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SOUTH POINT COUNSELING SERVICES, LLC Children - Individuals - Couples - Families - Substance Abuse - Weight Loss Roselene S. Dalanhese, LCSW & Associates
Therapy for Individuals and Families
Helpful Forms

If you're a new client, please complete the following forms and bring them to your first therapy session. Simply click on the title of the form to download it as a PDF.

If you would like us to coordinate care with another provider (for instance, your psychiatrist, insurance company, family, school personnel, Primary Care Physician, etc.), complete this form to authorize release of psychotherapy information.  If you chose not to release information to anyone at this time, please check the Decline to Release Information box and sign in the Client Signature area below:

Note: To download Adobe Acrobat Reader for free, click here.

Are you a healthcare professional, probation officer, judge, or therapist who would like to refer a client or patient to our office for mental health services? 




Please fill out the referral form below.  You can fax it to (801) 302-7248 or email it to [email protected]