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    Stephanie Kugler, M.A., LPC

    Forms

    Online Pre-Registration 

     

    After you complete the online registration please also complete the forms below, you can email them to Stephanie before your appointment or bring completed to your first appointment. 

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    Choose one of the following:

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    Client Information - Adult

    Client Information - Child/Adolescent

    Client Information - Couples/Family

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    Complete all 

     

    Stephanie's Disclosure Statement

    HIPAA Document

    Consent to Communicate PHI Electronically

    Credit Card Authorization

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    Complete if you would like me to speak to another professional (Physician, Teacher, Etc.)

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    Release of Information

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    Additional forms

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    Permission to video tape sessions

    © 2021 Canyon Pines Counseling

    19563 E. Mainstreet, Ste. 200 Parker, CO 80138

    Tel: 720-441-3537

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