Professional Administrative Documentation

(PAD) Request Form

First Name

Last Name

Phone *

Email *

Have you completed at least six (6) counseling sessions with your provider?

Do you currently reside in Texas?

Yes

What type of documentation are you requesting?

Upload Supporting Documents

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF Please upload any forms or paperwork provided by your employer, school, or organization that require completion.

Client Acknowledgements

I understand that submitting this request does not guarantee approval of documentation.

I understand that my counselor must determine whether the requested documentation is clinically appropriate.

I understand that the fee for Professional Administrative Documentation is $135 per document.

I understand that updated FMLA or Leave of Absence documentation requires a new PAD fee.

I understand that PAD fees are separate from counseling session fees.

I certify that the information I have provided is accurate and complete to the best of my knowledge.

Please read each statement carefully before submitting your request.