Stacey Laves-Khalifa, MEd, LPC, LMFT
  • Home
  • Specialties
  • Forms
  • Books & News
  • Contact
  • Privacy Notice

Forms/Formulaires (English & French versions)

Please print and fill out all the forms below before your first appointment.
Bring the completed forms with you at that time.


Click the form(s) below to download.
Veuillez imprimer et compléter les formulaires ci-dessous avant de vous présenter à votre premier rendez-vous. 
Apportez les formulaires dûment complétés à ce moment-là.

Cliquez sur les formulaires ci-dessous pour télécharger.

Forms

Personal Data.pdf
File Size: 64 kb
File Type: pdf
Download File

Information & Consent.pdf
File Size: 43 kb
File Type: pdf
Download File

Disclosure Authorization.pdf
File Size: 61 kb
File Type: pdf
Download File

Consent for Treatment of Minors.pdf
File Size: 172 kb
File Type: pdf
Download File

Formulaires

Données Personnelles.pdf
File Size: 8 kb
File Type: pdf
Download File

Information et Consentement.pdf
File Size: 144 kb
File Type: pdf
Download File

Autorisation pour la Divulgation d'Information Privée.pdf
File Size: 61 kb
File Type: pdf
Download File

Consentement pour le Traitement Thérapeutique des Mineurs
File Size: 175 kb
File Type: pdf
Download File

Authorization for Release of Information.pdf
File Size: 7 kb
File Type: pdf
Download File

Telehealth Authorization Form.pdf
File Size: 188 kb
File Type: pdf
Download File

Fill out the Authorization for Release of Information form                                    ONLY if requested by your therapist. Thank you

Complétez la forme pour l'autorisation de la divulgation de
l'information SEULEMENT si demandée par votre thérapeute. Merci


9575 Katy Freeway | Suite 291 | Houston, Texas 77024 | 281 793-8716
Stacey Laves-Khalifa, M.Ed., L.P.C., L.M.F.T.
Powered by Create your own unique website with customizable templates.