forms

Beginning 6/28/2021

Susan J Cardwell, M.A., LPC

1101 Scott Ave, #14

Wichita Falls, TX  76301

PH:940-312-9688      ​Fax:940-204-5420



Parent of Minors: Texas Administrative Code requires that custodial parents/guardians provide proof of custody when seeking mental health services for minors. Please bring a COPY of divorce documents or 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. 
PLEASE NOTE: 
TELEHEALTH users may submit Intake Paperwork through email; print paperwork, complete, scan and send through email provided after making contact with Susan Cardwell. OR you can complete the paperwork, take photos and email to Susan.

 
These are the intake forms to print, complete, and bring to your first appointment.  You will also need to bring in photo ID and your insurance card.


​​ Intake Form Rev.pdf  All new clients, including children, need to bring this paperwork to their first session.


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 the words to tell grown ups. 


Adolescent Privacy Form  ​Only print and complete this form if you are bringing an adolescent for treatment. Read the paperwork thoroughly.



The form below is used only if you want a provider, attorney, or another entity to transfer mental health records, medical information or psychiatric information to this office: 

Contact: 1101 Scott Ave, Ste 14 Wichita Falls, TX 76301     Fax 940-204-5420


Authorization to Release/Exchange Information 



Please print and read the HIPAA information; you will be asked to sign that you read the document.

The HIPAA Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. 


HIPAA Statement