Please fill out our electronic form below. Alternatively, you can view / download / print our form for manual submission using the link below.
HRA Counseling Intake PDF
I hereby authorize payment of medical benefits through my insurance policy to HRA Psychological Services. I have listed all health plans from which I may receive benefits. I hereby accept responsibility for payment for any services provided to me that are not covered by my insurance.
I agree to pay all copayments, coinsurance, and deductibles at the time services are rendered. I also accept responsibility for any missed appointment/late cancellation fees, NSF check fees, and a $10.00 charge per month on all overdue balances (past 60 days
I hereby authorize HRA Psychological Services to use and/or disclose my health information which specifically identifies me or that can reasonably be used to identify me to carry out my treatment, payment, and health care operations.
I understand that while this consent is voluntary, if I refuse to sign this consent, HRA Psychological Services can refuse to treat me. I understand this authorization can only be revoked in writing. If I revoke my consent, such revocation will not affect any actions taken by HRA Psychological Services prior to receipt of my revocation.
Click here to view our full financial policies.
Please click here to review our health privacy policies.
My signature below indicates that I have received the notice of HRA Pyschological Services policies and practices to protect the privacy of patient health information as required by law.
Click here to view our policies for in-person counseling during COVID-19.
By signing below, you are indicating that you understand and accept the risks of exposure to the coronavirus.
Click here to view our teletherapy informed consent documentation.
By signing below, you have read and understand the information provided above concerning teletherapy.