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WS New Client Intake Form 

WS New Client Intake Form 

Welcome!

HIPAA

Compliance

  • 1

    Helpful Information and Tips for Completing the New Client Intake Form: 

    • ​​TIP: Use a device with a large screen to fill out the form. You can use a phone or tablet to complete the form. However, the best user experience is generally on a larger screen. 

    • Official ID: Have images of the front and back of your current government issued photo ID available. You will be asked to upload these images to the form.

    • Insurance Card: Have images of the front and back of your current insurance card available. You will be asked to upload these images to the form. 

    • Information You Will Need: The following information will be needed for the form: The name and contact information of the guarantor for your care, the subscriber for your insurance, and your emergency contact.

    • TIP: The form is only available online. There is no paper version of this form.

    • TIP: To avoid potential data loss do not start the form and then leave the tab open to complete at a later time. Do not start the form and refresh your browser or allow your computer or device to go to sleep, restart, or time out. Please ensure your device or computer is updated completely or there may be "glitches" due to device issues.

    • TIP: This form will take approximately 20-30 minutes to complete. The form cannot be started and saved to complete at a later time. Please ensure you have the time to complete the form once you begin.

    • TIP: Once you click submit you will receive a confirmation message on your screen and you will receive an email confirmation that contains a copy of your completed form. If you did not receive the confirmation email then your submission was not received.

    • IMPORTANT: Questions that are required have a red * after the question. All other form elements are optional. Please provide the information you are comfortable with. We are sensitive nad understanding that many questions may cause distress and we are respectful of your triggers. 

     

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    By answering "Got it! :) I acknowledge understanding of this information.
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    By answering "Got it! :) I acknowledge understanding of this information.
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    By answering "Got it! :) I acknowledge understanding of this information.
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    By answering "Got it! :) I acknowledge understanding of this information.
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    By answering "Got it! :) I acknowledge understanding of this information.
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    By answering "Got it! :) I acknowledge understanding of this information.
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    By answering "Got it! :) I acknowledge understanding of this information.
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  • 13

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    Please provide your first and last name.
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  • 15

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  • 16
    Please provide your chosen name or nick name.
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  • 17
    Please provide your cell phone number. This number should be private to allow for scheduling and confidential communications via phone, text, and VM. PLEASE BE CAREFUL WITH FORMATTING!
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  • 18
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    Please provide your email address. This email should be private to allow for confidential communications. This email will be used to send links to your client appointments. PLEASE BE CAREFUL WITH FORMATTING!
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  • 20
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  • 21
    Please enter your date of birth in the following format XX/XX/XXXX. Wellness Solutions provides services to clients who are 18 years of age and older.
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  • 22
    Please provide your primary address below.
    Please Select
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    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    This information is required for appropriate identity verification.
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  • 24
    Please choose from the drop down menu.
    • New Client
    • Readmitting Client (It has been 2 months or more since your last appointment.)
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  • 25
    Please choose from the drop down menu.
    • Individual Counseling & Psychotherapy
    • EMDR Individual Counseling & Psychotherapy
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  • 26
    Please click on ALL appointment spots convenient to your schedule for consistent weekly appointments. The more availability you are able to provide the more likely we are to provide an appointment.
    1 of 10
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  • 27
    Please provide your answer in the space provided.
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  • 28
    Please provide the first and last name of the client's emergency contact.
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  • 29
    Please provide the cell phone number of the client's emergency contact.
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  • 30
    Please provide the email of the client's emergency contact.
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  • 31
    Please describe the emergency contract's relationship to the client.
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  • 32
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  • 33

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  • 34
    Guarantor - The individual responsible for his/her financial responsibilities for treatment services. If the client is a minor than usually one of the client's parents is the guarantor. If the client is an adult then usually the client is the guarantor. Please select the correct option from the drop-down options below.
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  • 35
    Please enter the first and last name of the client's guarantor.
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  • 36
    Please enter the phone number of the client's guarantor.
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  • 37
    Please enter the email of the client's guarantor.
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  • 38
    Please enter the address of the client's guarantor below.
    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 40
    Please choose the correct answer.
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  • 41
    Please choose the correct answer.
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  • 42
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  • 43
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    Sliding Scale Fees are discounted to assist clients who do not have insurance and would find regular fees cost prohibitive for receiving care. Sliding scale fees reduce some fees for services though they do not apply to all services.
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    Subscriber: An insurance subscriber is the person who signs up for and pays for an insurance policy. This person is also responsible for making decisions about the policy, like choosing what kind of coverage to get. This is the person who you get your insurance from. If your insurance is through a partner or parent then they are the subscriber.
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  • 47
    Please enter the first and last name of the subscriber.
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  • 48
    Please enter the subscriber's cell phone number.
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  • 49
    Please enter the subscriber's address.
    Please Select
    • Please Select
    • Afghanistan
    • Albania
    • Algeria
    • American Samoa
    • Andorra
    • Angola
    • Anguilla
    • Antigua and Barbuda
    • Argentina
    • Armenia
    • Aruba
    • Australia
    • Austria
    • Azerbaijan
    • The Bahamas
    • Bahrain
    • Bangladesh
    • Barbados
    • Belarus
    • Belgium
    • Belize
    • Benin
    • Bermuda
    • Bhutan
    • Bolivia
    • Bosnia and Herzegovina
    • Botswana
    • Brazil
    • Brunei
    • Bulgaria
    • Burkina Faso
    • Burundi
    • Cambodia
    • Cameroon
    • Canada
    • Cape Verde
    • Cayman Islands
    • Central African Republic
    • Chad
    • Chile
    • China
    • Christmas Island
    • Cocos (Keeling) Islands
    • Colombia
    • Comoros
    • Congo
    • Cook Islands
    • Costa Rica
    • Cote d'Ivoire
    • Croatia
    • Cuba
    • Curaçao
    • Cyprus
    • Czech Republic
    • Democratic Republic of the Congo
    • Denmark
    • Djibouti
    • Dominica
    • Dominican Republic
    • Ecuador
    • Egypt
    • El Salvador
    • Equatorial Guinea
    • Eritrea
    • Estonia
    • Ethiopia
    • Falkland Islands
    • Faroe Islands
    • Fiji
    • Finland
    • France
    • French Polynesia
    • Gabon
    • The Gambia
    • Georgia
    • Germany
    • Ghana
    • Gibraltar
    • Greece
    • Greenland
    • Grenada
    • Guadeloupe
    • Guam
    • Guatemala
    • Guernsey
    • Guinea
    • Guinea-Bissau
    • Guyana
    • Haiti
    • Honduras
    • Hong Kong
    • Hungary
    • Iceland
    • India
    • Indonesia
    • Iran
    • Iraq
    • Ireland
    • Israel
    • Italy
    • Jamaica
    • Japan
    • Jersey
    • Jordan
    • Kazakhstan
    • Kenya
    • Kiribati
    • North Korea
    • South Korea
    • Kosovo
    • Kuwait
    • Kyrgyzstan
    • Laos
    • Latvia
    • Lebanon
    • Lesotho
    • Liberia
    • Libya
    • Liechtenstein
    • Lithuania
    • Luxembourg
    • Macau
    • Macedonia
    • Madagascar
    • Malawi
    • Malaysia
    • Maldives
    • Mali
    • Malta
    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
    • Nigeria
    • Niue
    • Norfolk Island
    • Turkish Republic of Northern Cyprus
    • Northern Mariana
    • Norway
    • Oman
    • Pakistan
    • Palau
    • Palestine
    • Panama
    • Papua New Guinea
    • Paraguay
    • Peru
    • Philippines
    • Pitcairn Islands
    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
    • Saint Martin
    • Saint Pierre and Miquelon
    • Saint Vincent and the Grenadines
    • Samoa
    • San Marino
    • Sao Tome and Principe
    • Saudi Arabia
    • Senegal
    • Serbia
    • Seychelles
    • Sierra Leone
    • Singapore
    • Slovakia
    • Slovenia
    • Solomon Islands
    • Somalia
    • Somaliland
    • South Africa
    • South Ossetia
    • South Sudan
    • Spain
    • Sri Lanka
    • Sudan
    • Suriname
    • Svalbard
    • eSwatini
    • Sweden
    • Switzerland
    • Syria
    • Taiwan
    • Tajikistan
    • Tanzania
    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
    • Transnistria Pridnestrovie
    • Trinidad and Tobago
    • Tristan da Cunha
    • Tunisia
    • Turkey
    • Turkmenistan
    • Turks and Caicos Islands
    • Tuvalu
    • Uganda
    • Ukraine
    • United Arab Emirates
    • United Kingdom
    • United States
    • Uruguay
    • Uzbekistan
    • Vanuatu
    • Vatican City
    • Venezuela
    • Vietnam
    • British Virgin Islands
    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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  • 50

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  • 51
    EAP or Employment Assistance Plan insurance benefits are special benefits that provide a client with a specific number of free sessions before using their regular insurance benefits. To use your EAP benefits we will need the authorization number and number of sessions approved.
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  • 52
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  • 53
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  • 54
    Please take a picture of the front and back of your insurance card and then upload the pictures/images of the insurance card.
    Drag and drop files here
    Select files to upload
    Max. file size: 10.6MB
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  • 55
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  • 56

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  • 57
    Please select ALL that apply.
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  • 58

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  • 59
    Please provide your answer in the space provided. Your reply is limited to 250 characters.
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  • 60
    Please provide your answer in the space provided. Your reply is limited to 250 characters.
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    Please provide your answer in the space provided. Your reply is limited to 250 characters.
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  • 62

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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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  • 64
    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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  • 70

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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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  • 74

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  • 75
    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
    0/250
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  • 76

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  • 77
    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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  • 79
    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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  • 81
    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
    0/250
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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
    0/250
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    What leisure, hobbies, and recreational activities do you enjoy? How often do you engage in your leisure, hobbies, and recreational activities? Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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    Please select all that apply.
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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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    Please provide any information below that you would like to share that is relevant to your current symptoms and may influence your care. You may skip this question if you do not have anything to report or would prefer not to answer. Your reply is limited to 250 characters.
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    Instructions: The questions below ask about things that might have bothered you. For each question, select the circle with the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS. This is a general symptom identification tool and is not going to provide a specific diagnosis.
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    The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past 7 SEVEN DAYS. This is a general symptom identification tool and is not going to provide a specific diagnosis.
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    Please answer the below questions based on your feelings in the past 7 days. The following is the scoring range: 1. Never 2. Rarely 3. Sometimes 4. Often 5. Always
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    Please answer all questions. One answer is required for each question.
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    Notice of Privacy Practices (NOPP)

    Effective Date: 10/15/2025

    This notice explains how Wellness Solutions, LLC may use and share your Protected Health Information (PHI), and what rights you have over that information. “PHI” includes any details that identify you and relate to your physical or mental health, treatment, or payment for care.

    We are committed to protecting your privacy, treating your information with respect, and being transparent about how it is used.


    1. Your Rights

    You have rights when it comes to your health information. This section explains them in plain language.

    Get an electronic or paper copy of your records – You can ask to see or get a copy of your PHI, including electronic health information. We will provide it within 30 days or let you know if more time is needed.

    Ask us to correct your record – If you think your information is incomplete or incorrect, you can request an amendment in writing. If we deny the request, you may add a statement of disagreement to your record.

    Request confidential communications – You may ask us to contact you in a specific way (e.g., phone, email, mail) or at a specific location. We will honor reasonable requests.

    Limit what we use or share – You can ask us not to use or share certain information for treatment, payment, or healthcare operations. We may say “no” if it would affect your care, but we will always say “yes” if you pay out-of-pocket in full for a service and request that we not disclose it to your health plan.

    Get a list of disclosures – You can request a list of times we shared your PHI (up to six years prior), excluding disclosures for treatment, payment, healthcare operations, or those you authorized. One list per year is free.

    Get a copy of this notice – You can request a paper copy at any time, even if you’ve agreed to receive it electronically. It is also available on our website: www.wellnesssolutionsllc.com.

    File a complaint without retaliation – If you feel your privacy rights have been violated, you can file a complaint with us or with the U.S. Department of Health and Human Services. We will never retaliate against you for exercising your rights.

    2. Our Responsibilities

    We are required by law to:

    • Maintain the privacy and security of your PHI.
    • Notify you if a breach occurs that may have compromised your information.
    • Follow the duties and practices described in this notice.
    • Not use or share your PHI other than what is described here, unless you provide written permission. You may revoke your permission at any time in writing.

     

    3. How We Use and Share Your Information

    We typically use and share your PHI in these ways:

    Treatment – To provide, coordinate, or manage your care, and to communicate with other providers involved in your treatment.

    Payment – To bill and receive payment from your health plan or other responsible party.

    Healthcare operations – To run our practice, improve services, and train staff.
    Other reasons we may use or share your PHI (as required or allowed by law):

    • Public health and safety (preventing disease, reporting adverse events, recalls).
    • Reporting abuse, neglect, or domestic violence.
    • Health oversight (audits, inspections, investigations).
    • Legal proceedings (court orders, subpoenas).
    • Research (with approved safeguards).
    • Organ/tissue donation, coroners, funeral directors.
    • Workers’ compensation, law enforcement, and national security.
    • To prevent or reduce a serious and imminent threat to health or safety.

     

    4. Other Uses of Your Information

    Family and friends involved in your care – With your permission, or if you are unable to agree and it is in your best interest.

    Emergencies – If you are unable to provide consent, we may share information to ensure you receive care.

    Fundraising and community outreach – We may contact you about community programs or fundraising. You may opt out at any time.

    5. Questions, Concerns, or Complaints

    If you have questions about this notice, or believe your privacy rights have been violated, please contact:

    Corporate Privacy Officer
    Wellness Solutions, LLC
    Attn: Danielle C. Ellis, MA, MCJ, LPC, NCC
    Phone: (713) 893-3989 (Mon-Fri, 9 AM – 5 PM CST)
    Email: Admin@wellnesssolutionsllc.com
    Address: 8000 Research Forest Dr, Ste 115 PMB 1168
    The Woodlands, TX 77382

    You may also file a complaint with:
    U.S. Department of Health and Human Services, Office for Civil Rights
    200 Independence Avenue, S.W., Washington, D.C. 20201
    Phone: 1-877-696-6775
    Website: www.hhs.gov/ocr/privacy/hipaa/complaints/

    We will not retaliate against you for filing a complaint.

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    Client Rights, Expectations, & Responsibilities

    At Wellness Solutions, LLC, we believe that counseling is most effective when you feel respected, informed, and actively involved in your care. This document outlines your rights as a client, as well as what we ask from you to support a successful therapeutic relationship.


    Your Rights as a Client

    As a client, you have the right to:

    • Receive care without discrimination – You will never be denied services based on age, race, ethnicity, gender, gender identity, sexual orientation, religion, national origin, disability, or any personal characteristics.
    • Be in a safe and respectful environment – You are entitled to a space that is free from abuse, neglect, exploitation, or harm, where your privacy and dignity are protected.
    • Be informed about your treatment – You have the right to know the goals, benefits, risks, and alternatives of treatment. You may refuse any service, and your provider will explain possible consequences.
    • Take part in treatment planning – You are encouraged to actively shape your treatment plan and request changes whenever needed.
    • Have your information kept private – Your confidentiality is protected by law. Information will only be shared with your written consent or as legally required (such as in cases of safety or mandated reporting).
    • Withdraw consent at any time – You may change your mind and withdraw permission you’ve given for treatment or information-sharing.
    • Know your provider’s background – You have the right to know about your provider’s qualifications, training, and credentials.
    • Explore treatment options – You may ask about different approaches and request a second opinion or referral.
    • Plan for discharge – You will be involved in decisions about when and how treatment ends.
    • Raise concerns safely – You can file complaints or grievances without fear of retaliation, and you will receive a fair and timely response.
    • Be respected as the decision-maker – You are the expert in your own life. Your autonomy, values, preferences, and cultural background will be honored.
    • Receive clear communication – Explanations will be provided in plain language you can understand. Interpreters or alternative formats will be offered if needed.

     

    Your Role in Treatment

    For therapy to work best, your active involvement matters. As a client, you are expected to:

    • Keep appointments – Attend sessions on time and provide reasonable notice if you need to reschedule or cancel.
    • Participate fully – Engage honestly in therapy, complete agreed-upon assignments, and share your progress or challenges with your provider.
    • Take financial responsibility – Understand your insurance benefits and network status, and pay for services as agreed, regardless of insurance reimbursement.
    • Communicate openly – Let your provider know if your needs aren’t being met, if you have concerns about your care, or if something changes in your health or circumstances.
    • Follow treatment recommendations – Work collaboratively with your provider to follow through on the plan, including referrals to other services when appropriate.
    • Report safety concerns – Tell your provider if you experience thoughts of self-harm, suicidal urges, or any situation that may place you or others at risk.
    • Respect boundaries – Uphold the professional boundaries of the therapeutic relationship and the policies of Wellness Solutions, LLC.
    • Be honest and accurate – Provide complete and truthful information about your health, symptoms, and history.
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    Introduction to Informed Consent & Disclosures

    At Wellness Solutions, LLC, informed consent is an ongoing conversation—not just a form. It means we’ll explain how therapy works, answer your questions, and check in regularly so you can make choices that feel right for you.

    Qualifications of Owner & Staff

    About Our Owner
    Wellness Solutions, LLC was founded by Danielle C. Ellis, MA, MCJ, LPC, NCC. She is a Licensed Professional Counselor (LPC) in Texas (License #63315) and a National Certified Counselor (NCC) with the National Board of Certified Counselors. For more about her background, education, and professional experience, please visit our website: www.WellnessSolutionsLLC.com.

    Our Team
    Every clinician at Wellness Solutions meets or exceeds licensure and training requirements for their role. All staff—clinical, administrative, and support—are trained to uphold the highest standards of ethics, professionalism, and client care.

    Our commitment is to ensure that you are always supported by qualified, compassionate professionals who respect your privacy, dignity, and wellbeing.

    Emergency and Crisis Information

    Wellness Solutions, LLC is not an emergency or crisis service. If you are ever in immediate danger or feel unable to keep yourself safe, please call 911 or go to the nearest emergency room right away.

    If your needs are urgent and cannot wait for your next scheduled session, please use one of the following options:

    • Call 911
    • Go to your nearest emergency department
    • Visit our website’s Safety Resources page for a list of 24/7 crisis hotlines and emergency contacts
    • Our services are designed for outpatient care. If your symptoms become so severe that you require immediate or emergency support, we will work with you to connect you to a higher level of care that can better meet your needs.
    • Your safety is our priority, and we want you to always have clear steps to take if you are in crisis.

     

    Respectful and Safe Environment

    At Wellness Solutions, LLC, we work hard to create a space that feels peaceful, safe, welcoming, and supportive—for both clients and staff. We value compassion, openness, and respect, and we ask everyone who enters our community to help maintain that spirit.

    All members of our team—clinical, administrative, and billing—deserve to be treated with kindness, dignity, and professionalism, just as you deserve the same from us.

    We understand that therapy can bring up difficult emotions. Still, staff are not expected to accept disrespectful, threatening, or abusive behavior. If such behavior occurs, we may need to pause services or end the therapeutic relationship in order to protect the safety and wellbeing of everyone involved.

    Our goal is to preserve a healing environment where clients feel cared for and staff feel supported, so that true progress can take place.

    Managing Your Appointments and Care

    As an adult client, you are in charge of your own treatment and scheduling. This means you are responsible for:

    • Scheduling and attending your own appointments
    • Communicating directly with us about billing, insurance, and administrative matters
    • Taking an active role in your care
    • To protect your privacy, we do not discuss your treatment, scheduling, or billing with anyone else without your written permission. If you would like a trusted person (such as a spouse, family member, or caregiver) to help manage your appointments or billing, you may complete an Authorized Contact Form giving us consent to communicate with them.
    • Our goal is to help you feel empowered in your care while also protecting your confidentiality.

     

    Telehealth Services

    All sessions at Wellness Solutions, LLC are provided by secure telehealth video.

    How it works:

    • At the start of each scheduled session, your clinician will email you a unique, one-time-use link.
    • Links are sent only to the email you provided during intake.
    • For your privacy and security, links are not reused between sessions.

     

    Preparing for your session:

    To make the most of your time, please:

    • Use a reliable device and internet connection.
    • Join from a private, quiet, and stationary location where you feel comfortable.
    • Make sure you are able to focus fully without multitasking.

     

    Important safety reminders:

    • Sessions cannot be held while driving, operating machinery, or in public/semi-public places.
    • If you take a call, multitask, or are in a space where confidentiality cannot be maintained, your session may need to end early—and the full session fee may still apply.
    • We want telehealth to feel just as safe and supportive as meeting in person. Choosing a private and distraction-free setting helps protect your confidentiality and ensures the best possible care.

     

    Understanding Counseling, Therapy, and Coaching

    We want you to feel confident about the type of care you are receiving. Here’s a simple overview of what these terms mean in our practice:

     

    Counseling & Therapy

    • Counseling generally focuses on support for life stressors, relationships, and personal growth.
    • Psychotherapy (often called “therapy”) addresses mental health conditions or emotional difficulties using clinical approaches.
    • These terms are often used interchangeably. In general, counseling may focus on everyday challenges, while psychotherapy often involves diagnosis and treatment of mental health conditions.
    • Both aim to reduce distress, build coping skills, and improve daily functioning.
    • Services are provided by licensed mental health professionals who are trained, supervised, and required to follow ethical and legal standards.
    • Therapy provides important protections such as confidentiality, privacy, and privileged communication.
    • In many cases, therapy is a covered benefit by insurance.

     

    Treatment

    • The words treatment or therapy may be used interchangeably with counseling or psychotherapy.
    • Treatment plans are tailored to your needs, using evidence-based practices that have been proven effective.

     

    Coaching

    • Coaching is different from counseling and therapy. Coaching focuses on goals, strengths, and personal growth—not on diagnosing or treating mental health conditions.
    • Coaching can help with things like developing strategies, enhancing wellness, or planning for future goals.
    • Coaching does not provide the same confidentiality protections or insurance coverage as counseling/therapy, since it is not considered mental health treatment.
      Some providers may use coaching strategies alongside counseling, but it is not a substitute for therapy when mental health treatment is needed.

     

    The Therapeutic Process

    Therapy is a collaborative journey where you and your provider work together toward your goals. While each person’s experience is unique, the process often includes:

    • Building strengths – discovering and using the skills and abilities you already have.
    • Learning new tools – such as coping strategies, problem-solving, boundary-setting, communication, and stress management.
    • Receiving feedback and support – in ways that are encouraging, respectful, and honest. Sometimes this may include gentle challenges to unhelpful thoughts or behaviors.
    • Exploring deeper issues – including past experiences, trauma, values, or beliefs that may influence your present life.
    • Developing awareness – noticing your thoughts, feelings, and behaviors in new ways that bring insight and choice.
    • Creating change – setting goals, taking steps toward them, and holding yourself accountable with support from your provider.
    • Healing and growth – having a safe, non-judgmental space to process difficult emotions, reframe experiences, and strengthen resilience.
    • Outcomes You May Experience - The purpose of therapy is to help you feel better, function more effectively, and live in alignment with your values and goals.
    • Outcomes may include - Reduced distress and symptoms, Improved relationships and communication, Increased self-esteem, confidence, and coping skills, Stronger resilience and resourcefulness, and Greater satisfaction and wellbeing in daily life.

     

    The Therapeutic Relationship & Professional Boundaries

    Therapy is a unique kind of relationship. While it may feel personal and deeply meaningful, it is also a professional relationship designed to support your growth, healing, and wellbeing.

    What You Can Expect
    The therapeutic relationship is private, confidential, and non-judgmental. It is a safe space where you can explore thoughts, feelings, and experiences that may be sensitive, difficult, or painful.

    Your values, beliefs, and dignity are respected. Therapy focuses on what matters to you—not on the provider’s personal beliefs or opinions.

    Your provider’s role is to offer evidence-based support, feedback, and guidance rooted in professional training and ethics.

    Boundaries That Keep Therapy Safe
    The therapeutic relationship is professional, not personal. While it may feel emotionally close at times, it is not a friendship and is not meant to extend beyond your sessions.
    Communication outside of sessions is limited to professional or clinical matters.

    To avoid conflicts of interest and maintain fairness, providers do not accept gifts, barter services, or form dual relationships (such as social, business, or family relationships with clients).

    If we see each other outside of session, your provider will not acknowledge you unless you choose to acknowledge them first—this helps protect your confidentiality.

    Why Boundaries Matter
    These boundaries exist to protect you and ensure that therapy remains a safe, ethical, and effective process. They allow your provider to give you impartial, objective, and professional support.

    If you ever have questions or concerns about boundaries, please bring them up directly. You are also welcome to report any concerns about professional conduct to your provider’s supervisor or the appropriate licensing board.

     

    The Therapeutic Journey and Motivation

    Therapy is a personal journey of growth and change. It’s a place to develop insight, awareness, and skills that help you think, feel, and live in ways that are healthier, more resilient, and more fulfilling.

     

    Your Role
    For therapy to be effective, your active participation is essential. Progress happens when you:

    • Show up consistently and engage honestly
    • Practice new skills and strategies between sessions
    • Share openly about what’s working and what feels challenging
    • Stay committed to the process, even when it feels difficult
    • Talking through problems is an important first step, but real change often comes from putting insights into practice in your daily life.

     

     

    Our Role
    Your provider serves as a guide, support, and partner in the process. We bring professional knowledge, evidence-based strategies, and a safe space for exploration. But ultimately, the work of change belongs to you.

     

     

    Realistic Expectations
    Change takes time and effort—it’s rarely instant or linear. Some steps may feel small, while others may feel like big leaps. Together, we’ll set realistic goals and celebrate progress along the way.

     

    Services We Provide & Who We Serve

    At Wellness Solutions, LLC, we offer outpatient counseling and psychotherapy for a wide range of concerns, including:

    • Mild, moderate, and some severe mental health conditions
    • Substance use and recovery support
    • Eating disorders
    • Self-harm behaviors
    • Life stressors, relationship challenges, and other everyday concerns

     

    How Services Are Offered

    • By appointment only – we do not accept walk-ins.
    • Telehealth sessions – all services are provided virtually. 

     

    Additional Services

    • Coaching – We also offer coaching, grounded in positive psychology, to help clients focus on strengths, goals, and overall wellbeing. Coaching is not a substitute for therapy but can be a helpful complement.
    • Community involvement – We are proud to participate in community-based activities such as food and clothing drives, toy drives, workshops, and advocacy efforts in mental health, education, and disability awareness.

     

    Voluntary Services

    At Wellness Solutions, LLC, all services are provided on a voluntary basis. This means:

    • You have the right to accept or decline services at any time, for any reason.
    • You may withdraw your consent for treatment whenever you choose.
    • Your participation in therapy is always your decision.

     

    Our Responsibilities

    We are committed to providing safe, ethical, and effective care. In some circumstances, we may decide that continuing services is not in your best interest. We may end services or provide referrals if:

    • Treatment recommendations or safety plans are not being followed
    • Payment responsibilities are not met
    • Your needs require a higher level of care or a service outside our scope
    • Continuing the relationship is otherwise deemed inappropriate or unsafe

     

    Important Limitations

    • We do not provide court-ordered, mandatory, or forensic services (such as custody evaluations, testimony, or legal case involvement).
    • Our services are designed for outpatient, voluntary care only.
    • Our goal is to ensure that therapy is a collaborative, respectful, and empowering process. If services need to end, we will discuss this with you and, whenever possible, provide appropriate referrals to support your next steps.

     

    Modalities of Treatment

    At Wellness Solutions, LLC, our clinicians use a variety of evidence-based approaches—meaning they are supported by research and shown to be effective. The specific methods used in your care will depend on your needs, preferences, and goals.

     

    Some of the approaches we may use include:

    • Cognitive Behavioral Therapy (CBT): Identifying and changing unhelpful thoughts and behaviors
    • Dialectical Behavior Therapy (DBT): Building skills in mindfulness, emotion regulation, distress tolerance, and healthy relationships
    • Eye Movement Desensitization and Reprocessing (EMDR): A structured therapy often used for trauma recovery
    • Rational Emotive Behavior Therapy (REBT): Exploring how beliefs influence feelings and behaviors
    • Person-Centered Therapy: Creating a supportive, non-judgmental environment that empowers you to make change
    • Mindfulness-Based Therapies: Using awareness and presence to reduce stress and improve wellbeing
    • Skills-Based Interventions: Such as boundary setting, communication skills, and assertiveness training
    • We are committed to using therapies that are backed by science and tailored to your unique situation. Your provider will talk with you about which approaches may be most helpful and include you in the decision-making process.

     

    What to Expect in a Session

    Length of sessions: Most sessions last about 45–50 minutes. If a session goes over this time, additional fees may apply, and insurance typically does not cover the extra time.
    What happens in sessions: Sessions are a time for you and your provider to work together on the concerns that matter most to you. This may include:

    • Talking through problems, symptoms, or challenges
    • Exploring coping strategies, problem-solving skills, and stress management tools
    • Strengthening communication, boundaries, and relationships
    • Identifying and using resources and supports in your daily life
    • Reviewing and practicing new skills
    • Between sessions: Sometimes, your provider may suggest activities to support your progress outside of session—like worksheets, readings, apps, journaling, or other exercises. These are designed to help you apply what you’re learning and move toward your goals.
    • Personalized approach: Every person is different. Your provider will tailor sessions to your needs, goals, and learning style, using resources and methods that work best for you.
    • Your role in guiding sessions: To get the most out of therapy, it helps to come prepared with one or more topics you’d like to focus on. While your provider may guide the conversation, therapy works best when you take an active role in shaping what we talk about each session.

     

    What to Expect in Your Sessions

     

    First Session (Intake)
    Your first session is about getting to know you and laying a foundation for your care. During this time, your provider will:

    • Review informed consent and answer any questions you have
    • Ask about your history, current concerns, strengths, and goals for therapy
    • Begin an assessment to better understand your needs
    • Work with you to set expectations and start shaping a treatment plan
    • This session is also a chance for you and your provider to build rapport and see how working together feels.

     

    Future Sessions
    In ongoing sessions, you and your provider will work together on the issues and goals that matter most to you. This may involve:

    • Exploring symptoms, concerns, or challenges
    • Identifying strengths and resources you can draw on
    • Learning and practicing coping strategies, problem-solving, and decision-making skills
    • Using therapeutic techniques to reduce distress and support progress toward your goals
    • Sessions may sometimes feel uplifting and energizing, and at other times they may feel heavy or emotionally challenging. This is a normal part of the process of growth and healing.

     

    Your role:

    Share openly about your concerns, safety issues, and progress (including suicidal thoughts, self-harm urges, psychotic symptoms, or other safety risks if they arise).
    Bring one or more topics you’d like to focus on. While your provider can guide the conversation, therapy works best when you take an active role.

     

    Treatment Duration and Progress
    The length of time you spend in therapy depends on many factors, including:

    • The nature and severity of your concerns
    • Your treatment goals
    • Your motivation, participation, and support system
    • Access to resources and consistency in attending sessions

     

    Typical examples:

    • Short-term, solution-focused therapy for everyday stressors may last about 10 sessions.
    • Moderate to severe mental health or substance use concerns may last 35–50 sessions over a year or more.
    • Concerns such as trauma recovery, eating disorders, psychosis, or self-injury often require longer-term treatment.
    • Progress is measured by how well you are meeting your treatment goals. Goals are reviewed regularly and can be updated as new needs or priorities arise. It’s normal for goals to shift over time as you grow and discover new areas you’d like to work on.

     

    What to Expect in Ongoing Sessions
    After the first session, your future sessions will focus on the issues, goals, and skills that are most important to you. Together with your provider, you may:

    • Talk through current challenges, symptoms, or concerns
    • Identify and build on your personal strengths and resources
    • Learn and practice coping skills, decision-making strategies, and problem-solving tools
    • Explore patterns in thoughts, feelings, and behaviors that may be helping or hurting your progress

     

    What Sessions May Feel Like
    Therapy can bring up a wide range of emotions. Some sessions may feel encouraging and energizing, while others may feel emotionally heavy, tiring, or even uncomfortable. This is a natural part of the healing process, and your provider will support you through it.

     

    Your Role
    To make the most of your sessions, it helps to:

    • Share openly, especially if you experience safety concerns (such as suicidal thoughts, urges to self-harm, thoughts of harming others, or symptoms of psychosis).
    • Come prepared with one or more topics you’d like to discuss. While your provider may guide the conversation, therapy works best when you take an active role in deciding what’s most important to focus on.

     

    Our Role

    • Your provider may guide or redirect sessions at times to focus on symptoms, skill-building, or interventions that support your goals. Therapy is a collaborative process—you bring the expertise about your life, and your provider brings professional tools and support to help you move forward.

     

    Treatment Duration and Progress

    The length of time someone spends in therapy varies from person to person. Factors that can influence treatment duration include:

    • The type and severity of concerns you are facing
    • Your treatment goals
    • How consistently you attend and participate in sessions
    • The support systems and resources available to you
    • Therapy is most effective when clients engage honestly, openly, and with commitment to the process. Progress often depends not only on what happens in session, but also on the effort made between sessions.

     

    Examples of what treatment length may look like:

    • Short-term therapy for specific, everyday stressors may last around 10 sessions.
    • Moderate to severe concerns, including mental health or substance use issues, may last 35–50 sessions or more over the course of a year.
    • More complex needs—such as trauma recovery, eating disorders, psychosis, or self-injury—often require longer-term treatment.
    • Your goals and progress will be reviewed regularly with your provider. Goals may change over time, and that’s normal—many clients discover new priorities as they grow. You and your provider will collaborate to adjust your plan so it continues to meet your needs.

     


    Services We Do Not Provide

    While Wellness Solutions, LLC offers a wide range of counseling and psychotherapy services, there are certain services and situations we are not able to support. We want to be transparent so you know from the start if your needs may be better served elsewhere.

     

    We do not provide:

    • Court-ordered or mandatory treatment
    • Forensic services, including court testimony, custody evaluations, home assessments, or fitness-for-duty evaluations
    • Psychological or neurological testing
    • Workers’ compensation, disability, or FMLA evaluations or documentation
    • Emergency or crisis services, including 24-hour crisis intervention
    • In-home or off-site therapy services

     

    Treatment for certain conditions or circumstances, including:

    • Anger management or impulse control disorders as a primary focus
      Sexual addiction, compulsive gambling, or sexual dysfunction as a primary focus
      A history of violent behavior, threats, or current/past restraining orders (as defendant/perpetrator)
    • Developmental disorders or early childhood diagnoses as a primary focus
      Substance use services: We support abstinence-based recovery models, including the 12-Step approach and other evidence-based methods. However, we do not provide or support methadone or Suboxone maintenance programs.

     

    If your needs fall outside of what we provide, we will do our best to connect you with resources or referrals that may be a better fit.

    Risks Associated With Treatment: 

    It is important to be aware that counseling, psychotherapy, and treatment have potential benefits and risks associated with treatment. 

    Sessions involve discussions of potentially sensitive information surrounding relationships, trauma, personal or emotional issues, and exploring painful psychological experiences which may be difficult to cope with and potentially cause distress. There are times when counseling and psychotherapy can cause emotional distress as you will be addressing issues that may have been upsetting in the past. Discussion of previous distressing events and feelings may include re-experiencing these events and possibly recalling information that one did not remember previously which can cause increased negative feelings, symptoms, and functional impairments. Therefore, one should know that there are risks involved with seeking treatment. 

    If the client begins to experience an increase in symptoms it is very important to inform your provider. There is the possibility that a client may experience an increase in symptoms, resolve some symptoms only to develop new symptoms, or have unintentional or unforeseen consequences as a result of engaging in the therapeutic process. There are times when personal growth and development are preceded by emotional discomfort. Upon knowledge that treatment may be increasing distress, the client and provider can work together collaboratively to ensure that the client’s treatment plan, safety plan, coping skills, support system, and resources address the client’s needs to address these clinical issues and reduce distress. 

    Sessions can significantly reduce the number of symptoms or impairment in functioning a client is experiencing, improve relationships, and or resolve specific areas of concern or distress. While counseling, psychotherapy, and coaching have the potential to improve quality of life, there are occasions in which you may experience increased symptoms until sufficient progress is achieved. 

    Counseling and psychotherapy, itself, may not resolve all concerns and symptoms. The attainment of treatment goals is dependent on multiple factors including the quality of work from the client, the client’s support system, the client’s access to resources, the client’s ability to access healthcare, and many others. In the event, a client does not experience positive progress, especially once made aware of concerns regarding a resurgence in symptoms, and treatment plan changes have been sufficiently pursued, then it may become necessary to refer the client to an alternate provider. 

    Please be aware, to derive maximum benefit from treatment and the counseling relationship it is imperative to engage with honesty, transparency, motivation, willingness to change, and take ownership and responsibility for one’s thoughts, feelings, and behaviors. 

    Wellness Solutions, LLC is not able to make any type of guarantee for any specific results regarding counseling outcomes or treatment goal attainment. It is unethical and illegal for licensed mental health professionals to make guarantees or promises regarding treatment results, cures, or offer misleading or false expectations regarding treatment outcomes. 

    There may be clinical situations or circumstances where a client may require a referral to a higher level of care to stabilize his/her symptom severity and decompensation in functioning. Wellness Solutions, LLC may recommend alternative providers or treatments based on a client’s lack of therapeutic progress or decompensation in function in order to ethically attend to the client’s needs. Examples of potential treatment alternatives may include the following: A referral to another outpatient provider who specializes in the area of expertise relevant to the client’s presentation of symptoms, referral to a higher level of care such as an intensive outpatient program (IOP), partial hospitalization program (PHP), residential treatment program (RTC), or inpatient level of care for acute stabilization (IP), and/or referral to neuropsychological testing for diagnostic testing, and/or referral to a psychiatrist for a consultation to determine if medication management is clinically indicated. 

     

    Client Administrative Discharge, Client Termination, Financial Discharge, & Self-Discharge From Services:  

    Clients who self-discharge, cancel upcoming appointments and do not reschedule appointments, or no show for appointments, and do not respond to outreach are considered self-discharged from care or an administrative discharge from care.
    In order to ensure discharged clients do not incur any considerations regarding abandonment, please be aware that the proper referrals are contained herein, and that Wellness Solutions, LLC provides proper termination when the client verbalizes a desire to terminate care and requests proper termination as appropriate. Proper termination includes three termination sessions. If a client chooses to terminate care by canceling up-coming appointments or not responding to outreach then they forfeit proper termination sessions. 

    Clients who have not had an appointment for more than 2 months or 60 days are considered discharged from care administratively. 

    • If a former client would like to re-admit to care then they are welcome to do so as long as they are in good standing and were not terminated from care.
    • If a client self-discharges from care and the client would like to receive discharge disposition information or referrals to another provider the client is responsible for contacting Wellness Solutions, LLC to request the aforementioned information.
    • Clients do not receive specific individualized discharge disposition information unless the client terminates appropriately. Proper termination includes but is not limited to, the client discharges as part of a therapeutic agreement and successful achievement of treatment goals with the provider or unless the client contacts the provider and requests specific individualized discharge disposition information.
    • The client will find referral resources contained herein should the client require or need outpatient resources and referrals and the client opts to self-terminate care without receiving discharge recommendations. 
    • The referral resources contained herein act as discharge disposition in the absence of a termination session and/or a discharge termination summary or documentation and absolves any/all provider(s) of abandonment responsibilities.
    • The client agrees to hold harmless Wellness Solutions, LLC from any and all concerns pertaining to improper termination, improper discharge, or abandonment when a client discharges administratively, financially, or without the proper transition of care.
    • In the closing phase of the treatment process, a client may decrease the frequency of sessions as the necessity or need for services also decreases. It is helpful to discuss and process the pending discharge from care which is also referred to as client termination so a client may have the opportunity to reflect and process on his/her treatment journey.
    • It is beneficial to utilize the treatment environment and client termination process to identify one’s views on change, achievement, struggles, and most importantly have the opportunity to experience grief through a relationship ending.
    • Discharge from care based on achieving treatment objectives and goals is a positive outcome; however, many clients encounter uncomfortable emotions as they participate in the termination process as the therapeutic relationship is both professional and a very emotionally meaningful and powerful relationship. Therefore, the client is encouraged to terminate appropriately in order to avoid emotional unfinished business. A client may discharge from treatment at any time. However, engaging in the termination process assists a client to appropriately say goodbye in a purposeful and meaningful way.
    • Clients who discharge from care are welcome to return to care should new areas of concern arise, they recognize that they may benefit from returning to treatment, and they are in good standing.
    • Clients who discharge from care based on achieving treatment objectives and goals will receive a specific individualized discharge disposition with instructions regarding how they should continue their progress and include referrals and resources to assist the client. 

     

    Client Disposition & Discharge Referral Information: 

    The following is the recommended resources and generalized administrative discharge, financial discharge, and clinical discharge information for all clients who choose to self-discharge: 

    • Call/follow-up with your Primary Care Physician (PCP) or family doctor.
    • Call/follow-up with your psychiatrist or mental health prescriber.
    • Call the 800 number for one’s insurance company (found on an insurance card) and request a list of in-network providers
    • Visit the member website for one’s insurance company to perform an online search for in-network outpatient providers.
    • Visit www.psychologytoday.com , www.goodtherapy.org , or www.theravive.com to search for and find outpatient providers.
    • Call Family Psychiatry of The Woodlands (281-367-1015) or visit http://www.woodlandspsych.com/
    • Call The Woodlands Behavioral Health and Wellness Center (281-528-4226) or visit http://www.addwoodlands.com/
    • Call Lone Star Family Health Center (936-539-4004) or visit https://www.lonestarfamily.org/
    • Call 988 for mental health cisis support, information, and resources.
    • Visit the Wellness Solutions, LLC website for mental health and substance abuse resources, support, information, and referrals in Texas and Puerto Rico for an extensive list of helful providers. 

     

    Privacy, Confidentiality, and Privilege

    Your privacy is very important to us. We want you to feel safe and comfortable sharing personal information in therapy. Below is a clear explanation of how your information is protected, and the few situations where we may be required by law to share it.

     

    Privacy
    Privacy means you have the right to decide who has access to your personal information. If you give us permission to share your information with someone else (for example, another provider or family member), we will only share what is necessary and only within the limits you approve in writing.

     

    Confidentiality
    Confidentiality is our professional and ethical duty to keep the information you share in therapy private. In most cases, we cannot share your information without your written consent. However, there are some exceptions required by law, including:

    • If you are at risk of harming yourself or someone else
    • If we suspect abuse, neglect, or exploitation of a child, elderly person, or vulnerable adult
    • In these situations, we are required to share information with the proper authorities to protect safety.

     

    Privilege
    Privilege is a legal protection that generally prevents your private therapy information from being shared in court or legal proceedings. There are some legal limits to privilege, but in most cases your records are protected.

     

    Our Commitment
    At Wellness Solutions, LLC, we are committed to protecting your privacy and confidentiality. We will always:

    • Follow all ethical and legal guidelines for safeguarding your information
    • Only share information with your written consent (except in the specific situations required by law)
    • Inform you about your rights and answer any questions you have regarding your privacy
    • If you are in an emergency situation or crisis situation you can refer to the Wellness Solutions, LLC website for resources, or go to the nearest emergency room.
    • If you are in need of emergency or crisis resources then please refer to the Wellness Solutions, LLC website and click on the “Safety Resources” tab for extensive information that can be of assistance. http://www.WellnessSolutionsLLC.com This information is also available on the Wellness Solutions, LLC website under the “Safety Resources” tab. 


    EMDR Therapy


    What EMDR Is:
    Eye Movement Desensitization and Reprocessing (EMDR) is a specialized therapy approach used to help people process and heal from distressing or traumatic memories. It involves recalling memories while using bilateral stimulation (such as guided eye movements, tapping, or sounds).

     

    What to Expect:

    • Many people find EMDR helpful, but results vary.
    • It is common to feel temporary emotional discomfort or increased distress during or after sessions as your brain works through difficult material.
    • These effects are usually short-term and often lessen as therapy continues.
    • EMDR is not a “quick fix,” and progress looks different for everyone.
    • Open communication with your therapist is essential—we will adjust the pace and methods to keep the process safe and manageable.

     

    Important to Know:

    • EMDR is one tool among many, and sometimes additional or different forms of therapy may be recommended.
    • Confidentiality applies to EMDR therapy as with all services, though (as with all therapy) there are limits in cases of safety risks.
    • While EMDR can be highly effective, no specific outcomes can be guaranteed.


    Client Safety

    Your safety and wellbeing are our highest priority. To provide the best care, it is important that you share openly and honestly with your provider, especially if you are:

    • Not following your treatment plan or prescribed medications
    • Using or misusing substances (illegal, prescription, or over-the-counter)
    • Actively engaging in self-harm or unsafe behaviors
    • Experiencing abuse or harming others
    • Relapsing on alcohol, drugs, or eating disorder behaviors
    • Not sharing this information can increase risk to you and others and may result in discharge from services.

     

    Our Commitment:

    • We take threats of harm to self, others, or the public very seriously.
    • If there are safety concerns, we are ethically and legally required to act, which may include breaching confidentiality to protect you or others.
    • We will always make every effort to work with you on a safety plan and treatment adjustments first.
    • Therapy works best when there is honesty, trust, and active participation. Your role is to share openly; our role is to support you with skill, care, and compassion.


    Privacy in the Therapy Space

    To protect your confidentiality and the integrity of the therapeutic relationship:

    • Recording of any kind (audio or video) during sessions is not allowed.
    • This applies to telehealth sessions and any interactions with Wellness Solutions, LLC staff.
    • This policy ensures your privacy, helps maintain a safe space for open sharing, and protects both clients and providers.

    Grievances, Concerns, and Complaints

    At Wellness Solutions, LLC, your feedback matters. We believe concerns, complaints, or suggestions are valuable opportunities to improve the quality of care and strengthen our services.

    How to Share a Concern
    If you ever have a concern about your care, we encourage you to:

    Talk directly with your provider about the issue, if you feel comfortable. Often, many concerns can be addressed quickly through open conversation.

    Contact our Administrator by phone at (713) 893-3989 or by email at Admin@WellnessSolutionsLLC.com or Clinical@WellnessSolutionsLLC.com. Please include:

    • A description of your concern
    • Any suggestions you have for resolving it
    • We ask that concerns be raised within 30 days of the event, so we can respond in a timely and meaningful way.

    Our Response Process

    • Once we receive your concern in writing, we will review it carefully and may reach out for more information.
    • We aim to respond within 14 business days with next steps or a resolution.
    • If the issue cannot be resolved informally, we may recommend a neutral third-party mediation process. Mediation is voluntary and intended to provide a fair way to resolve concerns when needed.
    • Your Rights - You always have the right to file a complaint directly with the Texas State Board of Examiners of Licensed Professional Counselors: P.O. Box 141369, Austin, Texas 78714-1369 Phone: 1-800-942-5540 Website: https://www.dshs.texas.gov/counselor/lpc_complaint.shtm
    • Wellness Solutions, LLC will never retaliate against you for raising a concern or filing a complaint.

     

    Social Media Policy

    Wellness Solutions, LLC maintains a professional website and may use social media or referral sites to share resources, updates, and information about our services.

    • No requirement to participate: Clients are not required to follow or engage with any of our social media.
    • Privacy limitations: If you choose to engage with our social media, please be aware that these platforms are public. This means your participation (likes, comments, reviews, or shares) is not confidential and may be visible to others.
    • Our role: While we take care to protect client privacy in all clinical settings, we cannot guarantee privacy or confidentiality for information you choose to share publicly online.
    • Feedback and surveys: At times, we may invite clients to complete surveys for quality improvement. If feedback is shared in marketing or on social media, we will ensure personal information and Protected Health Information (PHI) is not disclosed.
    • Your decision to participate in social media or online activities related to Wellness Solutions, LLC is completely voluntary.

     


    Protection of Staff, Clients, and the Therapeutic Environment

    We are committed to creating and maintaining a safe, respectful, and supportive environment for all clients, families, staff, and guests of Wellness Solutions, LLC.

     

    • Respectful interactions: We do not tolerate aggressive, harassing, threatening, or inappropriate communication or behavior in any setting (including email, phone, social media, or in person).
    • Response to harmful behavior: Individuals engaging in harmful or unsafe behavior may be removed from communication channels, discharged from services, or blocked from online interactions with our practice.
    • Protecting reputation: If false, defamatory, or harmful information is shared publicly (including social media or review sites), we reserve the right to take reasonable steps to protect the safety, integrity, and professional reputation of our providers and staff.
    • Our goal is to maintain a healing space where clients feel safe, respected, and supported.

     

    Continuity of Care and Records

    Your care is important to us, and we want to make sure you are supported even if unexpected changes occur.

    If your therapist leaves the practice, becomes unable to continue providing services, or passes away, Wellness Solutions, LLC will contact you directly.

    You will be offered either a transfer to Sarah Messersmith, Wellness Solutions admin, or another therapist within Wellness Solutions, LLC or referrals to trusted providers outside our practice, based on your needs and preferences.

    In the event of changes in leadership, your records will continue to be securely maintained by designated administrative staff or a successor custodian. This ensures that your clinical records remain protected and accessible to you as allowed by law.

    Sliding Scale Fees
    We believe mental health care should be as accessible as possible. For clients who may not otherwise be able to receive services, we offer limited sliding scale rates.

    Sliding scale rates are available to:

    • Clients without insurance benefits
    • Clients with out-of-network insurance plans
    • Clients who express that they would not be able to afford services without a discounted rate

     

    Important details about sliding scale rates:

    • They are limited in number and based on availability.
    • They apply only to specific services, such as individual counseling and psychotherapy
    • Other services, such as case management or coordination of care, are billed at standard rates.
    • Sliding scale rates are not available if you have insurance with which we are an in-network provider.
    • Wellness Solutions, LLC may adjust or discontinue sliding scale arrangements at any time.
    • You may switch to using insurance or full-fee services if that becomes possible for you.
    • Sliding scale is a way we contribute to community accessibility, but it is not guaranteed for every client.


    Account Information and Receipts

    Receipts: You will receive an emailed receipt each time your card on file is charged.
    Monthly summaries: If your account has a balance, you will receive a monthly account summary by email.

    Insurance Benefits
    Understanding your insurance benefits is your responsibility. While we will do our best to assist you, your insurance company is ultimately the best source for questions about coverage, claims, or eligibility.

    If you have questions about your plan, please contact your insurance company directly.

    If you experience claim denials, billing issues, or benefit concerns, these must be addressed with your insurance provider.

     

    Mental Health Carve-Outs

    Some insurance companies “carve out” mental health benefits—meaning your mental health coverage is managed by a different company than your medical coverage.

    Often, the carve-out company’s name is not listed on your insurance card, which can cause confusion.

    If your plan has a mental health carve-out, you are responsible for informing us of the correct company so we can bill your claims correctly.
    If the carve-out company is out of network, you will be responsible for payment under our policies.

    We will always try to guide you if you’re unsure, but your insurance company is the best source of accurate and up-to-date information about your benefits.

     

    Employee Assistance Program (EAP) Benefits


    Wellness Solutions, LLC accepts a limited number of Employee Assistance Program (EAP) plans. If you wish to use your EAP benefits:

    You are responsible for contacting your insurance company to obtain:

    • The EAP authorization number
    • The exact number of authorized sessions
    • You must share this information with Wellness Solutions, LLC when completing your intake paperwork.

    Please note:

    • We will submit EAP claims for one treatment series only.
    • If your EAP benefits can be renewed, you may use them with Wellness Solutions, LLC one time only.

     

    Superbills for Out-of-Network Insurance

    If you choose to pay the full session fee and submit claims to your out-of-network insurance:

    • Wellness Solutions, LLC can provide you with a monthly superbill (an itemized receipt you can submit to your insurer).
    • Superbills are provided once per month and only upon request.
    • Clients receiving sliding scale rates are not eligible for superbills or out-of-network reimbursement submissions.

     

    Clinical Documentation and AI-Supported Notes

    To support accurate and efficient record-keeping, Wellness Solutions, LLC uses AI-assisted scribe technology during sessions to document clinical session and create master treatment plans. This allows your provider to remain fully present with you while ensuring accurate documentation of your care. The clinician is ultimately responsible for all clinical documentation and reviews all clinical notes and master treatment plans to ensure accuracy.

    The AI scribe system follows HIPAA and all current privacy regulations.

    Notes are stored securely within your clinical record.

    By signing this consent form, you acknowledge and agree to the use of this technology as part of your treatment documentation.

     

    Consent for Counseling, Coaching, and Psychotherapy

    By signing this online document below, you acknowledge that you have read, understood, and agreed to the Wellness Solutions, LLC Informed Consent & Disclosures.

    You are voluntarily consenting to receive counseling, coaching, and/or psychotherapy services from Wellness Solutions, LLC and you agree to all information contained herein as well as all Wellness Solutions, LLC policies and procedures. 


    Financial Agreement: “Money Matters”

    With my signature, to this online document below, I agree to the following:

    Wellness Solutions, LLC may accept payment from my insurance company or other third-party payors.

    I am financially responsible for all fees related to my care, including charges not covered by insurance, fees from denied or rejected claims, and any additional fees incurred on my behalf.

    I understand that a credit card on file is required for all clients, regardless of insurance status or patient responsibility (including $0 copay/coinsurance situations).

    My card will be charged for session fees and any balance owed.

    If I would like a detailed account receipt I can request it from Wellness Solutions, LLC

    If I would like a listing of Wellness Solutions, LLC fees for services I can request that from Wellness Solutions, LLC

    By signing, this online document below, I confirm that I am authorized to approve these charges and agree to take full responsibility for all costs related to my care.

    Disclaimer

    Wellness Solutions, LLC reserves the right to update or change policies, procedures, and information at any time. This includes, but is not limited to:

    • Notice of Privacy Practices (NOPP)
    • Client Rights, Responsibilities, and Expectations
    • Informed Consent and Disclosures

     

     

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    What Happens Next? 

    • Once you click on the "Submit" button you will see a "Thank You" confirmation page to verify we received your completed New Client Intake Form. 

     

    • You will also receive emails to confirm receipt of the New Client Intake Form and to provide information on the next steps of the intake process. 

     

    • We are hard at work reviewing your information to get you scheduled as quckly and easily as possible.

     

    • We will be reaching out within 2 business day to provide you with support, provide the result of your insurance benefits check (if applicable), and get you scheduled ASAP.

     

    • We will also send you a secure encrypted link to the STRIPE credit card on file form. The credit card on file must be completed to schedule an appointment. 

     

    • PLEASE make sure to be on the look out for helpful emails to keep you informed and updated throughout the care process. All Wellness Solutions emails will begin with WS in the subject of the email and will come from an email with the @wellnesssolutionsllc.com domain. If you have not received any emails please check your spam folder. 

     

    • Congrats and thank you for completing the Wellness Solutions New Client Intake Form! We are very grateful to be on this journey with you and look forward to helping you achieve your goals. 

     

    • If you have any questions please do not hesitate to reach out. We are here to help! 
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