Register

Registration is only required if you do not have a username. Please check your spam & junk mail folders to ensure you have not already received an email with a username and password. If you already have a username log in here

Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

Please fill out all forms before your first appointment. I look forward to connecting!

Client Information

/ Middle Initial

( optional )
 
( Must be at least 18 years old )
( MM-DD-YYYY )


( optional )
( optional )





( for Text Message Reminders )

Bill To Contact

/ Middle Initial







Emergency Contact

First Name
Last Name
Phone
Mobile
Relation
Email
Street Address
City
State
ZIP Code

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )



Between 8 and 40 letters and numbers

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )




( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

LPC-A Form

Consent to Treatment with a Licensed Professional Counselor Associate (LPC-A)

I understand that my counselor Miami Zarauskas M.S., LPC-A is recognized by the state of Texas as an L.P.C.Associate, and has earned a Master's degree in counseling from a fully accredited university. As a continuing part of the licensing process, my counselor is required to discuss their cases with a supervisor(s). The discussion of my case is for the express purpose of my counselor's continued growth and improvement. Every effort will be made to protect my privacy and confidentiality.

I consent to treatment with an LPC Associate and I consent to my case being discussed for supervision purposes only. I am also aware that I have the right to speak with my counselor's supervisor, Anne Hardegree (325) 947-5021, at any time regarding any questions or concerns about this or any other situation, now or in the future.

( Type Full Name )
( Full Name )