Counseling Forms
Clients interested in receiving counseling services are required to complete a variety of forms prior to their first appointment. For those clients who have access to the internet and a printer, these forms may be downloaded from this website. However, if you do not have access to a printer, please make the appropriate arrangements to arrive 20-30 minutes before your first appointment to complete these forms in the lobby.
The Counseling Application, Declaration of Practice,and Credit Card Form are required for all new clients, whether the client is an adult or a parent enrolling their child or adolescent in counseling. The Consent to Release Form is optional and used for the purpose of releasing information (i.e., progress, attendance, diagnosis, treatment goals) to third parties (i.e., school, pediatricians/physicians, supervisors, step-parents, etc.). While this form is optional, it is strongly recommended that parent’s complete this form if referred by their doctor or child’s pediatrician. This gives permission for the counselor and physician to work collaboratively in your child’s treatment.
Addendum A: Psychotherapy Records are required of all new clients, even if you are not currently involved in the judicial system or filing a claim with Workman's Comp, Disability Services, or changing your life insurance coverage. For parents who are divorced (or in which custody/visitation papers have been filed), you are required to complete Addendum A. Even if you believe that the court system or affiliates of the court system (i.e., Office of Juvenile Justice, Disability Services, Workman's Compensation Corporation) will not contact Jeremy H. Broussard, PhD, LPC, adults and parents are still required to complete this form prior to the first session.
Finally, please review the Notice of Privacy Practices outlined in the HIPPA document. This form outlines your rights as a patient receiving medical services. All clients are responsible for reviewing this form in its entirety.
The Counseling Application, Declaration of Practice,and Credit Card Form are required for all new clients, whether the client is an adult or a parent enrolling their child or adolescent in counseling. The Consent to Release Form is optional and used for the purpose of releasing information (i.e., progress, attendance, diagnosis, treatment goals) to third parties (i.e., school, pediatricians/physicians, supervisors, step-parents, etc.). While this form is optional, it is strongly recommended that parent’s complete this form if referred by their doctor or child’s pediatrician. This gives permission for the counselor and physician to work collaboratively in your child’s treatment.
Addendum A: Psychotherapy Records are required of all new clients, even if you are not currently involved in the judicial system or filing a claim with Workman's Comp, Disability Services, or changing your life insurance coverage. For parents who are divorced (or in which custody/visitation papers have been filed), you are required to complete Addendum A. Even if you believe that the court system or affiliates of the court system (i.e., Office of Juvenile Justice, Disability Services, Workman's Compensation Corporation) will not contact Jeremy H. Broussard, PhD, LPC, adults and parents are still required to complete this form prior to the first session.
Finally, please review the Notice of Privacy Practices outlined in the HIPPA document. This form outlines your rights as a patient receiving medical services. All clients are responsible for reviewing this form in its entirety.
01- Counseling Application (Required)
| counseling_application__2020_.pdf |
02- Declaration of Practice (Required)
| Declaration of Practice |
03- Addendum A: Psychotherapy Records (Required)
| 03-addendum_a--psychotherapy_records.pdf |
04- Credit Card Authorization Form (Required)
| Credit Card Form |
05- Consent to Release Form (Optional)
**to consult with pediatrician, school counselor, or other third party.
| consent_to_release__2020_.pdf |
06- Notice of Privacy Practices (Review)
| hipaa-notice-of-privacy-practices__drbroussard_.pdf |
Employee Assistance Forms (EAP)
Clients who plan to use their employee benefits (EAP) may have additional forms to complete, depending upon which EAP their employer/company carries. There are many different EAP companies, so it will be beneficial for you to find out which EAP company your employer carries prior to your first appointment.
For your convenience, the additional paperwork for these EAP companies are listed below for download.
For your convenience, the additional paperwork for these EAP companies are listed below for download.