Online Medical Consent Form
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Welcome! The information you provide will remain confidential and is intended to help me get to know you better.
Client Intake Form
For Linda K. Castor, RN, LCPC
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Date of Birth
*
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Month
-
Day
Year
Gender
Please Select
Male
Female
Email
*
Phone Number
*
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Area Code
Phone Number
Parent/Guardian or Emergency Contact Details
Contact Person Name
*
Primary Phone Number
*
-
Area Code
Phone Number
Secondary Phone Number
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Area Code
Phone Number
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
*
What is your current medical condition? Do you have any cardiovascular problems, diabetes, asthma etc.?
*
Acknowledgment, Authorization and Waiver
Client Financial Agreement
*
I authorize Linda K. Castor to provide the treatment necessary to me/or to my (for Parent/Guardian) dependent.
I understand that upon scheduling, I will receive an IvyPay invite via text, and this invite must be completed 3 hours before our session time, or I must reschedule.
If I choose to receive an electrontic superbill for out-of-network reimbursement, I understand that reimbursement for mental health services is dependent solely on the policy standards of my insurance plan, and Linda K. Castor is not involved in this process beyond generating the superbill.
I understand that a 24-hour notice is required if I need to cancel or reschedule an appointment, and that a full charge for the missed appointment will occur if I do not provide Linda K. Castor with a 24-hour notice via email to Linda@LindaCastor.com. I am aware that Linda K. Castor, upon her sole discretion, will waive this charge in the case of illness, unforseen sudden circumstance, or emergency.
I acknowledge that all information I provided in this form is true and accurate.
Confidentiality
*
I understand that the information I share with Linda K. Castor will remain confidential, unless I give her written consent.
I acknowledge Linda K. Castor is bound by legal and ethical standards to break confidentiality if she believes I am going to physically harm myself or another person or if she suspects I am abusing a child, elderly or disabled person
I am aware Linda K. Castor will not record our therapy session on audio or video without my written permission, and any information I share outside of therapy, willingly and publicly, will not be considered protected or confidential by a court of law.
I acknowledge that all information I provided in this form is true and accurate, and I agree to the policies set forth in the Client Financial Agreement and acknowledge my full understanding of my rights to Confidentiality, as stated.
Patient/Parent/Guardian Signature
*
Date Signed
*
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Month
-
Day
Year
SUBMIT
SUBMIT
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