COUNSELING FORMS

Counseling Referral 

For your own privacy or the privacy of your client, and in compliance with HIPAA laws, please fill out the intake form and either email to our confidential email address info@pridesouthcoast.com, or fax to our confidential line (508) 256-9866.

Attendance Policy

This form explains our policies regarding cancelled and missed appointments. 

Notice of Privacy and Confidentiality Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. 

If you are experiencing an emergency such as suicidal thoughts, please call 911 or The National Suicide Prevention Lifeline at 1-800-273-8255.

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©2020 by Emerson (Tracie) Rothwell, LICSW.

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