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


Everyone's

  Counseling

     Center, Inc.

and

Michael J. Story Beacon Ministry

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

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

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)



​​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

Some Evening Appointments Available

EMail: info@eccflorida.org