Forms

Please choose the appropriate packet for your needs from the Forms list below , print, fill out and sign, and bring with you to your appointment. (Choose General if you are unsure.)

Forms for children and teenagers MUST be filled out and signed by parent or guardian before first appointment.

Please read carefully before proceeding

Lee’s Place is a non-profit grief, loss, and trauma counseling center.
We are here to provide therapy.

If you want assistance with:

  • Lawsuits or other legal issues
  • Insurance claims or disputes, including Worker’s Compensation
  • Child Custody disputes
  • Disability claims or applications, including Social Security Disability

Please do not proceed.  These services are not offered at Lee’s Place.
If this applies to you and you currently have an appointment please call to cancel at (850) 841-7733

FORMS

Intake Adult – Death or Loss
Intake Adult – General

Intake for Child or Teen – Death or  Loss
Intake for Child or Teen – Divorce
Intake Child or Teen – General

These forms are pdf format. If you cannot open them please go to this link and download the free application from Adobe.

Sliding Fee Scale