Forms

Find forms for Life’s Journey Counseling here. Click the link below to download the forms. You can email us the forms directly to info@ekz.cfv.mybluehost.me or fax us at (832) 413-5072. You may also bring the forms with you to your appointment.

Consent to Treat and Rights

Personal History Adult

Patient Health Questionnaire Adults (PHQ-9)

Child Personal History

Severity Measure for Depression (PHQ-A) – Ages 11 to 17

PSC-Y Screen (Ages 4 to 10)

Associate Agreement [Form must be completed by all clients receiving counseling from an associate counselor]

Release of Information

Request Appointment

First Name

Last Name

Phone

Cell Phone

Date of Birth

Address1

City

State

Zip

Insurance Provider

Member ID

Group Number

Insurance Provider Number

Service Needed

Appointment Request With

All appointments will have to be confirmed first by us in order to be scheduled.

Date Requested

Time Requested

Message

Appointment Cancellation Policy Agreement:

Life’s Journey Counseling, PLLC is committed to providing all of our clients with exceptional care. When a client cancels without giving enough notice, they prevent another client from being seen.

Please call us at (281) 746-2704 by 3:00 p.m. on the day prior to your scheduled appointment to notify us of any changes or cancellations. To cancel a Monday appointment, please call our office by 3:00 p.m. on Friday. If prior notification is not given, you will be charged $(50) for the missed appointment.

Please Type "I AGREE" to Accept That You Understand Our Cancellation Policy

Please Type "I AGREE" to Accept That You Understand Our Cancellation Policy *

FORMS