F.A.M Healing Center - Intake Forms

F.A.M Healing Center - Intake Forms

Complete this intake packet to get started with your behavioral health services.
Client Name*

First NameMiddle NameLast Name
Today's Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Gender*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employment Status*
Income Range*
Disability Status*
Education Level*
Preferred Language*
Martial Status*
Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteDecline to AnswerOther
Ethnicity*
Veteran Status*
Emergency Contact Name*

First NameMiddle NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship*
Upload Picture Idenification*

Cancelof
How will you pay for services?*
EAP Referral*
EAP MAT #*
Referring Source*
Type of counseling are you seeking?*

Individual CounselingCouples CounselingFamily CounselingFaith-based CounselingEquine-Assisted TherapyIntensive Outpatient Program (IOP)Substance Use TreatmentOther
Presenting Concerns*

AnxietyDepressionTrauma/PTSDStress/BurnoutRelationships ConcernsFamily IssuesLife TransitionsGrief/LossSubstance Use/AddictionOther
Are you currently experiencing any of the following?*

Thoughts of harming myselfThoughts of harming othersRecent overdose or medical emergencyNeed immediate helpNo, none apply
If you are in immediate danger, call 911 or go the the nearest ER
How would you like services rendered?*
In-Person Service Location
Self-Pay / Financial Responsibility Agreement

F.A.M Healing Center offers self-pay (private pay) services for clients who are not using insurance or whose services are not covered. By choosing self-pay, you agree to be financially responsible for all services rendered.Payment is due at the time of service unless prior arrangements have been made. Fees for services will be provided prior to your appointment. Missed appointments or late cancellations may be subject to a cancellation fee in accordance with agency policy.F.A.M Healing Center does not submit claims to insurance for self-pay services unless otherwise agreed upon. You may request a receipt (superbill) for your records.
By checking each box below, you confirm that:*

I understand that I am choosing to receive services as a self-pay clientI understand that I am financially responsible for all services providedI understand that payment is due at the time of service unless arrangements are madeI understand the cancellation/no-show policy and potential feesI understand that F.A.M Healing Center is not billing my insurance for these servicesI understand I may choose to use insurance if eligible, but I am electing self-pay at this time
Signature*
Date Signed*

MonthDayYear
Date
Notice of Privacy Practices (HIPAA)

Notice of Privacy Practices (HIPAA)F.A.M Healing Center is committed to protecting your health information. This notice explains how your medical information may be used and disclosed and how you can access it.Your protected health information may be used for treatment, payment, and healthcare operations. We may also disclose information as required by law.You have the right to:-Access your records-Request corrections-Request restrictions-Receive confidential communications
HIPAA Privacy Practices Acknowledgment*

I acknowledge that I have received and reviewed the Notice of Privacy PracticesI understand how my protected health information may be used and disclosedI understand I may request a copy of the Notice at any time
Signature*
Date Signed*

MonthDayYear
Date
Informed Consent for Assessment and Treatment - Adult

By checking the box below and signing this form, you are providing informed consent to receive behavioral health services from F.A.M Healing Center.You acknowledge and understand the following:You are voluntarily seeking assessment and/or treatment services.The nature and purpose of services have been explained to you, including potential benefits and risks.You have the right to ask questions about your care at any time.You have the right to refuse or discontinue services at any time without penalty.Your information will be kept confidential in accordance with HIPAA and 42 CFR Part 2 regulations, except where disclosure is required or permitted by law (e.g., risk of harm to self or others, abuse/neglect reporting, court orders).Treatment may include individual therapy, group therapy, assessments, or other behavioral health services as clinically appropriate.No guarantees have been made regarding outcomes of treatment. A copy of this informed consent will be provided to you upon request.
By checking each box and signing below, you confirm and agree to the following:*

I have read and understand this informationI consent to participate in servicesI authorize F.A.M Healing Center to provide assessment and treatmentI understand I may withdraw consent at any time by notifying F.A.M Healing Center in writing or verbally
Patient Signature*
Date Signed*

MonthDayYear
Date
Authorization to Bill Insurance

I authorize F.A.M Healing Center to release any medical or other information necessary to process my insurance claims. I authorize payment of benefits to be made directly to F.A.M Healing Center for services rendered.I understand that I am financially responsible for any charges not covered by my insurance, including co-pays, deductibles, and non-covered services.
Name Insurance Carrier*
Insurance Card Front Upload*

Cancelof
Insurance Card Back Upload*

Cancelof
Policy Holder*
Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
I understand and agree to the above authorization.*
Signature*
Date Signed*

MonthDayYear
Date
Telehealth Informed Consent

Telehealth services involve the use of electronic communications to enable F.A.M Healing Center to connect with clients remotely. This may include video conferencing, phone sessions, or other digital communication tools.While telehealth offers convenience, there are potential risks including interruptions, unauthorized access, or technical difficulties. All reasonable steps are taken to ensure your privacy and confidentiality in accordance with HIPAA and 42 CFR Part 2 regulations.You have the right to: Refuse or withdraw consent at any time. Request in-person services when available. Ask questions about telehealth services. By signing below, you acknowledge that you understand and agree to participate in telehealth services.
Please enter the address where you will be located during telehealth sessions*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
I have read and understand the telehealth informed consent and agree to participate in telehealth services.*
Signature*
Date Signed

MonthDayYear
Date
AI-Assisted Documentation Consent

F.A.M Healing Center may use secure, HIPAA-compliant artificial intelligence (AI) technology to assist in documenting clinical sessions. This may include summarizing or transcribing portions of sessions to support accurate and efficient recordkeeping.These tools are used solely to assist your provider and do not replace clinical judgment or decision-making. All information is handled in accordance with HIPAA and, where applicable, 42 CFR Part 2 confidentiality regulations.Your privacy and confidentiality are protected. AI tools used by this practice do not use your information for training purposes and do not share your information outside of permitted healthcare operations.You have the right to ask questions about this process and may decline consent at any time without affecting your access to services.
I consent to the use of secure, HIPAA-compliant AI technology for documentation purposes.*
I understand that I may withdraw this consent at any time without affecting my right to receive services.*
Signature*
Date Signed

MonthDayYear
Date
Should be Empty:

F.A.M Healing Center - Intake Forms

Self-Pay / Financial Responsibility Agreement

Notice of Privacy Practices (HIPAA)

Informed Consent for Assessment and Treatment - Adult

Authorization to Bill Insurance

Telehealth Informed Consent

AI-Assisted Documentation Consent