Intake Forms

Intake Agreement

Outlines practice policies, expectations, and your rights and responsibilities as a patient, including communication, appointments, and consent for treatment.

Telehealth Consent

Explains how virtual visits work, including privacy, technology requirements, and potential risks/benefits of receiving care remotely.

Emergency Contact

Provides contact information for someone we can reach in case of an emergency or urgent concern related to your care.

Authorization for Release of Information

Allows you to give permission for your provider to share or obtain information with/from other providers, pharmacies, or supports involved in your care.

Fee Schedule & Financial Responsibility

Details session rates, billing practices, insurance information (if applicable), and your responsibility for payment, including cancellations and missed appointments.

Credit Card Authorization

Allows us to securely keep a card on file for payment of services, including session fees, late cancellations, and outstanding balances, in accordance with our financial policy. You can update or change your payment method at any time.