Julio L. Benezra, M.S.Ed., LPC Alegre Counseling & Consulting Services, LLC

New Client Forms

If you are a new client and have set up an initial appointment with me, please download and print out the five forms below. Once completed, please bring them with you to our first appointment. I ask that you do it this way for two reasons;

  1. Completing these forms can take up to 20 minutes, so I prefer to give you enough time to think about the responses.
  2. To save you the time of having to come in early to complete them in my lobby.

Please do not email me the completed forms back to me. They contain very sensitive personal health information and I cannot guarantee their privacy when sent via the internet.

In order to protect the formatting of the documents, they are set up as a PDF and you need to have the Adobe Acrobat application available on your computer to access them. Most computers have this application already installed, but if you don’t, please click on the link below to download this free software. If you choose not to do so, please contact me and I will be happy to send you a Word version of the documents.

In English:

Client Personal Health Information, 2016

Family Background Information

Practice Guidelines & Informed Consent Document, 2016

LEC-5 Standard Self Report

PHQ Long Version

En Espanol:

Historia Personal, 2016

Informacion sobre el paciente, 2016

GUÍAS DE PRÁCTICA Y FORMULARIO DE CONSENTIMIENTO INFORMADO

Spanish PHQ, long version

 

If you do not have the latest version of Adobe Acrobat, please click on the name in blue on this line, to download this free application.

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