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. Feel free to call or email us to ensure we got the paperwork prior to your first appointment.

If you need assistance, or have any questions please feel free to 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:
  • New Adult 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 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), they will complete the Adolescent Checklist, and we also ask that a parent/guardian completes the Parent/Guardian Checklist. If the client is a child (under 11) only the 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 feel free to e-mail us or call. 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

  • If you are receiving Telehealth (video or phone) session please complete the following form.

  • Consent for Telehealth

  • If you would like to authorize us to charge your credit/debit card for appointments please complete the following form.

  • Credit Card Authorization Form

  • Each year we review, and update our Client Rights & Responsibilities Form. If you are an existing client and have not completed this for 2021, please complete the following form.

  • 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