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Your tax deductible donations to Affordable Counseling Therapy (ACT) help us continue to provide services to clients in the Birmingham area, regardless of their ability to pay.​ Please consider donating to ACT today!  

Call To Action

Downloads

All documents needed to become a client are here.
Just click on download and fill your data correctly.
If you have any question please call us at (205) 933.1213

Burns Depression Checklist
This simple checklist helps us to better understand your “state of mind.” Please complete this form according to the instructions and return to us.
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HIPAA Notice
This is a 5-page notification of your rights under the Health Insurance Portability and Accountability Act. This is for your information. You may wish to print it out and keep it, or not.
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HIPAA Acknowledgment Receipt
Please sign this form and return it to us.
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Telehealth Consent Form
We need this signed consent form for counseling sessions conducted via telehealth.
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Act Intake
Please complete these pages, sign in the appropriate places, and return to us.
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Jefferson State Community College Students
This form is designed specifically for students of Jeff State. Please complete and sign this form, as well as the HIPAA ACKNOWLEDGEMENT form, BURNS DEPRESSION CHECKLIST, and TELEHEALTH CONSENT FORM.
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