HEATHER ASTILL HOLISTIC COUNSELING & THERAPY
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Forms

Please identify which packet you will need. Complete and email paperwork to me.
  • If printed and filled out by hand, please take a photo of required documents or use Adobe Scan (free app for phones) and send them to me via email.
  • If using a PDF writer such as Adobe Reader, Adobe Fill and Sign (phone app), Preview (Mac) please save and attach this document and the associated APA Assessment through email.

Disclosure Statement - Maryland
Required for all clients located in MD to read and understand. It is referenced on the signature page. This does not need to be printed unless you want one for your records.
Professional Disclosure Statement -MD
File Size: 122 kb
File Type: pdf
Download File

 Disclosure Statement - Kansas & Utah
Required for all clients in KS and UT to read and understand. It is referenced on the signature page. This does not need to be printed unless you want one for your records.
Professional Disclosure Statement- KS UT
File Size: 122 kb
File Type: pdf
Download File


Individual Adult Intake Packet
For each client
Intake Paperwork
File Size: 610 kb
File Type: pdf
Download File

Adult Questionnaire
File Size: 491 kb
File Type: pdf
Download File


​Release/Exchange of Information
This form is necessary if you would like me  to/or believe it would be helpful for me to speak with other practitioners (therapists, physicians, teachers, case managers, etc.) and exchange information about the services you are receiving.
Consent to Release and Receive Information
File Size: 77 kb
File Type: pdf
Download File


Additional Intake Paperwork Packets

Individual Child Intake Packet
For each child
​(any age)
Child Intake Paperwork
File Size: 221 kb
File Type: pdf
Download File

Parent-APA Level 1 Assessment
File Size: 500 kb
File Type: pdf
Download File


Additional doc for child 
(​
aged 11-17)
Child APA Level 1 Assessment
File Size: 514 kb
File Type: pdf
Download File

Couples Intake Packet
For each individual
Couples Individual Portion
File Size: 200 kb
File Type: pdf
Download File

Dyadic Adjustment Scale
File Size: 330 kb
File Type: pdf
Download File

One for couple
Couples Intake Family Portion
File Size: 93 kb
File Type: pdf
Download File


Family Intake Packet
One document for whole family:
Family Intake Paperwork
File Size: 118 kb
File Type: pdf
Download File


Each family member must complete:
Signature Page
File Size: 49 kb
File Type: pdf
Download File

Contact Me

Overland Park, KS
(913) 735-6771
  • Home
  • About
  • Services
  • Next Steps
  • Contact Me
  • Forms
  • FAQ
  • Blog