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. If you have any questions or concerns while completing the following forms, please feel free to call me at 210-774-8292. You will need to bring your insurance card and drivers license to the initial appointment.

 

 

Client Intake Form
All new clients must print and fill out this document and bring to the initial session.
Updated Client Intake Form.pdf
Adobe Acrobat document [30.0 KB]
Credit Card Authorization
All new clients must complete this form and bring to initial session. Additionally, any established client wishing to update the card on file must complete this form and bring to the next scheduled session.
Updated CC Auth Form.pdf
Adobe Acrobat document [46.8 KB]
Informed Consent for Counseling
All new clients, including those clients coming for couples counseling, must sign this form and bring to the initial session.
Updated Informed Consent.pdf
Adobe Acrobat document [50.5 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]
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

PLEASE WELCOME SHANNON MANUSZEWSKI, LPC-INTERN TO THE PRACTICE!! 

Shannon works with clients age 12+ and offers evening and Saturday appointments. To learn more about Shannon, visit the Specialties page. To schedule, call Shannon directly at 210-330-6502.

 

PLEASE NOTE THE OFFICE WILL BE CLOSED ON THE FOLLOWING DATES THIS FALL:

Sept. 4 (Labor Day)

Sept. 21-Sept.26 (Training)

Oct. 9 (Columbus Day)

Oct. 25-26 (Training)

Nov. 6 (School Holiday)

Nov. 22-24 (Thanksgiving)

Dec. 18-Jan. 1 (Xmas Break)

 

 

 

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Desirae Ysasi, LPC-S, PLLC