Contact Community Centered Counseling - Quad Cities

client forms

If you are a new client please review the information below and fill out all of the necessary forms below.


For a digital format of our paperwork to fill out and send back electronically please email

Adult Form (Age 18 and Older) Download Your Adult Form
Age 18 and Under Download Your Child Form


If you have insurance we ask that you call your insurance company before the appointment and ask:

  • If a pre-authorization is required
  • If you are meeting a deductible
  • The number of visits you are allowed
  • If you have a copay

John Deere Health Care or United Health Care Insurance

If you are insured by John Deere Health Care or United HealthCare, click below for an additional form. You may refuse to fill out this form without any loss of benefits but we are required to send it in so please bring it with you blank or filled out. The link will need to be changed here on these as well Adult Form Youth Form

New Client?

Please fill out the forms below. Bring the filled out forms to your first visit or email

CCCS Intake Form CCCS Insurance Form CCCS Telehealth Form CCCS Crisis Hotline

Need further assistance? Call us at Phone Icon(563) 388-1039