Patient Intake Information

Patient Intake Information
Name*

First Name Middle Name Last Name
Gender:*
Student Status:*

Yes. Full-TimeYes. Part-TimeNo. Not a student.
Date of Birth*

MonthDay Year
Date
Marital Status: (As registered with insurance carrier)*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number*

Area Code Phone Number
Email:*
example@example.com
Emergency Contact:*
Phone Number*

Area Code Phone Number
Are you requesting reunification counseling? (typically "no" unless discussed with your counselor)*

YesNo
Insurance Information
Do you have/plan-to-use insurance?*

Yes.No. I plan to pay out of pocket.
Insurance Card (front)*
Upload the front-side of your insurance card (photo or scan) - Max 8 MB
Insurance Card (back)*
Upload the back-side of your insurance card (photo or scan) - Max 8 MB
Insurance Carrier: (ie. Premera, Regence, Aetna, etc.)*
Policy Holder:*
Employer*
Date of Birth:*

MonthDay Year
Date
Relationship to Patient (or self):*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Disclosures and Acknowledgements

Privacy Practices, Disclosures, and Consent
PLEASE READ CAREFULLY: By signing below, I agree to begin therapy with Counseling West Seattle for the disclosed fee, and to pay deductible and/or co-pay portions at the beginning of each session. I understand that if insurance does not cover the entire amount, I am responsible for the full cost of my treatment.

CANCELLATIONS: If I am unable to keep a scheduled appointment for any reason, I must notify my provider at least 24 hours in advance or I will be charged the full amount for the allotted time.
I have read and acknowledge that I have been given a copy of the Notice of Privacy Practices of Counseling West Seattle and given opportunities to ask questions about them.*

I agree.
I give consent for Counseling West Seattle and its affiliate partners to contact me via email or text message for appointment scheduling and reminders. Protected Health Information (PHI) will not be transmitted over these mediums. **Your services will not be affected if you choose to decline this. However, all appointments must then be made by phone.**

I consent.
Document: Privacy Practices (Click to View)
I have read and acknowledge that I have been given a copy of my counselor’s Disclosure Statement (see below for digital copies) and given opportunities to ask questions about them.*

I agree.
Disclosure Statement: Alexa Harmon, M. Ed, NCC, CCM, LMHC

Disclosure Statement: AnnaMaria Austin, M. Ed Psy, LMHCA

Disclosure Statement: Aubrey Hardesty, Psy.D., LMHCA

Disclosure Statement: Colette Swenson, M. Ed., LMHCA

Disclosure Statement: Elliot Grossman, MSW, LICSW

Disclosure Statement: Eric Mulholland, MA, LMHCA

Disclosure Statement: Ernie McGarry, MC, LMHC

Disclosure Statement: Gayle Zeller, MA, LMHC

Disclosure Statement: Katherine Lincicum, MSW, MPH, LICSW

Disclosure Statement: Larisa Wendfeldt, MA, LMFT

Disclosure Statement: Toni Napoli, MA, LMHC
Signatures
I have read and agree to the Telebehavioral Health Informed Consent Form (see below for link). Due to COVID-19, this is required to provide services during the stay-at-home order.*

I consent.
Document: Telebehavioral Health Informed Consent (Click to View)
I give permission for Counseling West Seattle to store my credit card on the PCI compliant and secure platform, CardPointe.

I consent.
Are you filling out this application for your child?*

YesNo
Please fill out the following information about your child:
I am the parent/legal guardian of * Child's First Name* Child's Last Name* and agree to the terms on his/her behalf.
Electronic Signatures: The Parties agree that any form of electronic signature, including but not limited to signatures via facsimile, scanning, or electronic mail, may substitute for the original signature and shall have the same legal effect as the original signature.*

I agree
How would you like to sign?*

I prefer to draw my signatureI prefer to type my signature
Patient Signature:*
Type your full name (first, middle, and last)
Patient Signature:*

By signing above I hereby affirm that I have read and agree to the above terms and that the information I have provided is complete and fully accurate Clear
Signature Date*

MonthDay Year
DateHour Minutes AM/PM Option
Please verify that you are human*
For Office Use Only

Counselor Acknowledgement and Signature
How would you like to sign?*

I prefer to draw my signatureI prefer to type my signature
Electronic Signatures: The Parties agree that any form of electronic signature, including but not limited to signatures via facsimile, scanning, or electronic mail, may substitute for the original signature and shall have the same legal effect as the original signature.*

I agree
Counselor Signature*
Type your full name (first, middle, and last)
Counselor Signature:*

Clear
Date:*

MonthDay Year
Date
Should be Empty:

Patient Intake Information

Insurance Information

Disclosures and Acknowledgements

Signatures

For Office Use Only