required forms

To download forms, please right-click on the suitable format (PDF or DOC) and click "Save As.."

• Registration Form [ PDF ] - [ DOC ]

• Adult Intake Form [ PDF ] - [ DOC ]

• Child Intake Form [ PDF ] - [ DOC ]

• Consent to Services [ PDF ] - [ DOC ]

Optional Forms

• Authorization to Release Healthcare Information [ PDF ] - [ DOC ]

• LD Questionnaire [ PDF ] - [ DOC ]

 

 

"Healing Minds and Hearts"

contact information


Breton Ridge Office Condos
13656 Breton Ridge Street
Suite F
Houston, TX 77070

(FM 1960 entrance of Willowbrook Mall-- Left at the Jared Jewelry)

(For a Map and/or Directions, click Here)

Phone: (281) 890-7776
Fax: (281) 890-7785

CONTACT US

Form Object

physicians/practitioners


Referral Form [ PDF ] - [ DOC ]

*Right Click and "Save-As"


Please fax completed referral form(s) to (281) 890-7785