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YOUR CART

All new clients should complete the following four forms and return them before your first session.
​Each member of couples or family sessions should complete their own set of forms.
Note: These fillable forms work best in Acrobat. To download Adobe Acrobat Reader for free, click here.
1. Intake Questionnaire (complete, sign, and return)
intake_questionnaire_060125.pdf
File Size: 2176 kb
File Type: pdf
Download File

cuestionario_de_admision_060125.pdf
File Size: 2839 kb
File Type: pdf
Download File

2. Informed Consent (complete, sign, and return)
informed_consent_060125.pdf
File Size: 1002 kb
File Type: pdf
Download File

consentimiento_informado_060125.pdf
File Size: 1196 kb
File Type: pdf
Download File

3. Acknowledgement of Receipt of Privacy Practices (complete, sign, and return)​
acknowledge_privacy_practices_060125.pdf
File Size: 249 kb
File Type: pdf
Download File

acuse_practicas_privacidad_060125.pdf
File Size: 245 kb
File Type: pdf
Download File

4. Notice of Privacy Practices (KEEP for your records)
notice_of_privacy_practices_060125.pdf
File Size: 775 kb
File Type: pdf
Download File

notificacion_de_practicas_de_privacidad_060125.pdf
File Size: 558 kb
File Type: pdf
Download File


Telehealth clients (audio and/or video through a personal computer or mobile device) should complete this Informed Consent for Telehealth Services. I provide telehealth with Zoom video conferencing. Visit https://zoom.us/ for instructions or more information. Zoom is available as a desktop or mobile app (see this page for links).
5. Informed Consent for Telehealth (complete, sign, and return)​
informed_consent_telehealth_060125.pdf
File Size: 310 kb
File Type: pdf
Download File

consentimiento_informado_telesalud_060125.pdf
File Size: 377 kb
File Type: pdf
Download File


If you want me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), please complete an Authorization for Use or Disclosure of Protected Health Information.
6. Authorization for Disclosure​
authorization_for_disclosure_060125.pdf
File Size: 376 kb
File Type: pdf
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autorizacion_de_divulgacion_060125.pdf
File Size: 401 kb
File Type: pdf
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If you want to put a credit card on file for future charges, please complete and return this form. I will email a Square receipt at the time of each charge.
7. Card on File Authorization​
card_on_file_100324.pdf
File Size: 179 kb
File Type: pdf
Download File

tarjeta_en_archivo_100324.pdf
File Size: 204 kb
File Type: pdf
Download File

Please Contact Me

(925) 255-7704
[email protected]
4180 Treat Blvd, ​Concord, CA 94518
Abran (aka Abraham) Aviles-Scott
​Licensed Marriage & Family Therapist
CA LMFT #113688
​Concord Business License #5022539
Copyright ©2025 Abraham Aviles-Scott. All Rights Reserved.