F.A.M Healing Center - Intake Forms

Self-Pay / Financial Responsibility Agreement

By signing below, I acknowledge that I am electing to receive self-pay/private-pay services through F.A.M Healing Center. I understand that I am financially responsible for all services provided, that payment is due at the time of service unless prior arrangements have been made, and that missed appointments or late cancellations may be subject to fees in accordance with agency policy. I understand that F.A.M Healing Center is not billing my insurance for these services unless otherwise agreed upon, and that I may choose to use insurance if eligible.
Signature
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Notice of Privacy Practices (HIPAA)

By signing below, I acknowledge that I have received and reviewed the Notice of Privacy Practices and understand how my protected health information may be used and disclosed in accordance with HIPAA regulations. I understand that I may request a copy of this notice at any time.
Signature
Date Signed

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Informed Consent for Assessment and Treatment - Adult

By signing below, I acknowledge that I have read and understand this informed consent for assessment and treatment. I voluntarily consent to participate in behavioral health services provided by F.A.M Healing Center, including assessments, individual therapy, group therapy, and other clinically appropriate services. I understand that I may withdraw consent at any time by notifying F.A.M Healing Center verbally or in writing.
Patient Signature
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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. By signing I understand and agree to the above authorization.
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

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Signature
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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. By signing I have read and understand the telehealth informed consent 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.
Signature
Date Signed

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AI-Assisted Documentation Consent

F.A.M Healing Center may use secure, HIPAA-compliant artificial intelligence (AI) technology to assist in documenting clinical sessions. These tools may support summarizing or transcribing portions of sessions to improve documentation efficiency and accuracy. All AI-assisted documentation is used solely to support your provider and does not replace clinical judgment. Information is handled in accordance with HIPAA and applicable confidentiality regulations, including 42 CFR Part 2 where applicable. By signing below, you acknowledge and consent to the use of AI-assisted documentation technologies and understand that you may withdraw your consent at any time without affecting your access to services.
Signature
Date Signed

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Faith-Based Support Services Consent

By signing below, I voluntarily consent to participate in optional faith-based support services through F.A.M Healing Center. I understand that relevant information may be shared between my clinician and faith-based support staff for purposes of care coordination and integration of services as part of my overall treatment experience.
Would you be interested in optional faith-based support services at no additional cost alongside your clinical care?
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Faith-Based Support Services Consent