Bring a copy of your insurance card to your upcoming appointment.
Please download and complete the forms listed below, and bring them to your upcoming
appointment, or submit them to me via email prior to your
Please read all forms carefully and complete all sections. If a section does not apply please
indicate with non-applicable (N/A). All information submitted and shared with
Peaces 'n PuzSouls and its staff is kept in the highest of confidentiality.
|Click the links below to download...||Intake Document Description and Instructions|
|Business Info & Policies||Provides you with information about Peaces 'n PuzSouls, its staff, and its business policies and practices. Keep this copy for yourself.|
|Business Card||Provides contact information for Peaces 'n PuzSouls. Keep this copy for yourself.|
|Agreement for Psychotherapy Services|
Describes what you can expect in service delivery, as well as expectations for both client and staff. Please read carefully, then sign/date.
|Responsibility for Payment||This form assures that Peaces 'n PuzSouls and the client have the same understanding around payments, including and not limited to insurance payments, and client responsibility payments (i.e. co-payments, deductibles, self-pay, payment arrangements, fees, etc.) Please read carefully, then sign/date. |
|HIPPA Privacy Notice||Informs you how your personal medical data will be handled. Please read this.|
|Receipt of HIPPA ||Please complete this form to indicate that you have been given a copy of the HIPPA document, have read it, understand, and agree with it. |
|Intake Form |
Consent for Treatment of Minors
|Please complete this form, pages 1 and 2. If this appointment is for anyone under 18, please complete the Consent for Minors form. |
|Consent for Use Disclosure||If it is okay to call you, mail documents to you, and send/receive emails to the email address on file, please initial on the appropriate lines, sign/date this form. |
|Authorization to Release Information ||Complete this form as needed, if any other persons, both personal or professional, will need to be a part of your care.|
Copyright © Peaces 'n PuzSouls Journies thru Healing. All rights reserved.
Sheila Sweeney, PhD, LICSW Psychotherapist
777 Selby Avenue, Saint Paul, MN 55104
firstname.lastname@example.org - (651) 797-4094