Sign up for Therapy

  • Therapy Sign Up

  • I am completing this form for:*
  •  - -
  • Are you completing this form for a minor for which there is shared custody?

  • Client's Demographic Information

    All questions on this form relate to the client. Thus, if you are filling out for a minor and the question says "you," it is referring to the minor client. Also, please be aware that it is the responsibility of the parents/guardians of a minor to inform The Luminous Mind if there are any stipulations relating to the legal custody or care of a minor.
  •  / /
  • Please indicate which of the following ethnic/cultural/racial identify you. Select all that apply.*
  • Do require an interpreter?*

  • Contact Information

  • Format: 000-000-0000.
  • May we leave detailed voicemails if needed?*

  • Emergency Contact Information

  • Format: 000-000-0000.
  • Would you like your provider to speak with your primary care provider? If yes, we will ask you for the provider's name and contact information.*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Familial/Relational Information

    All questions on this form relate to the client. Thus, if you are filling out for a minor and the question says "you," it is referring to the minor client.
  • Relationship Status*
  • Do you have any children?*

  • Developmental Information

    All questions on this form relate to the client. Thus, if you are filling out for a minor and the question says "you," it is referring to the minor client.
  • Which of the following have you experienced or witnessed that may have resulted in distress:
  • Please indicate if any of the followed describe your past or current educational experiences. Select all that apply.
  • Level of Education*
  • Employment status*

  • Health Information & History

    All questions on this form relate to the client. Thus, if you are filling out for a minor and the question says "you," it is referring to the minor client.
  • I am seeking*
  • I am seeking services via*
  • Indicate if you have been diagnosed with any of the following. Select all that apply.*
  • Select your current symptoms. Select all that apply.*
  • Do you have any past or current safety/risk issues (self-harm, suicidal ideation, etc)?*
  • Are you currently receiving any of the following services?*
  • Rows
  • Are you seeking services as part of a court order or relating to legal proceedings?*
  • Have you ever been arrested?*

  • Insurance Information & Authorization form

  • I understand and agree to the following:

    • I authorize the release of information from my medical record to the insurance company or other third-party payer(s) named above. This information shall include only the information necessary to submit and process claims, such as my name, date of birth, address, medical diagnosis, and services provided to me.

    • I understand that insurance billing requires a completed and signed Insurance Authorization Form. Failure to complete and sign this form will result in services being treated as self-pay and will render me financially responsible for all charges incurred.

    • This authorization shall be effective for the duration of my treatment with The Luminous Mind unless I contact the practice in writing to revoke it. If this occurs while receiving treatment, I understand that I will be asked to make other financial arrangements to cover charges.

    • I understand that I am responsible for accurately disclosing the presence of any and all insurance coverage, and that by failing to do so I accept financial responsibility if other insurance coverage is discovered at any point in the future.

    • If no insurance company is indicated, I attest to the accuracy of this information and that I will not be requesting any back billing.

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