CLIENT INTAKE DOCUMENTS
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 via email prior to your appointment.
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 to download and complete the forms below:
Business Info & Policies
Provides you with information about Peaces 'n PuzSouls, its staff, and its business policies and practices. Keep this copy for yourself.
Click to download
Business Card
Provides contact information for Peaces 'n PuzSouls. Keep this copy for yourself.
Click to download
Agreement of Psycotherapy Services
Describes what you can expect in service delivery, as well as expectations for both client and staff. Please read carefully, then sign/date.
Click to download
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.
Click to download
HIPPA Privacy Notice
Informs you how your personal medical data will be handled. Please read this.
Click to download
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.
Click to download
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.
Click to download
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.
Click to download
Authorization to Realease Information
Complete this form as needed, if any other persons, both personal or professional, will need to be a part of your care.
Click to download