What YOU do makes a difference! You Deserve a Voice!
 What YOU do makes a difference!You Deserve a Voice!

New Patient Forms

There are several forms that new patients will need to fill out before therapy can begin. We provide the most important documents as downloads right here on our website to make the process as smooth and efficient as possible.


The forms which you will need as a new patient are indicated with a request to download and complete the form before your first appointment.  Simply select the appropriate download link and return the completed documents to our practice either at your first session or by fax. All forms are also available at the practice; however, filling them out in advance saves time so you can maximize your first session.

If you are unsure which forms to fill out, don't hesitate to contact us by calling the office. We are located in the Irving/Las Colinas area and plenty of parking is available.

Patient information
Download and complete prior to first appointment only if you have not already completed the on line one when scheduling your first appointment yourself.
Patient Information Form.pdf
Adobe Acrobat document [75.9 KB]
Assignment of Benefits
Only needed if filing on insurance.
Adobe Acrobat document [153.1 KB]
HIPAA Acknowledgment of Receipt
Download and complete prior to first appointment
2013 HIPAA Acknowledgment of Receipt of [...]
Adobe Acrobat document [123.4 KB]
2013 HIPAA Notice of Privacy Practices
Print out and keep for your records.
2013 HIPAA Notice of Privacy Practices.p[...]
Adobe Acrobat document [107.4 KB]
Mandatory Reporting Requirements
Download and complete prior to first appointment.
Adobe Acrobat document [177.6 KB]
Financial Policy
Adobe Acrobat document [176.0 KB]
On-Line Scheduling Release
On line scheduling release.pdf
Adobe Acrobat document [331.7 KB]

Privacy Policy – Please Review

** This information is covered by the Electronic Communications Privacy Act, 18 U.S.C. Section 2510-2521 and is legally privileged. This information and any attachments hereto may contain confidential information intended only for the use of the individual or entity named below. If you are not the intended recipient(s), or the employee or agent of the intended recipient(s), you are hereby notified that any dissemination, distribution or copying of this information is strictly prohibited. If you have received this information in error, please immediately notify the sender and delete this information from your computer. The sender does not waive any privilege in the event this information was inadvertently disseminated.**

Note: You will need Adobe(r) Reader(r) to view PDF files. If you do not have it, you can download it for free.

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Advance Counseling Centre