• Shelby Counseling Associates, PSC 
    12701 Townepark Way Suite 200, Louisville, KY 40243
    502-254-8880 - SCA@shelbycounseling.com

  • This form is HIPAA compliant and all information is confidential

  • Today's Date
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  • Date of Birth*
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  • Client Gender Identity*

  • Minor Child's Parents Are*

  • Marital Status*
  • Client Employment*
  • Do you wish to receive SMS TEXT appointment reminders*
  • Do you wish to receive EMAIL appointment reminders (you may choose to receive both)*

  • INSURANCE INFORMATION

  • I will be using: CHECK ALL THAT APPLY*
  • Do you have a secondary insurance?*
    • COPIES OF PHOTO ID & INSURANCE CARDS ARE REQUIRED - click to take a picture  
    • COPIES OF PHOTO ID & INSURANCE CARDS ARE REQUIRED - click to upload a file 
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  • HEALTH SUMMARY

  • Would you like us to contact your Primary Physician, Psychiatrist or other medical provider? (If yes, you will receive an email to complete a release of information)*
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  • Helpful information for your provider 
    Please answer honestly - this will help your provider prepare for your 1st session.

  • Have you previously received psychiatric counseling or hospitalization?*
  • Please choose the provider you are scheduled with. If you do not have an appointment please choose the providers you are interested in:*

  • SCA TREATMENT AGREEMENT

  • Primary Communication MethodShelby Counseling Associates primarily communicates via email. This includes, but is not limited to:InvoicesInsurance updatesStatementsClients are responsible for checking and updating their email address with SCA to ensure they receive all necessary communications.*

  • Notice of Privacy Practices
    HIPAA CONSENT FORM

  • Date
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