Below are links to the counseling forms which new clients need to complete prior to accessing services. Forms may be faxed to (606) 874-9170 or mailed to Catholic Charities, 60 Martha’s Vineyard, Prestonsburg, KY 41653. For confidentiality reasons, forms cannot be completed online and should not be emailed. Please print the forms and complete them OR call (606) 874-9170 and have the counselor mail you a packet! When the forms are received with the $10 application fee, the counselor will contact you to set up an appointment.
All new clients must complete the Application for Services
and the Clinical Counseling Agreement
Because COVID-19, inclement weather and other situations may require interaction through phone and online videoconferencing, please read, sign and date the Telemental Health Agreement
If you plan to use insurance to pay for your counseling, please complete this Insurance Form
If you want your counselor to have copies of your medical records to understand your condition or previous treatment, please send a completed Release of Information Form to each of the previous providers whose records you want your counselor to have.
The Notice of Privacy Practices (page 1 & page 2) is for your information only and does not require completion. Your counselor will offer you a copy at the first session.
