Call for an appointment (210) 774-8292
Call for an appointment (210) 774-8292

Client Forms

Please print and sign the applicable forms and bring the completed forms with you to your first appointment. Please read the descriptions carefully; there are multiple forms you will need to print, fill out, and bring with you to your appointment. For adolescent clients age 17 and younger: both parents must sign consent for treatment. If parents are divorced, both parents must sign consent for treatment. If you have sole legal custody of your child, a copy of the divorce decree indicating such must be provided. If you have any questions or concerns while completing the following forms, please feel free to call the office at 210-774-8292. You will need to bring your insurance card to the initial appointment.

 

 

Client Intake Form
All new clients must print, fill out, and bring this form to the initial appointment. Parent(s)/Guardian(s) of minor children can complete on behalf of or in collaboration with the child.
Updated Client Intake Form.pdf
Adobe Acrobat document [31.1 KB]
Credit Card Authorization Form
All clients are REQUIRED to keep a current credit card on file. No exceptions will be made. Please print, fill out and bring this to your appointment. For established clients needing to update their credit card on file, you can fill out this form and return to the office via fax or email.
Updated CC Auth Form-2019.pdf
Adobe Acrobat document [46.7 KB]
Notice of Privacy Practices
All new clients must review this document before signing Informed Consent Forms. Do not send this document back to the office with your other forms. This form is for you to retain for your records.
NOTICE OF PRIVACY PRACTICES.pdf
Adobe Acrobat document [194.9 KB]
Informed Consent For Counseling Services
All new clients must review, sign and bring this form to the initial appointment. Parents/Guardians of minor clients must sign on behalf of their child. Signatures from BOTH parents are REQUIRED. Legal documents must be presented to show guardianship or medical/legal custody of the child (such as a divorce decree).
Updated Informed Consent-2019.pdf
Adobe Acrobat document [86.3 KB]
Consent Form for Couples Counseling
This form should be printed and signed by both individuals participating in couples counseling. Please bring to initial session.
Updated Couples Consent Form.pdf
Adobe Acrobat document [27.8 KB]
Informed Consent Form for Children and/or Adolescents
This form is for clients 17 years and younger. This form must be completed by the minor client AND his/her parent or legal guardian and returned to the office. Parent(s)/legal guardian(s), you must also complete the Informed Consent for Counseling Services form, listed above.
Informed Consent Form-ADOLESCENT.pdf
Adobe Acrobat document [223.6 KB]
Consent for Text and Email Communication
If you would like to correspond via text or email, please print and sign the form below and return along with the other paperwork to your initial appointment. Because text and email correspondence are not secure forms of communication, confidentiality cannot be guaranteed. Your advanced, written consent is required if you would like to communicate with me via text or email regarding small, administrative issues.
TEXT consent.pdf
Adobe Acrobat document [47.1 KB]
Release of Communication
All clients must print and sign this form and return to the initial appointment. This form allows Desirae Ysasi, LPC-S, PLLC to communicate with your other treatment providers to ensure the continuity and quality of care. If you do not wish to give permission for release of communication to other providers, then check "I decline to give permission" and sign at the bottom.
Release of Communication.pdf
Adobe Acrobat document [135.8 KB]

News

****WELCOME CHRISTOPHER LANGE, LPC TO THE PRACTICE

 

SATURDAY AND EVENING APPOINTMENTS AVAILABLE

 

PLEASE NOTE THE OFFICE WILL BE CLOSED ON THE FOLLOWING DATES IN 2019:

September 2 (Labor Day)

November 28 and 29 (Thanksgiving Holiday)

December 24 and 25 (Christmas Holiday)

December 31 (NYE)

January 1, 2020 (NYD)

 

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Desirae Ysasi, LPC-S, PLLC