If you (age 18 or above) or your child/adolescent (17 years or younger) are a new client, please complete the following forms most appropriate to the age of the identified client for whom you are seeking services. The Nutritional Counseling Forms must be completed for services provided by Tina Renick. You must return the appropriate forms, along with your insurance card, to our office before a session can be scheduled. Services that are court-ordered require that you appear in the office to complete requisite forms. Please contact the Office Manager to coordinate a time for such completion.
- ACA Child and Adolescent Intake Packet.pdf
- ACA Adult Intake Packet.pdf
- ACA Nutritional Intake Packet.pdf
If you would like coordination of care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:
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