We believe Black lives matter. Our hearts and minds are united with our Black counselors, clients, family, and neighbors to seek social justice, restorative justice and build relationships that will heal the legacy of inequality in our country.

Keith Miller Forms

I look forward to meeting with you very soon. Please complete the forms and bring them to the first session or take the first few minutes of your session to fill them out after I greet you in the waiting area.

NOTE ABOUT PAYMENT: Payment is expected at each session. Checks or cash are preferred. A 4% discount is given for payment by cash, checks, or ACH direct debit. Please make checks payable to “Keith Miller Counseling, LLC.”  We also accept Visa, MasterCard, and Discover and American Express (see credit card form below).

The following three forms are REQUIRED for meeting with Keith Miller:

Client Data Form and Consent for Care – Keith Miller


Physician release of information


The following forms are OPTIONAL and used only when needed

Visa MasterCard Discover AmEx Form  (full fees apply to credit card users)

ACH Bank Debit Authorization Form (Discounted fees apply to ACH users or payment by check or cash).

Consent for Release of Information