Client Intake Form (*indicates a required field)

Terms of Service, Disclaimer, Payment, Lateness/Cancellation Policy, and HIPAA Information

We require 48-hour notice for unforeseen cancellations to avoid a fee.
TERMS OF SERVICE, HIPAA, Disclaimer, Cancellation/Lateness Policy--see www.healingnotes.com for the most current version. By signing the form below, the client indicates that s/he has read the aforementioned documents.
Please sign your name in the box below to indicate that you have read the TERMS OF SERVICE, HIPAA, Disclaimer, Cancellation/Lateness Policy on www.healingnotes.com and agree to them and that you have provided accurate information for the provider. *

Clear
Name of the person signing the form *

First Name Last Name
Relationship of person signing the form. The signature date will be the date at the top of the form. *

Client Spouse Other caregiver or friend
We appreciate the time that you spent completing this form so we can help you! We will follow up with you shortly.

Please contact us with any questions or concerns.

Shalom and blessings!

Shoshana Averbach

LMSW, MA, MT-BC, LCAT, CDP, CCM, CECP, Accredited Healer
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Client Information