Forms

Breakthru: A Place for Personal Development and Relationship Enhancement

In helping determine what method of communication you want to employ with us, we need to remind you if you choose to communicate with us via electronic transmission (video conferencing, faxes, cell phone, and/or emails), that, in this day and age of hackers, there is no 100% guarantee of confidentiality for any of us via electronic transmission. However, we’ll do our utmost to preserve your communication’s confidentiality through our security procedures.

Step 1. For New or Returning Former Client’s Appointment Setup:

Click here to fill out the Prospective Client Data Form Online (Or download and complete the Prospective Client Data form, then fax or mail to BCC).

Step 2. For Clients Who Have a Booked Appointment:

Please choose the relevant forms below, determined by age of the client(s), and, if you are coming in as an individual or as a couple. Click on each form below that applies to you to complete it online (Or download the forms, complete and mail or fax into BCC). Please note that all clients are asked to complete the “Information, Authorization, & Consent to Telemental Health” form below as it covers use of electronic communications (such as texts, emails, etc.) between BCC and its clients even if a client does NOT use video conferencing and/or phone sessions for therapy.

Online Forms Option to Fill Out and Submit Online

*For Best Results, please use “Google Chrome” Browser

*Please only use your “tab” key to move through the form(s)

Adult (18 years+) Client Forms

                         OR

Download Version of Forms To Print Out

Adult (18 years+) Client Forms

Couples’ Client Forms

Children’s ( 12 years and up) Client Forms