• Freedom Fighters Therapy LLC Insurance & Self Pay Intake Packet

  • Welcome to Freedom Fighters Therapy LLC

    Thank you for choosing Freedom Fighters Therapy LLC.This secure Health Insurance Therapy Intake Packet is designed for new clients who will be using health insurance benefits for mental health counseling services.This intake packet contains the required forms, treatment agreements, assessments, authorizations, releases, and consent documents needed to begin therapy with our practice.Please complete each section carefully. Your appointment cannot be finalized until all required intake paperwork has been completed and the required $50 Enrollment Fee and $50 Appointment Deposit (total $100) have been received. Freedom Fighters Therapy LLC provides professional telehealth mental health counseling services.Our licensed clinicians provide therapy only while clients are physically located in a state where the treating clinician is licensed or otherwise authorized to practice.

  • Enrollment & Payment Policy

    •  One-time Enrollment & Administrative Fee: $50 (non-refundable once administrative enrollment services begin).
    • Insurance Clients: $50 Advance Appointment Reservation Fee due when scheduling the first appointment. This prepayment is credited toward your deductible, copayment, coinsurance, or other patient responsibility after insurance processes the claim.
    • Self-Pay Clients: Initial Diagnostic Evaluation $200 due before the first session. Follow-up therapy sessions are $175 and due before each session.

  • Consent for Treatment

  • Treatment is voluntary and may include diagnostic evaluation, psychotherapy, CBT, trauma-informed therapy, psychoeducation, motivational interviewing, EMDR when clinically appropriate, Christian counseling upon request, and other evidence-based approaches. No specific outcome can be guaranteed.

  • Insurance Responsibilities

  • Clients are responsible for providing accurate insurance information, obtaining authorizations when required, and paying deductibles, copayments, coinsurance, denied claims, and non-covered services.

  • Self-Pay Policy

  • Initial Diagnostic Evaluation: $250. Follow-Up Therapy: $175. Payment is due before services unless other written arrangements have been approved.

  • Emergency Notice

  • Emergency Notice

    Freedom Fighters Therapy LLC is NOT an emergency service.

    If you are experiencing a medical emergency, mental health crisis,
    believe you may harm yourself or another person, or require immediate
    assistance:

    • Call 911
    • Call or Text 988
    • Go to the nearest Emergency Department

    Please do not use this intake form, email, voicemail,
    text message, or the client portal to request emergency assistance.

  • Superbill

  • Jeralyn Tharp, Practice Owner, is the only provider at Freedom Fighters Therapy who issues superbills. All other providers at the practice bill clients' insurance directly and do not issue superbills.

    Self-pay clients who receive services from Jeralyn Tharp may request a superbill for possible out-of-network reimbursement from their insurance company. A superbill is provided as a courtesy to assist clients in submitting claims to their insurance carrier. Reimbursement is determined solely by the client's insurance company and is not guaranteed. Clients are responsible for verifying their out-of-network benefits and remain financially responsible for all fees regardless of whether reimbursement is received.

  • Client Information

  • Please complete the following information exactly as it appears on your legal identification and insurance records (if applicable).

  • Date of Birth*
     - -
  • Biological Sex
  • Format: (000) 000-0000.
  • May we text you?*
  • May we leave a voicemail?
  • Format: (000) 000-0000.

  • Clinical Information

  • Please answer the following questions as completely and accurately as possible. These questions help your clinician prepare for your first appointment and develop the most appropriate treatment plan or coaching approach.

  • Are you currently experiencing thoughts of harming yourself?Single Choice*
  • Have you previously received counseling, therapy, or life coaching?*
  • Do you currently have a Primary Care Manager (PCM)?*
  • Format: (000) 000-0000.
  • Have you ever been hospitalized for mental health or substance use treatment?*

  • Scheduling Preferences

  • Please tell us your scheduling preferences. While we cannot guarantee specific appointment times or providers, we will make every effort to accommodate your preferences.

  • Do you have a provider preference?*
  • Preferred Appointment Days*
  • Preferred Appointment Times*
  • Would you like to be placed on our cancellation list for an earlier appointment if one becomes available?*
  • How did you hear about Freedom Fighters Therapy?*

  • Insurance and Self Pay Therapy Agreement

  •  

    This agreement explains your financial responsibilities, including insurance and self-pay payment obligations, insurance billing procedures, self-pay services and fees, attendance expectations, payment policies, telehealth services, confidentiality, and your rights as a client. Please read each section carefully before continuing.

  • Insurance Benefits

  • Freedom Fighters Therapy LLC will verify your insurance benefits as a courtesy.

    Verification of benefits is not a guarantee of payment. Your insurance company makes the final determination regarding coverage, deductibles, copayments, coinsurance, authorization requirements, and medical necessity.

    You remain financially responsible for all charges not paid by your insurance company.

  • Self Pay

  • Initial Diagnostic Evaluation: $250. Follow-Up Therapy: $175. Payment is due before services unless other written arrangements have been approved.

  • Enrollment Fee and Appointment Deposit

  • Before your first appointment is scheduled, a $50 non-refundable Enrollment and Administrative Setup Fee and a $50 Advance Appointment Fee are required.

    The Enrollment Fee covers administrative costs associated with establishing your account.

    The Advance Appointment Fee is credited toward your deductible, copayment, coinsurance, or other patient responsibility after your insurance claim is processed.

    If your insurance pays 100% of the allowed amount, any remaining credit will remain on your account or be handled according to the practice's financial policy.

  • Financial Responsibility

  • You agree to keep a valid payment method on file.

    You authorize Freedom Fighters Therapy LLC to charge your payment method for deductibles, copayments, coinsurance, balances due after insurance processing, no-show fees, late cancellation fees, returned payment fees, and any non-covered services for which you are financially responsible.

  • Attendance Policy

  • Appointments canceled with less than twenty-four (24) hours notice or missed without notice may be subject to a $125 no-show or late cancellation fee.

    Repeated missed appointments may result in discharge from the practice.

  • Medical Records

  • Medical record requests are subject to a $75 preparation fee when permitted by law.

    Court appearances, legal consultations, and written reports are billed separately according to the current practice fee schedule.

  • Telehealth Services

  • Most services are provided through secure HIPAA-compliant telehealth platforms.

    Clients must be physically located in a state where their assigned clinician is legally authorized to practice at the time of each therapy session.

  • Acknowledgment

  • Therapy Policies, Consents, and Client Rights

  • The following policies apply to all therapy clients receiving services through Freedom Fighters Therapy LLC. These policies explain your rights, our responsibilities, privacy practices, telehealth procedures, communication expectations, and informed consent for treatment.

    Please read each section carefully before continuing.

  • Consent to Treatment

  • I voluntarily consent to participate in behavioral health treatment provided by Freedom Fighters Therapy LLC.

    I understand the purpose of counseling is to improve emotional, behavioral, relational, and psychological well-being. My provider will discuss treatment options, potential benefits, possible risks, and alternatives throughout treatment.

    I understand no guarantees can be made regarding treatment outcomes.

  • HIPAA Notice of Privacy Practices

  • Freedom Fighters Therapy LLC is committed to protecting the privacy and confidentiality of your Protected Health Information (PHI).

    Your information will be used only for treatment, payment, healthcare operations, or as otherwise permitted or required by law.

    A complete Notice of Privacy Practices is available upon request.

  • Telehealth Consent

  • Most therapy services are provided through secure HIPAA-compliant telehealth platforms.

    You agree to participate in telehealth sessions from a private location whenever possible.

    You understand you must be physically located in a state where your assigned clinician is legally authorized to practice at the time of each session.

    You agree to provide your physical location at the beginning of each telehealth appointment.

    You agree to notify Freedom Fighters Therapy LLC if you will be located in a different state prior to your scheduled appointment.

     

  • Electronic Communication

  • Freedom Fighters Therapy LLC may communicate using secure telephone calls, text messaging, email, electronic forms, and approved client communication platforms for scheduling, reminders, billing, and administrative purposes.

    Electronic communication should never be used during emergencies.

    Text messages and email are intended for scheduling and administrative communication and should not be relied upon for urgent clinical concerns.

  • AI-Assisted Documentation

  • Freedom Fighters Therapy LLC may use secure technology tools, including AI-assisted documentation support, to improve documentation efficiency.

    Your treating clinician remains responsible for reviewing, editing, and approving all clinical documentation.

    AI tools are never used to replace professional clinical judgment.

  • Client Rights and Responsibilities

  • Freedom Fighters Therapy LLC may communicate using secure telephone calls, text messaging, email, electronic forms, and approved client communication platforms for scheduling, reminders, billing, and administrative purposes.

    Electronic communication should never be used during emergencies.

    Text messages and email are intended for scheduling and administrative communication and should not be relied upon for urgent clinical concerns.

  • Grievance Procedure

  • If you have concerns regarding your care, please discuss them with your provider or contact Freedom Fighters Therapy LLC administration.

    Every concern will be reviewed fairly and respectfully.

    Clients will never be retaliated against for filing a complaint.

    Receive information regarding fees, billing practices, and financial responsibilities.

  • Emergency Policy

  • Freedom Fighters Therapy LLC is not an emergency or crisis-response service.

    If you experience thoughts of harming yourself or another person, call 911, call or text 988, or go immediately to the nearest emergency department.

  • Credit Card Authorization

  • To simplify billing and help avoid interruptions in your care, Freedom Fighters Therapy LLC requires a valid credit or debit card to be securely stored on file for most non-VA services.

    Your card information will be stored using encrypted, PCI-compliant payment processing and will not be retained by Freedom Fighters Therapy LLC in an unencrypted format.

  • Authorization

  • By signing this authorization, you authorize Freedom Fighters Therapy LLC to securely maintain your payment method on file and to charge your card, when applicable, for:

    • Deductibles
    • Copayments
    • Coinsurance
    • Self-Pay therapy sessions
    • Life Coaching sessions
    • Outstanding balances
    • No-show fees
    • Late cancellation fees
    • Returned payment fees
    • Medical record fees (when applicable)
    • Court-related fees (when applicable)

  • Payment Processing

  • Charges will only be processed in accordance with your signed financial agreements and applicable practice policies.

    Whenever reasonably possible, clients will receive an explanation of charges before payment is processed.

    If a payment is declined, Freedom Fighters Therapy LLC may contact you to obtain updated payment information before scheduling future appointments.

  • Chargebacks

  • Clients agree not to initiate chargebacks for services that have been provided in accordance with this agreement.

    Questions regarding billing should first be directed to Freedom Fighters Therapy LLC so that concerns may be reviewed and resolved.

  • Authorization Statement

  • I authorize Freedom Fighters Therapy LLC to securely maintain my payment method on file and process charges as described in this agreement.

    I understand that this authorization will remain in effect until I revoke it in writing or until services are terminated, subject to any outstanding financial obligations.

  • Authorization to Charge Card on File

  • I authorize Freedom Fighters Therapy LLC to securely maintain my payment method through Stripe and to charge my card, when applicable, for:

    • Deductibles

    • Copayments

    • Coinsurance

    • Self-Pay Therapy services

    • Life Coaching services

    • Outstanding balances after insurance processing

    • No-show and late cancellation fees in accordance with the practice policies

    • Returned payment fees

    • Medical record preparation fees (when applicable)

    • Court-related fees (when applicable)

  • Payment Processing

  • Whenever reasonably possible, Freedom Fighters Therapy LLC will notify you of charges before processing your payment.

    You agree to maintain a valid payment method while receiving services.

    If your payment method expires or is declined, you agree to provide updated payment information before future appointments may be scheduled.

  • Payment Authorization

  • This authorization will remain in effect until revoked in writing or until services have ended, subject to any remaining financial obligations.

    Revoking this authorization does not eliminate responsibility for charges already incurred.

  • Acknowledgment

  • PHQ-9 Depression Questionnaire

  • Please answer the following questions based on how you have been feeling over the past two (2) weeks.

    Your responses help your provider better understand your current symptoms and monitor your progress throughout treatment.

  • Little interest or pleasure in doing things*
  • Feeling down, depressed, or hopeless*
  • Trouble falling or staying asleep, or sleeping too much*
  • Feeling tired or having little energy*
  • Poor appetite or overeating*
  • Feeling bad about yourself — or that you are a failure or have let yourself or your family down*
  • Trouble concentrating on things, such as reading the newspaper or watching television*
  • Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual*
  • Thoughts that you would be better off dead or of hurting yourself in some way*
  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

  • Generalized Anxiety Disorder 7 (GAD-7)

  • Over the last two (2) weeks, how often have you been bothered by the following problems?

    Please answer every question.

  • Feeling nervous, anxious, or on edge*
  • Not being able to stop or control worrying*
  • Worrying too much about different things*
  • Trouble relaxing*
  • Being so restless that it is hard to sit still*
  • Becoming easily annoyed or irritable*
  • Feeling afraid as if something awful might happen*
  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

  • Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)

  • Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic.

    For this questionnaire, please think about the worst event that has happened to you during your lifetime.

    In the past month, have you…

  • Had nightmares about the event(s) or thought about the event(s) when you did not want to?*
  • Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?*
  • Been constantly on guard, watchful, or easily startled?*
  • Felt numb or detached from people, activities, or your surroundings?*
  • Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?*

  • Authorization for Release of Information (ROI)

  • This authorization allows Freedom Fighters Therapy LLC to release and/or obtain information necessary to coordinate your care, verify insurance or VA benefits, communicate with healthcare providers, and process referrals when authorized by you or required by law.

    You may revoke this authorization at any time in writing unless action has already been taken in reliance upon it.

  • Do you authorize Freedom Fighters Therapy LLC to release and/or obtain information for purposes of treatment, payment, and healthcare operations?*
  • Type of Information to be Released or Requested*
  • Purpose of the Release*

  • Revocation

  • I understand that I may revoke this authorization at any time by providing written notice to Freedom Fighters Therapy LLC.

    Revocation will not affect actions already taken in reliance upon this authorization.

  • Final Certifications and Electronic Signature

  • Please review the statements below carefully before signing.

    By electronically signing this intake packet, you acknowledge that you have read, understood, and agreed to all applicable policies, consents, financial agreements, and disclosures presented within this Master Intake Packet.

  • By checking each statement below, I certify that:*
  • Date*
     - -

  • Thank you for completing the Freedom Fighters Therapy LLC Master Intake Packet.

    Your information will be reviewed by our administrative team. If additional information is needed, we will contact you.

    If payment is required based on the services you selected, you will proceed to the secure payment page after clicking Continue.

  • Secure Online Payment

  • Thank you for completing your Freedom Fighters Therapy LLC intake paperwork.

    To complete your registration, please submit the required Health Insurance Therapy Enrollment Fee and Appointment Deposit.

    Health Insurance Therapy – $100.00 (Enrollment Fee + Appointment Deposit)

    All payments are securely processed through Stripe. Freedom Fighters Therapy LLC does not store your complete credit or debit card information.

     

  • *

    prevnext( X )
        Health Insurance Enrollment & Appointment Deposit
        $100.00$100.00
          
        Self-Pay Therapy Intake
        $250.00$250.00
          
        Total
        $0.00$0.00
      • Should be Empty: