This page contains links to forms that all incoming clients must complete prior to beginning counseling, as well as forms related to insurance billing.

Payment Information

CMS-1500 - Standard Insurance Form
If you intend to send receipts to your insurance company for reimbursement purposes, or if you are paying via MD Medicaid, please print the CMS-1500 form and complete the indicated sections. Please also be sure to bring your insurance card, or a copy of both sides of your insurance card, with you.

Adults
Adult Form Pack - zip file
This pack includes all forms for adults entering counseling with Trinity Family Counseling Services.

Adult Information Form
This form must be completed by all adults (ages 18+) attending counseling.

Adolescents (ages 13 - 17)
Adolescent Information Form
This form is to be completed by a parent or guardian of each adolescent (ages 13 - 17) attending counseling.

Adolescent Intake Form
This form is to be completed by each adolescent (ages 13 - 17) attending counseling.

Psychosocial History
This form is to be completed by a parent for each child or adolescent (ages 17 and under) attending counseling.

Minor Consent Form
This form must be completed by a parent or guardian for each child or adolescent (ages 17 and under) attending counseling. In cases of divorce or legal guardianship, proof of conservatorship must be provided.

Children (ages 4-12)
Child Information Form
This form is to be completed by a parent or guardian of each child (ages 12 and under) attending counseling.

Psychosocial History
This form is to be completed by a parent for each child or adolescent (ages 17 and under) attending counseling.

Minor Consent Form
This form must be completed by a parent or guardian for each child or adolescent (ages 17 and under) attending counseling. In cases of divorce or legal guardianship, proof of conservatorship must be provided.