Facebook Twitter Instagram
  • (240) 986-1001
  • admin@breakthroughcounselingmd.com
  • Home
  • Services
    • Counseling Services
    • Psychiatry Services
    • Group Therapy Services
  • Providers
    • Therapists
    • Medication Management
  • Client Information
    • Client Forms
    • Online Payments
  • Careers
    • Job Opportunities
    • Staff Portal
  • Contact
Menu
  • Home
  • Services
    • Counseling Services
    • Psychiatry Services
    • Group Therapy Services
  • Providers
    • Therapists
    • Medication Management
  • Client Information
    • Client Forms
    • Online Payments
  • Careers
    • Job Opportunities
    • Staff Portal
  • Contact
Search
Close this search box.

Client Forms

**Please only fill out forms once you have secured an appointment. 

Client Information Form

Client Services Agreement

Client Telehealth Services Agreement

Credit Card Information & Authorization

Authorization Release Form

Minor Authorization Release Form

No Surprise Act- Self Pay Only

Health Insurance Portability and Accountability Act (HIPAA)

Voted #1 2022-01 (1)

Contact Us

Breakthrough Counseling Services
4014-J Mountville Rd.
Jefferson, MD 21755
Ph: (240) 986-1001
Fax: (240) 986-1002
admin@breakthroughcounselingmd.com

Copyright ©2020 Hipaa.cloud. All Rights Reserved. Powered by VerStandig Media.