CrownCounseling                                                                                               An Evidence Based Psychotherapy Practice                   

All of the following forms are in PDF format and require Adobe Acrobat Reader. Download the free Adobe Acrobat Reader by clicking on this link: Get Adobe Reader.  You will need to print the form and fill it out. Fax the insurance verification form, all others should be brought with you on the date of your inital appointment.

1. Insurance Verification & Preauthorization

Many insurance companies require pre-authorization prior to beginning therapy. If you would like to get pre-authorization, and an idea of your deductible, co-payments, and number of sessions permissible under your plan, you can fill out the information below and fax it to Behavioral Health Consultants-Debra Crown at (713) 463-7181.  

Brief Insurance Verification Form 

2. New clients

Please print out the following forms, fill them out in ink, and bring them with you for your first appointment. If you choose you can wait until you come to your first appointment. Please arrive 30 minutes prior to your scheduled time.

HIPPA Statement   

Welcome   

Informed Consent

Client Information-Insurance      

Client History      

E-mail Authorization

If you have sought therapy from another professional it is helpful for me to have access to your prior records. The following form gives me permission to contact your previous therapist and obtain information about you:

Release of Information Authorization

In addition to the new client forms, there are separate forms for minors. These forms inform both the guardian and the minor of their rights, the limitations of their rights, and the therapist obligation to report abuse.    

Consent to Treat Minor          

Confidentiality and Minors   

Obligation to Report Abuse