• Therapy Sign Up

  • I am completing this form for:*
  • Date of birth of person completing this form*
     - -

  • 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.
  • Client's Date of Birth*
     / /
  • Are you seeking services as part of a court order or relating to legal proceedings?*

  • We do not provide forensic services, nor do we accept referrals whose purpose is to generate evaluations or opinions for court. Our clinicians will not voluntarily write recommendation letters or appear in legal proceedings, and any compelled appearance will be billed and coordinated through clinic administration.

  • Do require an interpreter?*

  • Contact Information

  • Format: 000-000-0000.
  • Are you currently having thoughts about harming yourself or ending your life?*

  • Your safety matters to us. If you feel at risk of acting on these thoughts right now, please seek immediate help.

    Call or text 988 — Suicide & Crisis Lifeline
    Call 911 or go to the nearest emergency room

     

  • 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 and ask you to complete a Release of Information Form.*
  • 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?*
  • Please indicate which of the following ethnic/cultural/racial identify you. Select all that apply.*

  • 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 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
  • Have you ever been arrested?*

  • Insurance Information & Authorization form

  • I understand and agree to the following:

    • I authorize The Luminous Mind and its providers to release information from my health record to any insurance company or other third-party payer that is now, or later becomes, responsible for payment of my claims — whether listed above or provided to the practice later. This includes the information necessary to submit and process claims, such as my name, date of birth, address, mental health diagnosis, and the services provided to me.
    • This authorization and assignment apply to my current insurance and to any insurance coverage I have in the future. If my coverage changes, I am responsible for promptly giving the practice my updated insurance information; I do not need to sign a new authorization for the practice to bill the new payer.
    • This authorization allows the practice to verify my eligibility for benefits and to obtain payment for the services I receive. The practice will not refuse to treat me based on whether I sign this authorization, though a signed authorization is required for the practice to bill my insurance (see below).
    • I understand that information disclosed to a payer under this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy law (HIPAA).
    • This authorization remains in effect for the duration of my treatment with The Luminous Mind unless I revoke it. I may revoke it at any time by giving written notice to the practice. Revocation will not apply to information already shared before the practice receives my written notice. If I revoke this authorization while still in treatment, I understand I will be asked to make other financial arrangements to cover my charges.
    • In consideration of the services provided to me, I assign to The Luminous Mind all insurance benefits payable for those services, and I authorize any insurance company or third-party payer responsible for my claims — current or future — to make payment directly to The Luminous Mind on my behalf.
    • Insurance billing requires a completed and signed Insurance Authorization Form on file. If this form is not signed, my services will be billed as self-pay and I will be financially responsible for all charges incurred.
    • I am responsible for accurately disclosing all insurance coverage I have. If I fail to do so, I accept financial responsibility for any charges that result if other coverage is discovered later.
    • If I have not listed an insurance company, I attest that this is accurate and that I will not later ask the practice to bill insurance for these services ("back billing").
    • If I am using Medicare benefits, I also agree to the following: I request that payment of authorized Medicare benefits be made either to me or on my behalf to The Luminous Mind for any services furnished to me by the practice. I authorize any holder of medical or other information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.
       

     

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