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WTC

WILLOW TREE COUNSELING

FORMS

Here is a list of potential forms you may want to access related to services at WTC. If you are unable to open or access the forms please contact: support@willowtreecounselingfm.com

*Note: If you are completing forms on behalf of someone else, please know that we must verify information with the primary client (or legal guardian).

1

Intake Forms for First Appointment

Informed Consent

HIPAA Privacy Practices

Client Rights & Responsibilities

Grievance Policy & Form

Fee Schedule

No Surprises Act

2

Screening Assessments

Depression: PHQ-9

Anxiety: GAD-7

Mood/Bipolar: MDQ

Trauma: PCL-5

Substance Use: CAGE-AID

3

Information & Record Requests

Release of Information

4

Referring Providers & Agencies

For providers and agencies wanting to refer a client to WTC, please complete the referral form & fax required information to

(701) 552-7975.

For questions related to external referrals, please call (701) 730-8313 ext. 1.

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