New Client Intake Forms
Explanation of Forms:
The following forms are needed prior to your appointment or brought in to your initial appointment with you. You may also complete them at your first appointment if needed. If you do not have the option to print the forms below, they can be mailed or emailed to you. If I do not receive your completed packet via mail or email before a scheduled telehealth appointment, your appointment will be rescheduled.
Explanation of forms
*Forms Needed for Appointment (Left Column Printable PDFs Below)
Form 1 - Consent for Outpatient Services
Form 2 - Demographic and Insurance Authorization
Form 3 - Cancellation Policy
Form 4 - General Medical Information
Form 5 - Notice of Privacy Practice Receipt
Form 6 - Informed Consent Regarding Insurance and Billing
Form 7 - Telehealth Consent for Services
Please include a copy of your insurance card and Driver License with the forms above.
As-Needed forms (Right Column Below)
Form 2.1 - Self-Pay Auth. (do not print this form if you are utilizing your insurance).
Form 2.b - Recurring Automatic Payment Authorization Form
Form 8 - Records Release, as needed
Form 9 - Non-custodial parent release
Download the forms below, complete and sign where indicated. The forms can be scanned and returned to:
evolvecounselingoflansing@gmail.com or may be mailed or returned to me at your in-person appt.
COMPLETE PRIOR TO APPOINTMENT
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AS NEEDED FORMS
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See below for the DISCLOSURE STATEMENT and NOTICE OF PRIVACY PRACTICES for Evolve Counseling and Holistic Wellness, LLC. This serves as your formal electronic notice. Should you wish to have a paper copy of this notice, please request one during your appointment. You may need to view these forms in Desktop mode. Updated: 2/28/2021
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