Forms

Please use the following forms for your first appointment with your VCC Clinician.

If you’re an adult client, please click on the following forms to download. Fill them out and bring them in to your first appointment, or email them to your therapist.

Adult Intake Form

VCC Consent to Treatment

For Out of Pocket Pay – Fee Agreement and Cancellation Policy

For Gold Coast / Medical Insurance – Fee Agreement and Cancellation Policy

For Cigna / Evernorth Health Insurance – Fee Agreement and Cancellation Policy

Telemedicine Consent Form

Consent to Release Information (to allow us to speak to your doctor, psychiatrist, etc.)

Debit/Credit Card Authorization Form

If you’re the parent or guardian signing on behalf of a child or adolescent client, please click on the following forms to download. Fill them out and bring them in to your child’s first appointment.

Child Adolescent Consent to Treat

Child Adolescent Intake

Fee Agreement and Cancellation Policy

Debit/Credit Card Authorization Form

Los siguientes formularios están en español. Por favor, llénelos y tráigalos a su primera cita.

Spanish Consent to Treat – Consentimiento al Tratamiento

Spanish Fee Agreement and Cancellation Policy – Acuerdo Financiero y Politica de Cancelacion

Spanish Adult Intake Form – Formulario de Entrada