*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.
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 entirety and fill out the client name, and emergency contact accordingly. Please note there are 2-signature sections, one for legal policy and the second for consent to treatment. Thank you.
This form is both for consent for Telehealth services and Emergency Response Policy for your protection and rights as a client; it is legally required. Please read this form in its entirely and fill out client name and emergency contact, accordingly. 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.