Welcome!

Welcome!

Feel free to fill out the info below to the best of your abilities. Once you are done with this form, there will be a link available to set up your first appointment with Ace! :)
Notice of Privacy:

Our practice is committed to maintaining the privacy and security of your personal health information in accordance with the Health Insurance Portability and Accountability Act (HIPAA). All information shared during your therapy sessions, as well as in this intake form, is confidential and will not be disclosed to anyone without your written consent, except in situations where disclosure is required by law (e.g., imminent harm to yourself or others, or court orders). Your trust is important to us, and we ensure that all electronic records are securely stored and protected. Please feel free to discuss any concerns about confidentiality with your therapist.
Are you interested in In-Person or Telehealth Appointments?*
Patient's Contact Info:
First and Last Name*

First NameLast Name
Preferred Name (if different)
Your Pronouns:
(she/her, he/him, they/them, xi/xir, he/they, etc.)
Date of Birth*

MonthDayYear
Current Date

MonthDayYear
Date
Age:
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Phone Number:*
Please enter a valid phone number.
Parent/Guardian E-Mail:*
example@example.com
Phone Number:*
Email:*
example@example.com
Would you like me to call, or email you?*

CallE-Mail
Ace's Email
example@example.com

Insurance:

Some of these might seem like repeat questions, but insurance can be tricky. We just want to make sure we have all the right info before sending in the claims to avoid issues.
Are you covered by insurance?*

YesNo
Who are you insured through?*
BlueCross, Medicaid, Allegiance, etc.
Relation to Policy Holder?*
Policy Holder Name*

First NameLast Name
Policy Holder's Birthday*

MonthDayYear
Date
Policy Holders Phone Number*
Please enter a valid phone number.
Policy Holder's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Number*
Group Number*
*put N/A if there is no group number
Front And Back Picture Of Insurance Card

Cancelof
Would you like to talk to us about financial assistance or our slide discount application?*

YesNo

Informed Consent

Please look over these policies and sign. If you have any questions before signing or selecting "yes" for any of these, please reach out to us via call or text at (406) 201-9814.
1. Purpose of Therapy:

I understand that I am voluntarily seeking therapy for the purpose of improving my emotional, mental, and/or behavioral well-being. Therapy involves discussing personal life experiences and feelings, and there may be times when the process can lead to emotional discomfort. I understand that therapy may not have guaranteed outcomes, but it can offer significant benefits, such as personal growth, improved relationships, and coping strategies.

2. ConfidentialityI understand that all communications with my therapist are confidential, meaning my personal information will not be shared without my written consent, except in the following situations:

If there is a risk of harm to myself or others.
If child abuse, elder abuse, or dependent adult abuse is suspected.
If mandated by a court of law or other legal proceedings.
In cases where disclosure is required by law.
3. HIPAA ComplianceI acknowledge that this practice adheres to the guidelines of the Health Insurance Portability and Accountability Act (HIPAA) to ensure that my personal health information is protected. My health records will be stored securely, and only authorized personnel will have access to them.

4. Rights and Responsibilities:

I understand that I have the right to ask questions about any aspect of my treatment.
I have the right to terminate therapy at any time, although I am encouraged to discuss this decision with my therapist before discontinuing treatment.
I am responsible for attending scheduled sessions and providing 24-hour notice if I need to cancel or reschedule an appointment. Repeated cancellations or no-shows may result in termination of services.
5. Fees and PaymentI understand that I am responsible for all fees related to my therapy sessions unless agreed otherwise. I know that payment is expected within 7 days of the therapist's request for funds, following insurance payment. I am also responsible for verifying my insurance benefits and ensuring that sessions are covered, if applicable.

6. Risks and Benefits:

Therapy may involve discussing emotionally challenging topics, which can result in temporary discomfort, but it can also lead to significant personal growth, improved emotional well-being, and healthier relationships. I understand that therapy is a collaborative process, and I am encouraged to actively participate to achieve the best possible outcomes.

7. Telehealth Services:

If I engage in telehealth services, I understand that these sessions are conducted through secure, HIPAA-compliant platforms. I agree to take responsibility for ensuring that I have a private and secure space for participating in telehealth sessions to maintain confidentiality.

8. Cultural Competence:

I understand that my therapist is committed to providing culturally competent care that respects my unique identity, including my gender identity, sexual orientation, race, ethnicity, spirituality, and other cultural factors. I am encouraged to share any specific needs or concerns related to my identity so that therapy can be adapted to suit my background.
Do you fully understand and agree to the terms listed above Informed Consent?*

YesNo
HIPAA Compliance and Confidentiality Agreement

If you have any questions before selecting "yes", please reach out to us.
Introduction

At Montana Queer Alliance, we are committed to protecting the privacy and confidentiality of your personal health information in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable laws.

1. Use and Disclosure of Health Information:

Your health information will be used and disclosed only for the following purposes:
- Treatment: To provide, coordinate, or manage your health care services.
- Payment: To obtain payment for your health care services.
- Healthcare Operations: For activities necessary to support the operations of the practice, such as quality assessment and improvement activities.
2. Your Rights:
- Right to Access: You have the right to inspect and obtain a copy of your health records.
- Right to Amend: You may request corrections to your health information if you believe it is incorrect or incomplete.
- Right to an Accounting of Disclosures: You can request a list of disclosures we have made of your health information.
- Right to Request Restrictions: You may ask us to limit the use or disclosure of your health information.
- Right to Confidential Communications: You can request that we communicate with you through alternative means or at alternative locations.
- Right to a Copy of this Agreement: You are entitled to a paper copy of this agreement upon request.
3. Our Responsibilities:
- We are required by law to maintain the privacy of your health information.
- We will notify you in the event of a breach of unsecured health information.
- We must follow the duties and privacy practices described in this agreement.
4. Limits of Confidentiality:

Your health information may be disclosed without your consent in certain situations, including but not limited to:
- If there is a threat of serious harm to yourself or others.
- Suspected abuse or neglect of a child, elderly person, or dependent adult.
- Compliance with a valid court order or other legal processes.
5. Complaints:

If you believe your privacy rights have been violated, you may file a complaint with:
- Our Office: Ace Reba-Jones, ace@montanaqueeralliance.org
- Office for Civil Rights, U.S. Department of Health and Human Services
You will not be retaliated against for filing a complaint.

6. Contact Information:

If you have questions about this agreement or wish to exercise your rights, please contact:

Ace Reba-Jones
406-475-0070
ace@montanaqueeralliance.org
Do you fully understand and agree to the HIPPA Compliance and Confidentiality Agreement terms listed above?*

YesNo
Consent to Use/Share Insurance Information

If you have any questions before selecting "yes", please reach out to us.
1. Purpose of Consent:

I understand that in order for my therapist and this practice to bill and receive payment from my insurance provider, it may be necessary to share certain personal health information, including diagnosis, treatment plans, and session notes, with my insurance company.

2. Information Shared:

I give my consent for the release of the following information to my insurance provider, as required for billing purposes:
- Personal identification information (name, date of birth, address)
- Diagnosis codes
- Treatment dates and types of services provided
- Any other information required by my insurance company for claims processing and payment
I understand that only the minimum necessary information will be shared with the insurance provider to process claims and manage coverage of services.

3. Revoking Consent:

I understand that I may revoke this consent at any time, but that doing so may result in my insurance provider declining to cover future services. If I choose to revoke this consent, I will notify my therapist in writing.
Do you fully understand and agree to the Consent to Use/Share Insurance Information listed above?*

YesNo
Patient's Legal Name*

First NameLast Name
Parent/Guardian's Legal Name (if patient is under 18)

First NameLast Name
Signature of Patient or Legal Guardian (if under 18)*

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Today's Date*

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Date
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Welcome!

Notice of Privacy:

Patient's Contact Info:

Insurance:

Intake Questions:

Informed Consent

HIPAA Compliance and Confidentiality Agreement

Consent to Use/Share Insurance Information