Counseling Intake Form

Thank you for choosing Atlee Counseling, LLC/Dominica N. Stuckey, LPC.   

EMERGENCIES: With the exception of weekends and holidays, I will try to return your call within 24 hours.  However, I am not an emergency mental health service. If an emergency situation for which you feel immediate attention is necessary, please dial 911 or go to the nearest emergency room.  I will follow those emergency services with standard counseling and support to the client or the client's family. 

FINANCIAL: Payment is due at the time of booking and is non-refundable.  Appointments may be re-scheduled with 24 hours advance notice.

Please take a moment to review the Notice of Privacy Practices and Client’s Rights document.


Please complete and submit this form prior to your first session.