*INTAKE FORMS
*All Forms are Mobile Friendly / Electronic Forms that are HIPPA compliant, and ENCRYPTED which means your information is safe and secure.
This form is for NEW Prospect Clients & *Returning Clients to request an Intake Appointment as well as an Insurance Verification / Benefits Quote to make scheduling easy and effortless! This pertinent form allows us to gather basic information to determine reasons for seeking treatment to determine Client-Clinician Match; to provide you with a Benefits Quote, and to schedule your Intake Appointment based on your noted availability.
What Happens Next?
Upon receipt of your Appointment Request Form, we will promptly review your submission. If an appropriate client-clinician match, we will subsequently provide you with a Welcome Message.
The Welcome Message will contain the following:
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Intake Appointment Day/Time
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Benefits Quote
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Intake Forms
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Virtual Waiting Room Link (no account setup)
Simply, reply "C" to CONFIRM Intake Appointment.
Yes, scheduling is really that simple!
Thank you,
Melissa E. Mendoza, LMSW
*Returning Clients are past clients that have not been seen in 2-months.
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.
*BECK DEPRESSION INVENTORY-II
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 assessment will be e-mailed to you.
*BECK ANXIETY INVENTORY
This is an assessment tool to assess the magnitude of client's level of Anxiety; form only takes 5-7 minutes to fill out.
*This assessment will be e-mailed to you.