Client and Intake Forms

On this page, current and future clients will find useful forms to download.  Before our first appointment, we ask that clients download and complete the New Client Information form along with the appropriate Client History and Background form.

 

All forms are in PDF format, and can opened with Adobe Acrobat Reader.  If you do not have this software, you can download it for free at the following website:

http://get.adobe.com/reader/.  All forms also allow you type your information if you prefer.

 

Please do not send any confidential information in an email transmission since email cannot be considered secured.  If you choose to communicate with The Mauriello Group via email, you are consenting to the risks associated with use of email.

New Client Information
This form is for new clients to provide us with identifying information, emergency contacts, and insurance coverage.
Mauriello Group - New Client Information[...]
Adobe Acrobat document [143.6 KB]
Client History and Background
This form is to give us background information on your history of symptoms, treatment, and social development
Mauriello Group - Client History.pdf
Adobe Acrobat document [408.7 KB]
Client History and Background for Children and Adolescents
This form is similar to the adult version above, but for background information about minor clients.
Mauriello Group - Client History (Minor)[...]
Adobe Acrobat document [374.8 KB]
Acknowledgement of Compliance with PA Act 147
The form explains Act 147 and how The Mauriello Group complies with the law to protect minor clients. We require parents to sign this form before accepting a minor as a client.
Mauriello Group - Act 147.pdf
Adobe Acrobat document [79.1 KB]
Consent and Authorization for Treatment
This form is an agreement between you, the client, and us, the treatment provider. It specifies the information necessary for you to agree and make an informed decision to enter treatment.
Mauriello Group - Consent to Treatment.p[...]
Adobe Acrobat document [101.3 KB]
Authorization to Release Information
This form authorizes us to release your protected health information to a person or organization of your choice.
Mauriello Group - Authorization to Relea[...]
Adobe Acrobat document [115.3 KB]
Authorization to Release Information to Insurance Company
This form explains the limits of confidentiality when using your insurance benefits, and authorizes us to release your protected health information to your insurance carrier(s) for billing purposes.
Mauriello Group - Authorization to Relea[...]
Adobe Acrobat document [75.0 KB]
Cancellation Policy
This form explains our Cancellation Policy that requires 24 business hours' notice when cancelling a scheduled appointment as well as exceptions in the event of weather- or illness-related emergencies.
Mauriello Group - Cancellation Policy.pd[...]
Adobe Acrobat document [60.8 KB]

Contact Us:

The Mauriello Group

139 West Market Street, Suite D

West Chester, PA 19382


Phone: 814.934.7960

Fax: 888.976.5828

What's New:

We Moved!  The Mauriello Group moved to a new location in downtown West Chester.  Our new address is 139 West Market Street, Suite D.

Matthew J. Mauriello is a National Certified Counselor, which represents completion of and commitment to national standards determined by the counseling profession.

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© Matthew J. Mauriello, MA, P.C.