Intake Form

Patient Information

Today’s Date*

Clinician

Diagnosis

Personal Information

Client’s legal name*

Date of birth*

Home address

Street*

City*

State*

Zip*

Email address*

Phone number*

YesNo

Gender*

Marital Status*

Work Status*

Payment information

***All co-pays and private pays are due at the time of service***

VisaMastercardDiscover

Card number*

Expiration Date*

3 digit code*

Billing Zip code*

Primary Insurance information

Primary Insurance company*

Subscriber’s name*

Date of birth*

Subscriber’s insurance identification number*

Relationship to client*

Secondary Insurance Information

None

Secondary Insurance company

Subscriber’s name

Date of Birth

Subscriber’s insurance identification number

Relationship to client

Issues For Seeking Counseling Services*

If the client is a minor, please print the name of the parent or guardian on minor’s behalf

Print Full Name

Relationship to client

Missed appointments and no shows:

I am financially responsible for my attendance at all scheduled appointments, unless the appointment is canceled with at least 24 hours’ notice. A minimum charge of $50.00 will be applied to my account for a cancellation and a $75.00 charge for a no show.

Paperwork

Completion of paperwork for social security, disability, worker's compensation, etc is at the discretion of the provider at Whole Life Solutions, LLC. The decision will be heavily influenced upon prior consultation with your provider regarding the need for completion of these documents as well as frequency and duration of treatment. Should paperwork be required, I understand my cost will be $45 per 15 minute increment and paperwork will not be released until I pay in full.

Insurance Billing

I authorize Whole Life Solutions, LLC to release any medical information to my insurance company which may be deemed necessary to process an insurance claim. I agree to notify Whole Life Solutions, LLC whenever I have changes in my insurance coverage.

Account Responsibility

I am responsible for payment to Whole Life Solutions, LLC for all services rendered which is due at the time of service. If I default on any payment and am sent at least three statements, I acknowledge that my account will be turned over to a third party collection agency

Clinical Staff Release

I understand that, as part of professional clinical consultation, my situation may be reviewed using general clinical information, and that my therapist will obtain a release of information from me prior to discussing details of my situation.

Informed Consent and Notice of Privacy Policies

I am consenting to have copies made of my driver’s license, insurance card, and credit card to be kept on file at Whole Life Solutions, LLC. I am consenting to treatment and have received and understood the contents of the Counseling Policies, including the Notice of Privacy Practices (HIPPA). My signature below indicates that I have been provided a copy of, and that I fully understand and agree to, all of the terms and conditions of the Whole Life Solutions, LLC Policies

Client’s signature*

Today’s date

Parent or Guardian’s signature*

Today’s date