Mindful Paths Therapy Intake Form

Standard Therapy Questionnaire
Mindful Paths

161 Summer St. Ste 5 Kingston, MA 02364-1275

Phone: 781-287-8676 Fax: 800-593-2560
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth
What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can.
yesno
yesno
yesno
yesno
yesno
If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number. Also indicate any supplements you are presently taking and for what reason.
yesno
If you are in a relationship please describe the nature of the relationship and months or years together
Describe your current living situation Do you live alone or with others/with family?
increased appetitedecreased appetitetrouble concentratingdifficulty sleepingexcessive sleeplow motivationisolation from othersfatigue/low energyanxietydepressionfearhopelessnesspanictearful or crying spells
What is your current occupation? What do you do? How long have you been doing it?
What are your goals for counseling?
Who is your insurance provider?
Please upload pictures of the front of your insurance card. *

insurance card front.
Cancelof
Please upload pictures of the back of your insurance card. *

insurance card back
Cancelof
Payment Authorization & Financial Responsibility

By providing your payment information, you acknowledge and agree that a valid form of payment must be kept on file to schedule and hold all appointments. This card may be charged at any time for any outstanding balances on your account, including copays, deductibles, late cancellations, no-show fees, or unpaid services.

Please note that Mindful Paths is not a representative or agent of your insurance provider. If you have questions or concerns about denied claims, coverage, or reimbursement, we recommend contacting your insurance carrier directly using the number on the back of your insurance card.

We do not withhold medical records due to non-payment. However, we reserve the right to pause or discontinue services on open cases when a balance remains unpaid. We are committed to working with you to clarify any billing issues and encourage timely communication if you need assistance.
Signature*
I understand that I am responsible for keeping track of my appointment times and dates and for contacting the practice 48 hours before my appointment if I need to cancel or change it for any reason.

I understand that although a reminder is sent, ultimately it is my responsibility to know when my appointments are scheduled. If you cancel the same day or do not attend your appointment, you will be automatically charged a $100.00 fee for telehealth appointments.

If this fee is not paid or credit card on file is declined your appointment will not be rescheduled. When the office is closed, you will be prompted to leave a voicemail. If an emergency happens that is outside of your control that prevents you from appearing at your appointment at the scheduled time you can request the fee to be waived. Excessive no-shows or cancellations may result in the termination of services. By signing this form, you agree to commit to your appointment or cancel with more than 48 hours' notice or otherwise be subject to a fee SHOW/CANCELLATION FEES ARE NON-REFUNDABLE AND NOT BILLABLE TO INSURANCE
Signature*
Should be Empty:

Standard Therapy Questionnaire