Please Note!!

This Email Sign Up is for Counseling Updates and Services ONLY

© 2019 by Be Replenished Counseling All Rights Reserved

For New Clients Please fill out these forms at least ONE day before your appointment. 

THERAPY CLIENTS

Intake information

Disclosure Notice to SIGN

Online Therapy Agreement

All New Online Clients must FILL OUT/SIGN

 ELECTRONICALLY the top THREE forms in Orange at least ONE DAY BEFORE your appointment (In office clients can sign the top two forms ahead or time or in the office.) You will be able to save copies of these documents for your records. 

Each button will walk you through the process. Thank you. 

For Couples, each person will have to fill out their own forms separately. 

For ALL Online Clients: We are required by law to verify your identity. Please email a copy of a picture ID that has your name on it. (you can simply take a legible photo of your ID and email it to us.) You may black out any information except Name, Address, and Date of Birth off of the ID if you want. We do not keep hard copies of your ID. We advise you to send the copy through an encrypted email server from your end. You can create a free account with Send Inc to forward any information to our encrypted email. (info@bereplenished.com)

LIFE COACHING CLIENTS

Life Coaching Agreement

All New Life Coaching Clients must FILL OUT/SIGN

 ELECTRONICALLY the TEAL Button at least ONE DAY BEFORE the appointment (In office clients can sign the form ahead or time or in the office.) You will be able to save copies of these documents for your records. 

Each button will walk you through the process. Thank you. 

Once you have completed the forms online, the paperwork is automatically sent to our office. You are ready for your appointment. Thank you!

Additional Forms

Credit Card Authorization Form (Only Required when BRC Manually Enters Payment. Normal Payments are taken through our Client Appointment Scheduler and you enter payment information.)

No Harm Contract

RELEASE OF INFORMATION AUTHORIZATION

Client Intake Paperwork