Forms for Counseling & Telehealth Counseling
IN-OFFICE APPOINTMENTS: Please print and complete forms 1-6 below and bring them in to your appointment. If you are unable to print and complete packets in advance, please arrive 10 minutes prior to your appointment. Please bring your insurance card and photo ID to your appointment.
TELEHEALTH APPOINTMENTS: Telehealth refers to either HIPAA compliant computer-based format such as Doxy.me or audio appointment (telephone). While many insurances have opened up their panel at this time, some will not cover both computer-based or telephone options or either. You must check with your insurance company prior to scheduling an appointment if you select Telehealth counseling. If your insurance does not cover this and benefits were not verified in advance, you will be charged out-of-pocket for the appointment.
If you wish you can pick the forms up at my office. I am not a walk-in office so arrangement to pick-up must be made. Please be sure ALL forms are mailed back via US mail or dropped off in my mailbox prior to your appointment. Forms must be received at my office, completed and signed, at least one day prior to your appointment. If I do not receive your packet via mail or drop-off prior to your appointment, your appointment will be rescheduled. If you need your records released for any reason, please also print and complete Form 8. (See below).
You can now complete the forms in PDF format online, save them and email them back to me at: evolvecounselingoflansing@gmail.com prior to your appointment.
IN-OFFICE APPOINTMENTS: Please print and complete forms 1-6 below and bring them in to your appointment. If you are unable to print and complete packets in advance, please arrive 10 minutes prior to your appointment. Please bring your insurance card and photo ID to your appointment.
TELEHEALTH APPOINTMENTS: Telehealth refers to either HIPAA compliant computer-based format such as Doxy.me or audio appointment (telephone). While many insurances have opened up their panel at this time, some will not cover both computer-based or telephone options or either. You must check with your insurance company prior to scheduling an appointment if you select Telehealth counseling. If your insurance does not cover this and benefits were not verified in advance, you will be charged out-of-pocket for the appointment.
If you wish you can pick the forms up at my office. I am not a walk-in office so arrangement to pick-up must be made. Please be sure ALL forms are mailed back via US mail or dropped off in my mailbox prior to your appointment. Forms must be received at my office, completed and signed, at least one day prior to your appointment. If I do not receive your packet via mail or drop-off prior to your appointment, your appointment will be rescheduled. If you need your records released for any reason, please also print and complete Form 8. (See below).
You can now complete the forms in PDF format online, save them and email them back to me at: evolvecounselingoflansing@gmail.com prior to your appointment.
| 1._consent_for_outpatient_services__2_.pdf |
| 2._insurance_authorization__2_.pdf |
| 2.1_self-pay_demogrphics-auth__2_.pdf |
| 3._cancellation_policy__2_.pdf |
| 4._general___medical_information__2_.pdf |
| 5._notice_of_privacy_practice_receipt__2_.pdf |
| 6._informed_consent_regarding_insurance_billing_and_payments__2_.pdf |
| 7._telehealth_informed_consent__2_.pdf |
| 8._authorization_to_release_information__2_.pdf |
See below for the NOTICE OF PRIVACY PRACTICES AND DISCLOSURE STATEMENT 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.