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YOUR FIRST VISIT

To ensure that your first visit with Old Towne Counseling Services is stress-free, please take time to find and fill out the appropriate forms listed below. If you need assistance, please call us and we will be happy to help you.

Filling Out a Form

To prepare for your first visit, please:

Arrive 20 minutes early to your appointment. This allows time for our check in process.

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Complete the appropriate forms below and bring them to your first appointment.

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Please bring your insurance card and a Government-issued form of identification, such as a birth certificate, drivers license, or a DMV identification card.

If you are seeing a therapist, please print and complete these forms:

Patient Record

Form

Physician Care Communication Form

Coinsurance

Policy

Credit Card

on file

If you are using our telehealth option, please print and complete these forms:

Telehealth Information Form

Telehealth Consent Form

If you are meeting with Diana Boutté, please print and complete these forms:

Consent Form

Patient Record Form

Diana Self Pay Agreement

Diana Cancellation Policy

Credit Card on file

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