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New Client Forms

Below is paperwork that can be printed out for you to bring to our initial meeting. We will review the paperwork and we will answer any questions you may have at that time. Feel free to email us at or call the office at 540-880-2208.

To download all forms at once, please select the packet!

Adult Intake Packet

Child Intake Packet

Child Intake Form

This form is essential in maintaining the appropriate information about your child for evaluation and treatment.

Adult Intake Form

This form is essential in maintaining the appropriate information about you for evaluation and treatment.


Consent to Treatment:

I cannot see your child unless this form is completed. This forms explains important policies about Bolden Therapy & Wellness, LLC. This form must be signed if your child is under 14 years of age. If you and your partner are divorced and both have legal custody, both parents need to sign this form. If 14 years or older, child may sign and accept agreement without parental signature. If you or your child is participating in Telehealth click here for Telehealth Consent to Treatment form.


Release of Information:

This form gives us permission to communicate with another provider from your child's teacher to pediatrician. This form can always be filled out after meeting to make the best plan.  We work closely with school professionals and others involved with you and your child. 

SMS & Email Consent: 

This form is used to obtain consent to communicate with you via email or text. Transmitting client information by SMS and emails has a number of risks that clients should consider before granting consent

Payment Authorization Form

Authorization for billing insurance and preferred payment method for therapeutic fees. Please complete form ​necessary for insurance (if applicable) and provide preferred form of payment.

Custody/Access Dispute Contract

Bolden Therapy & Wellness, LLC does NOT participate in custody hearings, custody/access disputes, visitation, or divorce proceedings. These matters are not within our scope of practice.  Please contact a Parent Coordinator or another neutral party to assist you in this matter. Please print and sign the contract if this pertains to your family situation.


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