breaking free services center for wellness logo | Counseling and Therapy in Tarpon Springs Florida

Request an Appointment
1501 South Pinellas Ave, Suites Q + H, Tarpon Springs FL 34689
727-547-3692   |   clientcare@breakingfreeservices.com

Breaking Free Services

  • Home
  • Meet Our Team
  • Services
    • Counseling
    • Supplements
    • Acupuncture
    • Nutrition
    • Life Coaching
  • Groups
  • Client Information + Forms
    • Client Forms
    • Medical Records Requests
    • Rates & Insurance
    • Appointment Request
    • FAQs
    • No Surprises Act
  • Resources
    • Mental Health Links
    • Physical Health Links
  • Blog
  • Contact
  • Join Our Team
    • Open Positions
    • Practicum/Internship Requests
  • Referrals
  • Share Your Feedback

Client Forms

All New Clients
General Client Intake Packet

New Clients Aged 12-18
Teen Questionnaire

Optional for All Clients
Consent to Release Verbal & Written Information


Telehealth Attestation Form (18+)


Telehealth Attestation Form (Under 18)

 

Not sure which forms to fill out?

Adults: Please fill out the General Client Intake Packet and Consent to Release Information (optional, if there is anyone with whom you wish us to communicate).

Teens: Parents, please fill out the General Client Intake Packet and Consent to Release Information ((optional, if there is anyone with whom you wish us to communicate). Have your teen complete the Teen Questionnaire

Children Under Age 12: Parents, Please fill out all forms except the Teen Questionnaire

breaking free services logo | Therapy and counseling in Tarpon Springs Florida
Counseling, Massage Therapy, Health Coaching, Nutrition Planning, Yoga & Acupuncture

Phone: 727-547-3692

Email: clientcare@breakingfreeservices.com

Connect With Us



"It's okay to not be okay,
It's just not okay to stay there."
-- Matt Chandler, The Village Church

Get Started

Click on the button below to schedule an appointment with one of our therapists

Request an Appointment

Privacy Policy
A Website by Brighter Vision

  • Home
  • Meet Our Team
  • Services
    ▼
    • Counseling
    • Supplements
    • Acupuncture
    • Nutrition
    • Life Coaching
  • Groups
  • Client Information + Forms
    ▼
    • Client Forms
    • Medical Records Requests
    • Rates & Insurance
    • Appointment Request
    • FAQs
    • No Surprises Act
  • Resources
    ▼
    • Mental Health Links
    • Physical Health Links
  • Blog
  • Contact
  • Join Our Team
    ▼
    • Open Positions
    • Practicum/Internship Requests
  • Referrals
  • Share Your Feedback