Request for Services

Are you seeking services for yourself or your child? Please complete this form including insurance information and our office administrator will contact you within 24 business hours to confirm your information and schedule your intake.

New Adult Client Intake Packet

This packet is for new clients aged 14 and older. NM law states that individuals age 14 and older can consent for their own treatment. If someone other than the client is covering the cost of services, please have them complete a credit card authorization form as well.

New Child Client Intake Packet

This packet is appropriate for individuals under the age of 14 and should be completed by their legal guardian. 

*If there is joint custody, each parent/guardian need to complete a packet for their child.

Master Level Clinician Consent

If your assigned therapist is a Master Level clinician, they receive direct supervision under A New Hope Therapy Center Clinical Supervisor, Jessica Cauthorne, LCSW. Your assigned therapist received their Master’s degree in a clinical field and is receiving supervision to obtain their independent license.

Intern Level Clinician Consent

If your assigned therapist is a Clinical Intern , they receive direct supervision under A New Hope Therapy Center Intern Supervisor, Eric Gomez, LMFT. Your assigned therapist is receiving their Master’s degree in a clinical field and is providing clinical hours with our group. 

Treatment Plan Signature Page

Once you and your therapist have created and reviewed your treatment plan, please sign this page in acknowledgement. **This form is for individuals age 14 and older.

New Relational Client Intake Packet

This packet is for new clients who are engaging in relational/couple/marital counseling. The person whose insurance we are using should be listed as "Client" and their partner as "Partner". Both individuals will "sign" the same intake packet. 

Electing to Self Pay

A New Hope Therapy Center accepts many of the major insurance plans for our area. There are many reasons why you may opt to not use your insurance coverage. If we accept your insurance plan, but you would rather not use them, please complete this form.

Release of Information (ROI)

If you would like your therapist to be able to speak to others about your treatment, please complete this form. This is often used for communication with other providers for you and your family. 

Credit Card Authorization

An additional authorization form should the cost of services be covered by someone other than the client. All packets include this form, this is an additional one to be used as needed.