In order for us to get to know you more thoroughly and in order to avoid missing any areas that could be of concern to us in dealing with your issues, we ask you to complete the following information. We will review it together in session for further detail.

Your may complete the form in one of two ways.

• The printable version can be printed, completed, and brought with you to your next session.
• The Online version consists of four input pages. As you complete each page, your answers will be emialed to your counselor, who will print a copy for review and discussion at your next session.

Regardless of which version you choose, please complete the entire form.  Click the version you would like to complete, to begin.

Due to HIPAA Privacy Rules we need to notify all senders of information to us that while you are sending your information to us, and all information is kept confidential by us, that you are assuming any and all risk for sending personal and private information via the Internet. Once information is sent via the Internet it is technically in the public domain, although not readily available to the public since it is being sent to a personal and private e-mail address that will be kept confidential. By sending the information to CCCOI, LLC or its designee, you are acknowledging and assuming any and all risk for your personal and private information. Should you not wish to assume such risk you may print off the necessary forms and mail them to us via the U.S. mail, which is protected by HIPAA and privacy laws.

Send all Printed Forms to the Addresses Listed on our FAQ "How to Reach Us" page.