Intake Form - Autistically Allied

Comments

This field is for validation purposes and should be left unchanged.

Personal Information

Name*

First Last

What is your gender?

What are your pronouns?

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Preferred Method of Contact

(select all that apply)

Phone Call

Text Message

Email

Mail

Other

If other, please explain*

Highest Level of Education

Relationship Status

Living Situation

Please list your place of employment and your last two jobs, dates of employment, and reason for leaving.

Mental Health History

If you have worked with a therapist, please explain in two to three sentences what you liked and did not like about the experience(s):

If you have been hospitalized due to your mental health, please explain the circumstances:

Please list your current medications:

What led you to scheduling this appointment with Jeanne?

Currently, your 3 biggest concerns leading up to this appointment are the following:

What do you want to achieve from working with Jeanne?

Policies

Please read each policy and provide your signature to document your understanding.

I acknowledge the email address I am providing will receive emails regarding treatment.*

I Understand

I am aware there is a fee associated with the creation of documentation for school, work, or medical purposes. Communication of that fee by Jeanne and payment of that fee by the client are required before Jeanne will release the documentation.*

I Understand

I understand that Jeanne is not a mental health therapist, counselor, or psychologist. She is an autism specialist with a background solely in working with autistic individuals.*

I Understand

Jeanne requires 24-hour notice for a cancelation. Cancelations and “no shows” (missing an appointment without providing notice) are charged as follows: $50 for individual session. Fees must be paid before the next appointment. To provide notice of a cancelation, please email Jeanne or call the office.*

I Understand

The undersigned patient or responsible party consents to, and authorizes, services by Jeanne Holverstott, MS. Client understands that client has the right to a copy of this Consent; and has the right to withdraw this Consent at any time. Client understands that if signed consent is not given, Jeanne Holverstott, MS cannot provide services to the client.*

I Understand

The undersigned patient or responsible party (parent, legal guardian, or conservator) acknowledges that client has been informed of the privacy practices for New Leaf Therapy Group, and has read and understands the Notice of Privacy Practices for Protected Health Information. Client consents to the use and sharing of protected health information as described in the Notice. Client understands that they are entitled to a copy of the privacy practices, which is available upon request from the office staff and on the office website.*

I Understand

I have read and understand the fee structure as it applies to Jeanne Holverstott’s services. Clinical Initial Consultation: $150, Clinical Individual/Family Intervention: $100, Clinical Group Therapy: $50, Report (Scoring, Analysis, Writing): Vary*

I Understand

Jeanne is a private pay clinician. Her services are not billable to or reimbursable by health insurance carriers. The services that Jeanne provides do not fall within the parameters of the CPT codes (Current Procedure Terminology) required to bill to health insurance. Some cafeteria plans or flexible spending plans may cover these services. Please check with your employer’s human resource department to determine if you can be reimbursed. Payment is due at the time of service delivery. You will have the opportunity to place a credit card on file or use Square at the time of service.*

I Understand

INTAKE ASSESSMENT - START HERE

HIPAA Form

Personal Information

Mental Health History

Policies

INTAKE ASSESSMENT - START HERE

HIPAA Form

Personal Information

Mental Health History

Policies

Contact Jeanne