
File Type: pdf
Download File

HIPAA
File Size: 277 kb
File Type: pdf
Download File

Authorization to Release or Obtain Records
File Size: 198 kb
File Type: pdf
Download File

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Anne Toles Counseling
930 Ebenezer Blvd., Suite D
Madison, MS 39110
Phone: 601.941.7171
Fax: 601.790.7909
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  • Home
  • About Anne
  • Appointments
  • New Client Forms
  • FAQ
  • Contact