Breakthrough Forms

New Patient Forms

Please print and fill out these forms and bring them with you to your first session.

Client Contact Record

Click Here to Download the Breakthrough Counseling Client Contact Record Form. Print and fill out your form and bring it with you to your first appointment.

Client History

Click Here to Download the Breakthrough Counseling Client History Form. Print and fill out your form and bring it with you to your first appointment.

Informed Consent

Click Here to Download the Breakthrough Counseling Informed Consent Form. Print and fill out your form and bring it with you to your first appointment.

Patient Information

Click Here to Download the Breakthrough Counseling Patient Information Form. Print and fill out your form and bring it with you to your first appointment.

HIPAA Notice of Privacy Practices

Click Here to Download the Breakthrough Counseling HIPAA Notice of Privacy Practices Form. Print and fill out your form and bring it with you to your first appointment.

Acknowledgment of Receipt of Notice of Privacy Practices

Click Here to Download the Breakthrough Counseling Acknowledgment of Receipt of Notice of Privacy Practices Form. Print and fill out your form and bring it with you to your first appointment.

Financial & Missed Appointment Policy

Click Here to Download the Breakthrough Counseling Financial & Missed Appointment Policy Form. Print and fill out your form and bring it with you to your first appointment.

Contact Us


918.286.3278
info@breakthrough-counseling.com

2446 W New Orleans St
Broken Arrow, OK 74011

Location


Where to Start


Set Up an Appointment
Click Here to contact us.

Client Intake Form
Get your form together for an appointment.