As part of the counseling process, we ask that you print out the intake forms, double sided if possible. Please complete each one as fully as possible. Once in our possession, all the information you provide is subject to the rules of confidentiality.
Bring all four completed forms with you, to include driver license and insurance card (if applicable) to your initial appointment. All forms must be completed prior to the beginning of your first session. Arriving with incomplete forms will result in wasting session time finishing them, as we cannot legally begin the session without them.
Thank you very much for taking the time to complete the forms prior to your appointment. Providing this amount of information will undoubtedly save considerable time during your first several visits.
Patient/Client Intake Form (Counseling)
This form is to be completed by each person, age 14 or older receiving therapy or are returning to therapy AFTER a period of one year. Do not share the completed form with other family members. It is designed to provide the counselor with personal information that may be relevant but not yet known by others. Parents, please allow your child the privacy necessary to be successful; do not force them to share their completed form with you.
Patient/Client UPDATED Intake Form (Counseling)
This form is ONLY to be completed by a person, age 14 or older who is returning to therapy AFTER a period of FOUR MONTHS TO ONE YEAR, or when requested. Do not share the completed form with other family members. It is designed to provide the counselor with personal information that may be relevant but not yet known by others. Parents, please allow your child the privacy necessary to be successful; do not force them to share their completed form with you.
Please ensure you use the correct form! Bringing in the incorrect form will delay the process.
Informed Consent Form (Counseling)
The Informed Consent form is filled out by those scheduled to see the counselor. Multiple family members may use the same document (to save trees & storage space).
Good Faith Estimate / Financial Agreement Form (Counseling)
The Good Faith Estimate (GFE) / Financial Agreement form is used by those assuming financial responsibility for payment. All information requested is required, as is both signatures of a married or non-married couple.
For the sake of security, please wait until you are physically in the office before adding social security numbers or credit card information.
HIPAA Acknowledgment of Receipt of Notice of Privacy Practices (Counseling)
We are requried by state law to offer you a copy of our Privacy Practices. We ask that you to sign this Acknowledgement form which states that the offer was made to you. You are not required to receive a copy of the Privacy Practices unless you ask for it, in which case we will make it available to you. Reading the document is the best known cure for insomia!
Other Documents
Lastly, be prepared to render your driver’s license for identification purposes and if applicable, insurance documents to our office staff. We are legally required to know who we are serving.
Photo of Grand Canon taken by Dan Graham, Homestead Counseling Services
