FORMS REQUIRED FOR INTAKE
Prior to your intake appointment, you can download all of the forms below (recommended). The first four forms (1-4) must be completed; 5 is completed ONLY if you want us to communicate or provide records to anyone (such as physician or parent/guardian). The remaining forms are informational.
You have two choices for arrival time:
1) Bring all of the completed forms with you to your intake interview and arrive 15 minutes early to complete an online questionnaire designed to help the therapist assess your situation. If you have any questions/concerns about the forms or information requested, you can discuss it with the counselor at your appointment. The administrative staff at the front desk can answer any questions you may have about our fees, insurance, and payments.
2) If you prefer, you may fill out the forms at our office when you come for your intake interview; please come 30 minutes early if you choose this option.
PLEASE NOTE: The therapist needs the entire intake appointment time to gather information and help you decide your next step. If you do not come early and complete the paperwork and online questionnaire, it may be necessary to reschedule your appointment. If so, you will incur a $20 charge.
● If you have insurance other than UC Student Health Insurance, please bring your insurance card to your Intake Interview. We need to make a copy so we can verify your coverage; this will help us determine your co-pay amount. You will owe $60 per session until we can verify coverage. If necessary, your account will be credited when coverage is verified.
● If you have UC Student Health Insurance, please bring your insurance card. Otherwise you will owe $60 per session until we can verify coverage. If necessary, your account will be credited when coverage is verified.
- Request for Services
- Information for Clients
- Consent for Video Recording
- Fee Agreement
- Authorization for Release of Protected Health Information(this form must be completed if you want us to communicate or provide records to anyone)
- Information for Clients- Client Copy
- Health Insurance Worksheet(may be beneficial in helping you communicate with your insurance company regarding your coverage)
- Information About Group Therapy
- Community Mental Health Providers
- Notice of Privacy Practices