First appointment? Print and fill out first 4 forms.

Consent for treatment

Privacy and Client Rights

Client Intake Info

Fee agreement 2015.215.3

Alternate fee agreement 2015.2

Release forms (when you want to give permission to release information):

Consent for Release of Confidential Records

(Use to anytime treatment information needs to be shared for continuity of care or consultation)

Authorization to release information to family

(Use for anyone you want to bring to treatment including a friend, family member, partner or spouse)

 Consent to Record

(Use when you desire to record a relaxation or tapping script for repeat use. Recordings cannot be used for legal matters.)


Norma J. Vaillette MA LMHC
Licensed Mental Health Counselor
Click here
Address: 215 E. Oak St. Lakeland, FL
Phone: 863-284-0817
Fax: 863-284-0608

Social Accounts:

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