Inner Strength Counseling

Individual, Couple, Adolescent, and Family Counseling

Eleanor Salemi, LCSW

Florida Lic. SW9620

2840 West Bay Dr., Suite 253

Largo, FL 33770

727.418.0735

Fax: 866.706.0538

Email

Intake Packet – Child/Adolescent
(under 18)

Personal History for Children and Adolescents (to be filled out by parent/caretaker)

 

Agreement Regarding Minors (signed by all)

No Secrets Policy For Couples and Families (signed by all)

Payment Contract for Services (Fee Agreement) (signed by person responsible for payment)

Privacy of Information Policies (signed by parent/caregiver)

 

Recipient's Rights Notification (read and keep)

 

Consent to Treat (each person signs one; children and adolescent form signed by parent/caregiver)

 

Services Provided

 

Credit Card Authorization


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