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Lotus Counseling Center

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atrepagnier.lpc@gmail.com

Forms

Adult Intake

Adult Intake Packet

No Show/Cancellation Fee Form

Credit Card Payment Authorization Form

Declaration Form

Limits of Confidentiality Form

PBI Patient Information Form

Release of Information Form

Child Intake

Child Intake Packet

No Show/Cancellation Fee Form

Credit Card Payment Authorization Form

Declaration Form

Limits of Confidentiality Form

PBI Patient Information Form

Release of Information Form

Couples Intake

Couples Intake Packet

No Show/Cancellation Fee Form

Credit Card Payment Authorization Form

Declaration Form

Limits of Confidentiality Form

PBI Patient Information Form

Release of Information Form

Forms: Files

1 Galleria Blvd, Ste. 1900 #1903

Metairie, Louisiana 70001

504-444-1149 phone

800-915-1248 fax

atrepagnier.lpc@gmail.com

©2020 by Lotus Counseling Center

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