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

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1501 South Pinellas Ave, Suite P, Tarpon Springs FL 34689
727-547-3692   |   clientcare@breakingfreeservices.com

Breaking Free Services

  • Home
  • Meet Our Team
    • Kathi Hannon, MA, LMHC
    • Shari Linger, MS, LMHC, CEO
    • Lisa Martino, LMT, CPMT
    • Maureen Murphy-Lee, MS, LMHC
    • Megan Roberts, MA, LMHC
    • Christie A. Shubert, MS, RD, LDN, CNSC
    • Savannah Arseneau, MS, Registered Mental Health Counselor Intern
    • Troy Bishop, MS, Registered Mental Health Counselor Intern, CCTP
    • Meagan Cherry, MA, Registered Mental Health Counselor Intern
    • Carly Riley, MSW, Registered Clinical Social Work Intern
    • Elizabeth DiMartino, RN, Mental Health Nurse Practitioner Intern
    • Kaitlyn Shelp, MA, Registered Mental Health Counselor Intern
    • Aundrea Sponsel APRN, FNP-BC
    • Toni Blocker, BS, Graduate Practicum Intern
    • Kelli Everton, MS, Registered Mental Health Counselor Intern
    • Cassandra Szarejko, MA, Registered Mental Health Counselor Intern, ATR-P
    • Nathan Vail, MSW, Registered Clinical Social Work Intern (pending)
  • Services
    • Counseling
    • Massage
    • Supplements
    • Yoga
    • Psychiatry/Med Management
  • Groups
    • Let’s Learn Coping Skills
    • Healthy Boundaries in Relationships
    • Growing Healthy Relationships
    • Life Skills Teen Group
    • Languages of Love
    • Positive Body Image Group for Teens
    • Addressing the Elephant in the Room: Social Anxiety & the Impact it has on Self-Esteem
  • Client Information + Forms
    • Client Forms
    • Medical Records Requests
    • Rates & Insurance
    • Appointment Request
    • FAQs
  • Resources
    • Mental Health Links
    • Physical Health Links
  • Blog
  • Contact
  • Join Our Team
  • 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

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

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A Website by Brighter Vision

  • Home
  • Meet Our Team
    ▼
    • Kathi Hannon, MA, LMHC
    • Shari Linger, MS, LMHC, CEO
    • Lisa Martino, LMT, CPMT
    • Maureen Murphy-Lee, MS, LMHC
    • Megan Roberts, MA, LMHC
    • Christie A. Shubert, MS, RD, LDN, CNSC
    • Savannah Arseneau, MS, Registered Mental Health Counselor Intern
    • Troy Bishop, MS, Registered Mental Health Counselor Intern, CCTP
    • Meagan Cherry, MA, Registered Mental Health Counselor Intern
    • Carly Riley, MSW, Registered Clinical Social Work Intern
    • Elizabeth DiMartino, RN, Mental Health Nurse Practitioner Intern
    • Kaitlyn Shelp, MA, Registered Mental Health Counselor Intern
    • Aundrea Sponsel APRN, FNP-BC
    • Toni Blocker, BS, Graduate Practicum Intern
    • Kelli Everton, MS, Registered Mental Health Counselor Intern
    • Cassandra Szarejko, MA, Registered Mental Health Counselor Intern, ATR-P
    • Nathan Vail, MSW, Registered Clinical Social Work Intern (pending)
  • Services
    ▼
    • Counseling
    • Massage
    • Supplements
    • Yoga
    • Psychiatry/Med Management
  • Groups
    ▼
    • Let’s Learn Coping Skills
    • Healthy Boundaries in Relationships
    • Growing Healthy Relationships
    • Life Skills Teen Group
    • Languages of Love
    • Positive Body Image Group for Teens
    • Addressing the Elephant in the Room: Social Anxiety & the Impact it has on Self-Esteem
  • Client Information + Forms
    ▼
    • Client Forms
    • Medical Records Requests
    • Rates & Insurance
    • Appointment Request
    • FAQs
  • Resources
    ▼
    • Mental Health Links
    • Physical Health Links
  • Blog
  • Contact
  • Join Our Team
  • Referrals
  • Share Your Feedback