Everyone's

  Counseling

     Center, Inc.

CHILD NEW PATIENT FORMS - Please print & complete one full set for each child

PLEASE PRINT, COMPLETE AND BRING ALL COMPLETED FORMS WITH YOU TO YOUR APPOINTMENT PLEASE BRING YOUR PHOTO ID & INSURANCE CARD

  • Adult Forms ~ 18 years and above
  • Child/Children Forms ~ Ages 3 - 17

       *For children under the age of 18, The Authorization to Treat MUST be signed  by both parents or legal guardian(s)



CHILD/CHILDREN AUTHORIZATION TO TREAT ~ MUST BE COMPLETED BY BOTH PARENTS OR LEGAL GUARDIAN

ADULT NEW PATIENT FORMS - Please print & complete one full set for each adult

​​CLICK HERE TO EMAIL US NOW:

(407) 423-3327

Hours: Monday-Thursday  9:00 am-5:00 pm

Friday 9:00 am - 3:00 pm

Saturday 9:00 am - 3:00 pm

 Hours Vary Per Location & Therapists

EMail: info@eccflorida.org