• Alba Wellness, Inc. Intake Form


    _____________________________________________
    Counseling – Transformation – Empowerment
    433 Kitty Hawk Rd. Suite 219 Universal City, TX 78148
    Phone (210 ) 566-1280 | Toll Free (855) 566-ALBA | Fax (210) 566-1289

  • Consent to Treat a Minor

    I, as the parent and/or legal guardian for the minor childgive my consent for said child to receive counseling from a representative of Alba Wellness Incorporated. I understand that I may withdraw this consent at any time. I will first notify a representative of Alba Wellness Incorporated by telephone and then in writing, if and when I choose to withdraw this consent.

  • Parent/Guardian Information:

  • Child’s Information:

  • Parent/Guardian Information(Name)
  • Child’s Information: (Name)
  • By signing below, I agree that the above information is accurate to the best of my knowledge.