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 provide counseling for women

Helping You


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.

  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**

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.


​​We will follow-up with you to confirm your appointment

Scheduling an Appointment is Easy! 

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