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INTAKE FORMS

 

 

 

 

 

 

 

 

*All Intake Forms are Mobile Friendly / Electronic Forms that are HIPPA compliant, and ENCRYPTED which means your information is safe and secure. 

 We're excited about meeting you! 

This form is used to request an appointment to make scheduling easy and effortless!

 

This pertinent form let's us gather basic client contact information, insurance information, and it is used to briefly identify the reasons a client is interested in counseling. This helps us to streamline registering you as a new client or returning client and to promptly verify your Mental Health benefits.

 

What happens next? 

Upon receipt of your APPOINTMENT REQUEST FORM, we will promptly review you submission and verify your insurance eligibility.  This process is normally completed same business day - but in some cases, may take up to two business days to complete.  

 

Simply Reply back "C" to Welcome Message with Courtesy Benefits Quote to Confirm Appointment. 

 

 

Thank you,

 

The Pink Positive Psychology Team

This form serves as an authorization to input your Credit Card and / or Health Savings Account Card / Flexible Spending Account Card  information into our secure system and charge it when a balance on your account exists.

This form explains our expectations of you as a client, your protections and rights as a client, and our fees. Please read this form in its entirely and fill out client name, and emergency contact accordingly. Please note their are 2-signature session, one for legal policy and the second for consent to treatment.  Thank you.

Please make sure to have all *Intake Forms filled out 48-hours prior to your first Intake Appointment. Thank you.

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. References to “medical record” include, but are not limited to, psychological/social work records.

This form is an assessment tool, simply check all symptoms/presenting problems that apply from list and note how long the symptoms have been present for.  This is an important assessment tool for diagnosing and determining client meeting medical necessity for treatment or not.

This is an assessment tool to assess the magnitude of client's level of Depression; form only takes 5-7 minutes to fill out.

This is an assessment tool to assess the magnitude of client's level of Anxiety; form only takes 5-7 minutes to fill out.