New Client Forms
Susan J Cardwell, M.A., LPC
1101 Scott Ave, Suite 14
Wichita Falls, TX 76301
+1.9403129688 • 19402045420
You can now submit documents on-line after making your appointment or if you are a current client. Please do not submit Intake Forms or documents if you do not have a scheduled appointment.
Note: 2022 per Texas Medicaid- All Clients who are insured by Texas Medicaid (includes Amerigroup, Superior, etc) MAY BE required to obtain preauthorization for counseling. Please identify which Medicaid insurance you have. I AM NOT A MEDICARE PROVIDER. If you have both Medicaid and Medicare please seek another provider.
Parents of Minors from divorced families: Texas Administrative Code requires custodial parents/guardians provide proof of custody when seeking mental health services for minors. Please bring/submit a COPY of the MOST RECENT custodial agreement at the time of the first session which will become part of your child's permanent health record. Please be aware that if both parents are shown to be legal managing conservators per custody documents, that the parent not bringing the minor for counseling will likely be contacted for input unless abuse is suspected or identified/documented. Note: Susan Cardwell,MA,LPC is not qualified, per Texas State Law, to make custody recommendations.
Please click on the appropriate link below for the intake forms you need. You can now submit through the box below or print, complete, and bring to your first appointment. You will also need to bring photo ID and your insurance card.
New Client Intake Form.pdf All new clients, including children, need to submit this paperwork prior to their first session. Telehealth clients can submit through the secure form below.
Children's Symptom Checklist This is a list of behaviors that may indicate your child is experiencing emotional distress. Children typically "act out" when they feel overwhelmed and may not have words to tell grown ups.
Authorization to Release/Exchange Information This form is used if you want to transfer medical records to another provider.
HIPAA Statement Please print and read the HIPAA information; you will be asked to initial on the Intake Paperwork that you read and understand your Privacy Rights.