New Client Intake Form
Informed Consent
HIPAA Notice of Privacy

If you would like for Survival 2 Victory to coordinate

care with another provider (for example, your

psychiatrist, primary care physician, etc.), complete

this form to authorize release of information:​​

Authorization for Release of Information 

 Complete & Submit the Form  Below

​​​​We will follow-up with you to

confirm your appointment

Scheduling an Appointment is Easy! 

Fax # 877-300-2734

Note: To download Adobe Acrobat Reader for free, click here

We provide counseling for women

If for some reason you cannot print out the forms, then you will need to arrive to the office 15 minutes

before your appointment to fill them out completely.

Helping You



What are Sessions Like?

Your initial session may last for up to 75 minutes and will involve a comprehensive intake interview and assessment. During this time, information will be gathered to gain a better understanding of who you are and your goals for counseling. You will have the opportunity to ask questions and talk about things that are bothering you. Your counselor will begin addressing the issues that are bothering you the most.

Your following regular sessions are 60 minutes and will involve continuing to address your identified concerns and any other issues that may come up later.  In counseling we will work together to help you achieve your desired goals, work through challenges, learn new skills, attain personal growth, and become a healthier, happier, you. 

Please fill out the New Client Intake Form, read and sign the Informed Consent document, and bring these two documents to your first counseling session. Also, it’s important to read the Health Insurance Portability and Accountability Act (HIPAA) informing you of your rights regarding client confidentiality, please keep it for your own files.

​For video counseling, completed forms must be emailed or faxed before the session starts.

  Appointments are considered confirmed when you receive a phone call from the office confirming the date and time. 

**NEW client appointments will be confirmed during the required 10- minute phone consultation**