Client Forms
REFERRAL FORM
If you would like to make a referral, please complete our referral form. Email it to [email protected] or Fax it to 888-972-4998. You may also Make a Referral Online.
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NEW CLIENT REGISTRATION
Complete the Contact Form below or give us a call and we will begin the New Client Registration process, schedule you for an Intake and Evaluation and assist you in reaching your Counseling and/or Relationship Goals.
You may also Print out the Consents below following Client Registration and Consents. You may either bring them or send them to us by fax or email prior to your first appointment. Additional items to bring include a valid id, insurance card, proof of guardianship for minors such as birth certificate and a list of medications if applicable. You can send the forms confidentially by Fax @ 888-972-4998 or by Email to [email protected].
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AUTHORIZATION TO RELEASE INFORMATION
All client health information discussed in sessions is Confidential as stated in the HIPAA-Privacy Policy and will only be released at the request of the client or legally responsible person. If you are using insurance, we must have an Authorization to Release Information on file for Insurance Billing Purposes only. You may also use this form if you would like us to have communications with a family member, family doctor or any other designated person, agency or facility. Proof of client identity and signature may be requested. Fees may apply for medical records requests.
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CREDIT CARD PAYMENT AUTHORIZATION & PAYMENT POLICY
Thank you for choosing us as your mental health provider. We are committed to providing you with quality and affordable care. Because some of our clients have had questions regarding client and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request.
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