INTAKE FORMS

CLIENT RIGHTS & INFORMED CONSENT

Use link below to review client rights.  After your review, fill in your name, and sign the form on-screen to provide informed consent.  Form will be transmitted to Connections Counseling.  Form can be provided to you on paper or electronically at time of service or upon request to 608-233-2100 ext 0 or info@connectionscounseling.com

TELEHEALTH INFORMED CONSENT

Press button below to review and approve TELEHEALTH informed consent.  After your review, fill in your name, and sign the form on-screen.  Form will be transmitted to Connections Counseling.  Form can be provided to you on paper or electronically at time of service or upon request to 608-233-2100 ext 0 or info@connectionscounseling.com

PERSONAL HISTORY PACKET

Survey for new clients

Please fill out this history completely and honestly to assist your therapist in making your first session as productive as possible.

RELEASE OF MEDICAL INFO (ROI)

Complete this form to allow records release to or from Connections and another provider or individual.  Review all fields carefully as this will allow release of your HIPAA protected healthcare information.  Sign when complete.   Completed form will be transmitted to Connections Counseling.  Form can be provided to you on paper or electronically at time of service or upon request to 608-233-2100 ext 0 or info@connectionscounseling.com

CHOICES ABOUT ALCOHOL FORMS

CHOICES ABOUT ALCOHOL

*Please use single-sided printing, not double-sided (back-to-back)*

Please bring your Compliance Form, provided to you by your UW-Madison referrer (i.e., Dean of Students, Housing, UHS, Farm and Industry Short Course), to the first Choices About Alcohol session, in order to provide evidence of completion.
Please print and bring additional copies of the Compliance Form (link below) to the first Choices About Alcohol session, if evidence of completion is needed for additional referral sources (i.e., attorney, court system) and/or a personal copy of the Compliance Form is desired.

BASICS FORMS

BASICS

*Please use single-sided printing, not double-sided (back-to-back)*

Please download and print the BASICS Paperwork and then complete the pre-test. Bring your completed paperwork with you to the first appointment.

BRIEF MARIJUANA ASSESSMENT FORMS

NEW CLIENT FORMS

*Please use single-sided printing, not double-sided (back-to-back)*

Please print and complete the Brief Marijuana Assessment Required Documents listed below; bring it to the first Brief Marijuana Assessment session.