Freedom, Health, and Wholeness

Forms

New Client Paperwork

New Client Paperwork – Print and fill out information about yourself and read consent to treatment and practice policies.

Health Insurance Portability and Accountability Act (HiPAA)

Health Insurance Portability and Accountability Act (HiPAA)  – This form details the legal duties and privacy practices of the counseling center as well as how your medical and mental health information may be used and disclosed. HIPAA is referenced in the client paperwork and it available here for you to read. Please let me know if you have any questions regarding your protected health information.

Release of information

Release of Information – This form authorizes me to discuss your treatment with your physician, or anyone other than yourself that you want me to be able to talk with, including your spouse. If you were referred by your physician or psychiatrist, please print this form and bring it to the session with your doctor’s name and contact information. If you do not have a medical doctor, former counselor or other individual you want me to communicate with, this form is not required.

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Freedom, Health, and Wholeness

Kimberly Wallace LPC LLC

2852 Johnson Ferry Road, Suite 101

Marietta, GA. 30062

404-906-9831

Eagle’s Landing Christian Counseling Ctr, Inc.

1944 Brannan Road

McDonough, GA 30253

404-906-9831