Basic Client Information Form

ICC Inc. Media Services Portal: Forms

This form is part of the Client Intake Packet. It was last updated May 17, 2021.

Innovative Counseling & Consulting, Inc.

Basic Client Information

Part I: Client Information

Please complete the following information about the Client.

Part II: Insurance Information

Please describe the insurance coverage for this visit.

Part III: Treatment Authorization

Innovative Counseling & Consulting, Inc. must have a copy of the insurance card, front and back.
By signing below, I am giving permission to Innovative Counseling & Consulting, Inc. to perform either diagnostic or treatment services for the client named below:

Part IV: Signature

By clicking “Submit,” you give us permission to email you.


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