Counseling Connections for Change, Inc.

A 501(c)(3), nonprofit Christian Counseling Center
We Believe Mental Health Matters!

DEMOGRAPHIC INFORMATION2018-10-05T16:39:18+00:00

INTAKE FORM

Counseling Connections for Change, Inc. is a 501(c)(3) nonprofit organization. Collection of demographic information is necessary to fulfill our mission as a nonprofit organization and seek outside funding support.

Counseling Connections for Change, Inc. is fully compliant with the HIPAA Standards for Privacy, Electronic Transactions and Security (including the HITECH Act and the Omnibus Rule of 2013).  Counseling Connections for Change, Inc. has implemented policies, processes, and procedures designed to ensure compliance with Federal and State information security laws, regulations, and rules, and monitors ongoing compliance efforts and maintains various reporting mechanisms that are required by law.

1 Demographic Information for Person Receiving Services
Name:
Last Name:
Date of Birth:

Responsible Party DOB:




Persons authorized to consent for this child's medical care.













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