Letter Writing Information

( for clients needing surgical/hormone letters)

Credit Card Authorization

Insurance Worksheet (for BCBS Clients only)

  • ​Please note that for children/adolescent clients under 18 years of age receiving individual therapy, a parent or guardian will need to complete the consent and release of information forms. There is a similar information form geared towards children and adolescents that may be filled out either by the parent/guardian or child/adolescent depending on developmental abilities. For child/adolescent clients, an adult symptom measure is not necessary, however, I will ask the parent or guardian, to complete a similar form made for children based on your observations, during our first session. 
  • For couples seeking counseling, each individual should complete a full packet of their own (each of the above forms) as information and symptoms are uniquely individual.
  • For families seeking counseling, each of the adult members of the family unit that will be attending counseling should complete a full packet (each of the above forms). Parents/guardians will also be asked to complete a child/adolescent symptom measure as well as a brief child client data sheet for each child who will be attending the sessions.

Consent for Release of Information


Adult Symptom Measure


Professional Disclosure Statement/Informed Consent

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Client Information Sheet 



Forms


Prior to our first session together, I will ask you to complete/sign the forms below. These forms may be downloaded from this site, or, if you prefer and time allows, I will mail them to you.  Either way, these documents are intended to give you a greater idea of the nature of my therapeutic work and the counseling process, and to let me know what some of the general areas of our work together will be.  Please bring these documents to our initial session and, in the meantime, do not hesitate to call or email should you have a question about any of the forms below. A few helpful hints/notes are listed below the attached forms.

Express Yourself

Saturday appointments available!



Capital Connections Counseling Center, LLC

Nicole Hast, LCPC, NCC

966 Hungerford Dr. #7A

Rockville, MD 20850

301-971-2950