Patient’s First Name

Patient’s Last Name

Gender

Male Female Non-Binary

Date Of Birth

Social Security Number

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Best Time To Call You

Morning Early Afternoon Late Afternoon Early Evening

Phone

Emergency contact:

Name

Relationship

Phone Number

Patient Insurance Information

Insurance Carrier

ID#

SSI Benefits

Yes No

DISABILITY BENEFITS

Yes No

If Referred

Name

Phone

Who Made this Appointment?

Name

Phone

Employment

Employer

Position

School

Medical History

Primary Physicians Name

Phone Number

Psychiatry Name

Phone Number

Have you ever received mental health treatment?

yes no

Current Medications

Medicine Name

For

By clicking this box, I understand or I submit my electronic signature.

I agree to the terms and conditions.

CANCELLATION / NO SHOW POLICY FEE FORM

To our patients: Therapy is a continuous process, which necessitates your commitment to attendance every week, or the necessary amount of times you have arranged with your therapist. We are asking our patients to let us know 24 hours in advance if they cannot come to their appointment. Please call your therapist or the office so we can discuss a makeup session. If you cannot arrange a makeup session, you will be charged $80.00. Additionally, if two consecutive appointments are missed the same appointment time is not guaranteed.

IMPORTANT NOTICE FOR OUR PATIENTS

All patients and/ or representatives will be held responsible for notifying our practice immediately of any changes or terminations with current insurances. Failure to do so will hold patient responsible for all therapy session payments that were not covered by the insurance on file. Thank you for your cooperation.

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon the execution of this consent.

May we phone, email, or send a text to you to confirm appointments.

yes no

May we leave a message on your answering machine at home or on your cell phone.

yes no

May we discuss your medical condition with any member of your family.

yes no

By clicking this box, I understand or I submit my electronic signature.

I agree to the terms and conditions.