Client Forms

We are pleased that you have chosen to take advantage of the excellent counseling services offered here at The Center.

For appointments in Vienna, please check in on the 2nd floor of
Building 127 (click here for map).

For appointments in Washington, DC, please check in at Suite 310.

Please complete each form below and bring them with you to your first appointment.

If you have questions regarding any of the forms please contact us at (703) 281-2657, extension 266 for our Vienna office, or (202) 293-4580 for our DC office.

What to Expect at Your First Appointment

At your first appointment, please check in at the front desk (in Vienna, this is on the 2nd floor of Building 127; in DC this is in Suite 310). We recommend printing and completing the below forms in advance, but if you are unable to, you may get them when you check in and fill them out in the waiting room.

Your therapist will greet you in the waiting room and escort you to a private
therapy room. Together you will review the service agreement,
confidentiality, contact information, and other forms, orienting you to
the procedures at the Center and to the therapeutic process in general.

The first three sessions constitute an intake assessment in which you and your therapist get to know each other. You review current
symptoms and presenting problems as well as pertinent historical
information. From there, your therapist will be able to determine how best to proceed in treatment.

Client Forms

Click on the boxes below to find the PDF forms available to download. Read each form carefully before signing. Your therapist can answer questions about them at your first appointment.

Please read the Services Agreement carefully. After the form is completed by your provider, sign it and give it back to your provider.

*For clients under 14, a parent or guardian must sign the form

Click to download:

Services Agreement (PDF)

The Center must have a communications address and billing address for you (and a home address if different from the other addresses). Also, please complete other demographic information, which is held in confidence and only provided in aggregate form to Center funders.

Click to download:

Client Data Form (Fillable PDF)

Client Data Form (Word Document)

You must complete a financial arrangements form, indicating who is responsible for fee payments. Also on this form, optionally for your convenience, you may set up a credit card account.

Click to download:

Financial Arrangements Form

Please thoroughly review the notice of privacy practices and complete the form to acknowledge your receipt of this notice. Please give the signed acknowledgment to your provider.

Click to download:

Notice of Privacy Practices (PDF)

Acknowledgment of Receipt (PDF)

If you are seeing a licensed therapist and wish to have the Center submit insurance claims, you must complete the following insurance forms. If you have questions about using insurance, please call our Insurance Department at 703-281-2657, Ext. 234.

Click to download:

Insurance Information (PDF)

Mental Health Coverage Verification Form (PDF)