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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. 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 the following documents:
  • New Adult Intake Paperwork
  • Bio/Psycho/Social Information

    In addition to the New Client Intake paperwork, please complete the DSM-5 Checklist. This documents helps your provider better understand any symptoms that you (the client) may be experiencing.

  • DSM-5 Symptom Checklist – Adult

    New Child/Adolescent Client Paperwork

    Prior to your child/teens first appointment please review and complete the following documents:
  • New 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. This documents helps your provider better understand any symptoms the client may be experiencing. 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 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

  • 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
  • Make an appointment Information Request Form