Therapy Intake Form

Referring Agency
Referring Person's Name
Position/Tittle
Phone Number
Financial Information
How I plan to pay for treatment:*

InsuredSelf PayMedicaidCareFirst
Name of Insurance Company *
Insurance Number*
Insurance Card

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History of the Present Problem
Purpose of this appointment:*
Have you ever had the same or a similar problem?*

YesNo
If yes, please describe:

What are your expected goals/outcomes for treatment?*

The Therapy Process
Working with you to identify presenting issues and develop a plan of care is the goal. However, it is your commitment to identifying personal goals towards which you desire to move and obstacles which may prevent that movement which will, in large part, determine the success of the therapy. If you have a crisis situation develop after hours, call the suicide prevention hotline at (800) 784-2433 or go to your local emergency room.
Legal Responsibility
Under the laws of the United States and the state of Maryland your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.
Use and Disclosure of your Personal Health Information (PHI)

Please read and sign
The information that you provide will be shared with CSP Billing and Consulting, LLC. CSP Billing and Consulting is a third party agency that processes insurance claims for Inspiring Change Mental Health Services, LLC. The informtion you provide today will assistance with determining your insurance coverage and eligiblity for services. Please sign below to agree for Inspiring Change Mental Health Services to share your information with CSP Billing and Consulting Services, LLC.
Signature*

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Signature and Submission
Please sign your name below to indicate your consent to be contacted by Inspiring Change MHS to scedule an appointment for assessment. .
Please type Client or Referring Person's Name *
Signature

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Date*

MonthDayYear
The parent or legal guardian must type and sign their name below. Please provide proof of guardianship at the time of your assessment. If you are a referring agency, please skip this section.
Please type Parent/Guardian's Name
Date

MonthDayYear
Signature

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Identification Card

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Are you the client's LEGAL guardian? Please be prepared to provide legal documentation during your scheduled appointment.

YesNoI am 16 years or older.
Enter the message as it's shown*
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Inspiring Change Mental Health Services, LLC

Financial Information

Personal History

History of the Present Problem

The Therapy Process

Legal Responsibility

Use and Disclosure of your Personal Health Information (PHI)

Signature and Submission