Intake Forms

Required 48 hours prior to your appointment with any clinician at our office. Includes:
- Information and Consent Form
- Fee Agreement 2024
- Notice of Privacy Practices
- Client Information Form
- Client Contacts Form
- Client Insurance Form
- Payment Authorization Form
- Client History Form

If you are working with a Supervisee in Social Work, Resident in Counseling, or an intern, please all fill out their specific consent form.

Please fill out this consent form if you will be working with Eli Mick, Supervisee in Social Work.

Please fill out this consent form if you will be working with Hayley Jenkins, Supervisee in Social Work.

Please fill out this form if you will be working with Kevin Salvas, Supervisee in Social Work.

Please fill out this consent form if you will be working with Jacquie Shires, Resident in Counseling.

Please fill out this form if you are working with Molly Haynes or Fatima Batool, Social Work Interns.

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, click on the button below.