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Client Paperwork

Welcome to Stein Counseling & Consulting!

We look forward to working with you. Before we get started, please read and fill out the forms below. Once you complete them, they will be electronically forwarded to us and no paper copies will be needed. If you want to check that we received the correct paperwork prior to your first appointment, you can contact us by email or phone at 608-785-7000.

New Adult Client Paperwork

Prior to your first appointment please review and complete ALL THREE of the following documents:

Adult New Client Intake Paperwork

Bio/Psycho/Social Information

DSM-5 Symptom Checklist- Adult

New Child/Adolescent Client Paperwork

Prior to your child/teen’s first appointment please review and complete ALL FOUR of the following documents (the two documents listed below as well the checklist(s) in the next section):

Child/Adolescent New Client Intake Paperwork

Bio/Psycho/Social Information

In addition to the New Client Intake Paperwork, please complete the DSM-5 Checklist(s) that correspond to the client being seen. If the client is an adolescent (ages 11-17), then they will complete the Adolescent Checklist themselves, and we also ask that a parent/guardian completes the Parent/Guardian Checklist. If the client is a minor under 11, ONLY Parent/Guardian Checklist is needed.

DSM-5 Symptom Checklist – Adolescent

DSM-5 Symptom Checklist- Parent/Guardian

Additional Paperwork

If you are unsure if these documents apply to you, please e-mail or call us. We are happy to help!

Pursuant to the Health Insurance Portability and Accountability Act (HIPAA), we must have your expressed written consent (Release of Information) in order to release any of your Protected Health Information (PHI). This is commonly to a spouse/family member, health care provider, or court official. Read more about your federally protected Privacy Rights here.

Release of Information (ROI)

If you are receiving Telehealth (video or phone) sessions, you MUST complete the following form.

Consent for Telehealth and Credit Card Authorization

Each year we review and update our Client Rights & Responsibilities Form (CRIC). If you are an existing client from last year and have not completed a new form for 2021, please complete the following form.

2021 Client Rights & Responsibilities Form

After Your Appointment

We value your feedback! Please complete the appropriate survey for the services you receive from Stein Counseling after your first, or any follow-up appointment with a provider.

  • Outpatient Counseling Survey

  • In-Home Counseling Survey

  • NMT Paperwork

    Please note before any NMT Assessment can be administered the following documents need to be completed. Please contact us directly for access information.
  • NMT Child & Adolescent History Form
  • NMT Play Preference Checklist (ages 0-10)
  • NMT Activity Preference Checklist (Adolescents/Adults)
  • Mobius Therapeutic Plan 4.5
  • Medical Sensory Form
  • Make an appointment Information Request Form