HER HAVEN OF LIGHT

HER HAVEN OF LIGHT
Today's Date

Month Day Year
Date
Client First and Last Name
Date of Birth

Month Day Year
Date
Age
Preferred Name
Address

Address

Street Address Line 2

City State

Zip Code
Mobile Phone
Work Phone
Email
Gender
Ethnicity
Marital Status
How did you hear about us?
In the event of an Emergency Contact (required):
First and Last Name
Relationship to Client
Mobile Phone
Work Phone
Physician Name
Office Name
Address

PCP Address

Street Address Line 2

City State

Zip
Phone
Fax
What are you in immediate need of? (Check all that apply)

Food Toilitries Clothing Transportation Shelter/Housing
Insurance Information (for referral purposes only):
Insurance Company Name
Group #
DOB
City
State
Zip
Primary Concerns (please check all that apply)

Addiction Abortion Counseling Domestic Violence Suicidal Thoughts Suicide Loss Unexpected Pregnancy Eating Disorder Rape Support Groups Depression Homelessness
What is your reason for seeking help
What specific changes would you like to see take place in your life
What are your goals for seeking help
Are you currently involved in any legal litigations?

Yes No
If yes, please explain
HIPAA Authorization Form

Please complete this form if you would like for us to share any client information, otherwise check the option to decline at the bottom of this page.

HerHaven of Light, Inc protects all of our client's private information. We will not release information to anyone unless you provide us with requested information below. HIPAA does not allow us to release any of your information to outside entities on your behalf without your written consent.

Iam authorizing the person(s) as listed below to obtain protected health information about myself. I understand that Her Haven of Light, Inc. is not responsible for the information provided as long as it's given to the person(s) that I have listed below. I am aware and understand that I may revoke this authorization in writing at any time. This form is not valid without client signature or the effective start and expiration dates.

*Date of Birth must be provided so that we can verify who we are speaking with when they call our office.
Name
Date of Birth

Month Day Year
Date
Relationship
Effective start date

Month Day Year
Date
Expiration date

Month Day Year
Date
I do not authorize Her Haven of Light, Inc. to release any of my protected health information to anyone other than the entities that are listed in the Notice of Privacy Practices.
I do not authorize Her Haven of Light, Inc. to release any of my protected health information to anyone other than the entities that are listed in the Notice of Privacy Practices.

I do not authorize
(Client's Signature)

Clear
(Date)

Month Day Year
Date
Welcome! We are honored that you would choose Her Haven of Light, Inc. to help you with your personal concerns and needs. We understand that taking this step to ask for help is not always easy. We want you to know that we are here for you and it is our goal to PROVIDE WOMEN WITH A SAFE PLACE TO LAND to help make this process as easy as possible for you.

Her Haven Of Light, Inc. is a place of hope. secured in love, formed on faith, to land in freedom. We have a heart and passion to serve women and want you to know you're never alone and have others who will meet you exactly where you are without any judgment.

This safe space was created for women by women. It's a place where women can land to get the resources and directions they need to flourish. We provide for women in need to help them find hope and begin to love who God has created them to be. This is a place of refuge and safety for women to come and feel at peace. We provide a safe, healthy, loving and sincere environment to help bring restoration and wellness to those in need. We extend our hands in love to help serve the community through our faith in Jesus Christ. This resource center is here to empower women to walk in confidence as they thrive in their today and find freedom in tomorrow.

Professional Boundaries: We have a responsibility to refrain from personal relationships with clients that would create a conflict of interest. Therefore if one of us were to come in contact with you in a personal setting, we would not engage in conversation with you in an effort to protect your confidentiality. Here at Her Haven of Light, Inc. we will not accept friend requests or interact in any way on any social media platform. If you choose to follow or like Her Haven of Light's business social media pages, you acknowledge that this may pose a risk to your confidentiality as others will see that you follow this page. Choosing to do so is completely up to your discretion.

Litigation Limitations: If you become involved in any legal disputes that must be settled in court, you are agreeing that we will not give testimonies in court on your behalf as we are not trained to make recommendations and this creates a dual relationship. You understand that should you become involved in legal proceedings, there is a potential risk that the professional relationship could be jeopardized. We have found it best that we do not become involved with legal proceedings, which include court testimonies and disclosure of your personal records.

Contacting Us: If you need to contact us, please call our office number at 919-897-8770, select the appropriate extension and leave a detailed message if we are unavailable. We will do our best to call you back within 24 hours unless it is a Holiday. Messages received after hours will be returned the next business day.

Emergencies: Due to the nature of our work, we are not always immediately available. In the event that we are unavailable and you are at risk of harming yourself or someone else, please call 911 or immediately go to your nearest hospital emergency room.

Electronic Communication Policy: Due to the confidential nature of your visits, we limit the useof correspondence via electronic methods such as text, email, etc. The scheduled times that we will use text and email to communicate with you are for appointment reminders, cancellations, rescheduling your
appointment or providing you with a list of resources. All other use of text and email is discouraged. If you do not wish to be contacted through email or text, please be sure to document so on the demographic page of this packet. Email or text is not to be used in place of an in office visit. If you reach out to us through your personal email account or an unsecure email account (Gmail, Yahoo, etc) you are acknowledging that this is an unsecure means of communication and will not hold Her Haven of Light, Inc. responsible or liable in the event the personal information you have shared with us is breached.

Confidentiality: Information disclosed during your office visits and in your records are kept fully confidential and may not be released without your written permission, except when required so by law.

Financial: Here at Her Haven of Light, Inc. we offer services at no cost to you. We are fully funded from the donations of our Sponsors and others so that we can provide you services without the financial stress and burden through extreme hardships. In no circumstances do we give out cash donations to help our clients but we do offer our services at no cost to you. We do not accept insurance so in no way will your insurance be responsible for payment of services rendered to you. However, we do request your insurance information so that we can give you referrals to the proper resources that are in network should you need counseling or medical help.

I hereby agree to all of Her Haven of Light, Inc's policies and consents. My signature below indicates that I have read and understood all of the office policies in place and I am acknowledging that I agree with the information presented to me as it is written.
Printed Name
Signed Name

Clear
Today's Date

Month Day Year
Date
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform