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Pathways to Wholeness
Home
About
Forms
Insurance & Pricing
Resources
Contact
Home
About
Forms
Insurance & Pricing
Resources
Contact

Consent & Authorization Forms

Click on the form name below to download and print.

Email completed forms to me at ptwmarcia@gmail.com or bring them to your first appointment.

 

Consent for Treatment

Authorization for Release of Information

Consent for Couples or Family Therapy

Client Demographic & Insurance Information

Consent to Treat a Minor

Credit Card Payment Form

Notice of Privacy Practices

Marcia Rebelo, LCSW

Adult, Adolescent, Child & Family Therapy

187 Calle Magdalena, Suite 212, Encinitas, CA 92024

(760) 846 -1284 | ptwmarcia@gmail.com

Copyright 2020 Pathways to Wholeness | All Rights Reserved