21st Century Counseling, PLLC

(833) 909-9090

(910) 817-9181

Español (Spanish)

Helpful Forms

If you're a new client, please complete the following forms and bring them to your first therapy session.
 

 
If you would like me to coordinate care with another provider, such as your psychiatrist or family physician, school, department of juvenile justice or the local department of social services, 
please complete the following form to authorize the release of your therapy information:
 
 
 
If you are a provider and wish to make a referral for someone for services, please complete the attached form:
 
 
 
Note: To download Adobe Acrobat Reader for free, click here.

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