Peaceful Connections Clinical Services
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Client Forms

Complete your paperwork securely online. All forms are encrypted and stored confidentially.

Intake FormRequired

Share information about yourself, your background, and what brings you to therapy. This helps us prepare for your first session.

Informed ConsentRequired

Review and agree to the terms of your therapeutic services, including fees, confidentiality, and your rights as a client.

HIPAA AuthorizationRequired

Authorize how your protected health information may be used and disclosed in accordance with federal and Florida law.

Release of InformationOptional

Optional — authorize Peaceful Connections to share or receive information with a school, medical provider, or other party.

Your privacy is our priority. All forms are protected under HIPAA and Florida law. For questions, contact us at (813) 602-1892.

Peaceful Connections Clinical Services

A safe, compassionate space where healing begins and connections are restored. We walk alongside you on your journey toward peace.

"Every step toward healing is a step toward yourself."

Services

  • Clinical Supervision
  • In-Home Counseling
  • Online Counseling
  • Pre-Marital Counseling
  • Skills Groups
  • Islamically Integrated Therapy

Company

  • About Us
  • Client Resources
  • Make a Payment
  • Contact

Text: (813) 602-1892

Email: amatullah@thepeacefulconnection.com

Serving: Wesley Chapel · New Tampa · Zephyrhills · Temple Terrace

In-person & telehealth available throughout Florida

© 2026 Peaceful Connections Clinical Services, LLC·Made with care