(832) 940-2352

info@heightsadc.com

Client Forms

If you are new, please feel free to fill out these intake forms before our first session. These forms can also be filled out during the first session.

Consent for Treatment/Adult

Consent for Treatment/Minor

Information Sheet

Limits of Confidentiality

Credit Card Authorization Form

Email Consent

Informed Consent

Privacy Practices

To allow Heights Anxiety and Depression Center to receive and share my PHI from another provider:

Authorization for Release of Protected Health Information (PHI)

logo Heights Anxiety & Depression Center | No Matter How Hard the Past, You can Always Begin Again

3410 Austin Street
Houston, TX 77004

info@heightsadc.com
(832) 940-2352


verified by Psychology Today | Heights Anxiety & Depression Center in Houston
 

Questions?
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This information will be sent to our operation manager’s confidential email for initial scheduling.


By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.