​​​​​​AMY E. BROWN, MS, CAC, LPC, CCTP, SAP

CERTIFIED ADDICTIONS COUNSELOR 
Licensed Professional counselor
Certified  Clinical TRAUMA PROFESSIONAL
Certified DOT-SAP PRovider


​​​​ 780 East Market  Street #280
 West Chester, PA 19382

  c   610.416.0793
  f  610. 566.3274  ​​
  amyebrown.lpc@gmail.com

6
Forms for new clients  

Please download, print, and complete the appropriate set of forms and 
bring them to our first meeting.
Legal and ethical guidelines prevent me from providing
any services without these completed forms.

All clients should read the HIPAA information and return only the signature page.​


New therapy clients should complete the 6 forms in purple.

DOT-SAP clients should complete the 5 forms in blue.

  















Forms for new therapy clients:
each form will open in a new window


Assignation of benefits
Only for folks using insurance


Please enter the your co-pay or the session fee we agreed upon


Release of information
Please complete this if you'd like me to speak with a physician, previous therapist, or anyone else




Forms for DOT-SAP clients:
each form will open in a new window



Please enter your DER's contact information