New Client Intake Dr Kendra

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Session Format

VirtualIn-PersonHybrid

Preferred Days/Times for Sessions

Insurance Provider/Self-Pay

Provide a brief description of what we can help you with:

What is the best way for us to contact you?

CallTextEmailOther

HIPAA Privacy Acknowledgment

Notice of Privacy Practices (HIPAA)

I understand that my health information is protected under the Health Insurance Portability and Accountability Act (HIPAA). This includes information about my mental health, medical history, insurance details, and any personal identifiers I share during treatment.

Key Points:

My information will only be shared with third parties (such as insurance companies or collaborating professionals) for treatment, billing, or healthcare operations, and only with my consent or as required by law.
I have the right to access my records, request amendments, and file a complaint if I believe my privacy rights have been violated.
All digital communications and stored records are secured and encrypted to ensure confidentiality.
A full copy of Dr. Kendra Huber’s Privacy Practices is available upon request.

Telehealth Informed Consent

By signing below, I acknowledge and consent to engaging in telehealth therapy sessions with Dr. Kendra Huber and/or her team of licensed professionals. Telehealth involves the use of secure electronic communications (such as video conferencing or phone calls) to facilitate mental health services when in-person sessions are not feasible or preferred.

I understand the following:

Telehealth is conducted using HIPAA-compliant technology to protect my privacy and confidentiality.
There are potential benefits including convenience, accessibility, and continuity of care.
There are potential risks such as technical issues, limited physical cues, or potential interruptions to privacy (e.g., background noise).
I am responsible for securing a private, quiet location for sessions to protect my own confidentiality.
I may revoke this consent at any time by informing my provider in writing.
In case of emergency or technological failure, I will have access to alternate means of communication or referral to local emergency services.
By checking the box below and/or signing, I voluntarily consent to receive therapeutic services via telehealth.

I have read and agree to the HIPAA & Telehealth Policies. By signing, I give permission to be contacted regarding appointment scheduling.

Yes

Signature

Appointment Request Form