Helpful Forms

-For your first appointment please print and complete applicable forms and bring to your initial appointment.

-The "HIPPA Notice" is to inform you of

  HIPPA regulations regarding your protection 

  of privacy. Please keep this form.

-Please bring  Drivers License & Insurance card

    Click on link below to download:

​

• HIPPA Notice

• ​Adolescent Intake Form

• Adult Intake Form

• Child Consent Form
  

• ​Adolescent Form​​ (to be completed by adolescent)

1401 Providence Park  Birmingham, Al 35242

P 205.585.8761

F 205.982.8465

​smallwooddana24@gmail.com

Source For Change Counseling

Dana S Smallwood LCSW, PIP 

With a loving dedication to my own growth, I began studying principles to help others find a Source for Change in their own lives...