Please fill out the following information prior to first visit. Please ensure all information is filled out to the best of your ability. Additionally, copies of insurance card (front/back) must be submitted to counselor once assigned.
*By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Submit," you agree to hold Awareness To Change Counseling and Consulting Services harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.