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

Scheduling an Appointment is Easy! 

Fax # 877-300-2734

Note: To download Adobe Acrobat Reader

for free, click here

We provide counseling for women

 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.


Helping You


If you are unable to print out the forms, then you will need to arrive to the office 15 minutes before your appointment to fill them out completely.

**NEW client appointments will be confirmed during the free REQUIRED phone consultation**

​  For all other appointments you will receive a phone call from the office confirming the date and time. 

What happens during the phone consultation?
During our 10-15 minute phone consultation you will have the opportunity to ask any questions that you may have surrounding counseling. We will briefly discuss any challenges or issues that you are experiencing. From there we discuss your payment options (using insurance or self-pay) and then we will schedule your first appointment. 

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 talk in more details 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.