Psychiatric Intake Form (Page 11 of 11) in pdf

Please acknowledge that you:

Have carefully reviewed all information in this document

Received a printed copy of this document if so requested

Received a Notice of Privacy Practices explaining HIPPA

Understand that his is an agreement with Counseling Services for Wellbeing, a corporation that is unrelated to

your caregiver except as a billing, promotional and facilities service.

Understand that your caregiver is an individual business responsible for providing mental healthcare services.

Print name____________________________________________ Signing on behalf of _____________________________________

Relationship_______________________________________________________________________ (if patient is unable to consent)

Signature____________________________________________________________ Date ____________________________________

Print name____________________________________________ Signing on behalf of _____________________________________

Relationship_____________________________________________________________

Signature____________________________________________________________ Date ____________________________________

Print name____________________________________________ Signing on behalf of _____________________________________

Relationship_____________________________________________________________

Signature____________________________________________________________ Date ____________________________________

Print name____________________________________________ Signing on behalf of _____________________________________

Relationship_____________________________________________________________

Signature____________________________________________________________ Date ____________________________________

Financial Responsibility

I authorize my provider and/or Counseling Services for Wellbeing to release information to insurance carrier(s) listed and be

paid directly by insurance carrier(s) for services billed. I acknowledge that I am responsible for all charges not paid by my

insurance companies including: copays, coinsurance, deductibles, insurance plan refusal to pay for failure to obtain

authorization, and missed and late cancellation fees.

Print name______________________________________________________________________________________________

Signing on behalf of ___________________________________________________ (If patient is not financially responsible party)

Relationship_____________________________________________________________________________________________

Signature____________________________________________________________ Date ______________________________

Psychiatric Intake Form Page 11