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. 

Choose one of the following:

Client Information - Adult

Client Information - Child/Adolescent

Client Information - Couples/Family

Complete all 

 

Stephanie's Disclosure Statement

HIPAA Document

Consent to Communicate PHI Electronically

Credit Card Authorization

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

Release of Information

Additional forms

Permission to video tape sessions