Office Phone: 513-770-3231

Deerfield Twp. Family Counseling

Deerfield Twp. Family CounselingDeerfield Twp. Family CounselingDeerfield Twp. Family Counseling

Deerfield Twp. Family Counseling

Deerfield Twp. Family CounselingDeerfield Twp. Family CounselingDeerfield Twp. Family Counseling
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    • About
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  • About
  • Forms
  • Contact Us
  • Make A Payment

Deerfield Twp. Family Counseling

Intake Forms

The download links for our intake paperwork are below. The forms are different for adults (18 or older) and children (17 or younger), so please be mindful of the difference.


If you need for us to contact anyone on your behalf, your child's behalf, or if you are involved with the court in any manner, please complete the Release of Information forms.


If you are able to print ahead of time, please bring all forms to your first visit filled out with black ink. We can give you a copy if you are unable. Thank you!

Questions?

If you have any questions about the forms or the intake process, call our office phone 513-770-3231 during business hours.

Adult

If you are an adult (18 or older) coming in for the first time, please complete the forms below (10 pages total).

Adult Intake Forms (10 pages) (pdf)Download

Child/Teen

If you are a parent completing forms for your child's (17 or younger) first visit, please complete the forms below (12 pages total).

If your child is 12 or older, they may fill out the last 3 pages (pg 10-12) on their own.

Child Teen Intake Forms (12 pages) (pdf)Download

Release of Information

If you need for us to contact anyone on your behalf, your child's behalf, or if you are involved with the court in any manner, please complete the form below.

Release of Information (pdf)Download
Release of Information Child (pdf)Download

HIPAA

The form here is to advise you of your HIPAA rights.  You do not need to bring this form in with you.

HIPAA explanation (pdf)Download

HIPAA

Notice of Privacy Practices

The form here is to advise you of your HIPAA rights.

You do not need to bring this form in with you.

Download PDF

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