Intake Form

Intake Form
We know your time is valuable, so we appreciate your taking the time to complete this intake form. We appreciate your time.

WRITE N/A WHERE NOT APPLICABLE
Personal Information
Name as Registered with Insurance*

First NameLast Name
Preferred Name

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Gender*
E-mail*
Marital Status
Emergency Contact
Emergency Contact Phone Number
Primary Care Physician
Primary Care Physician or Clinic's Phone Number
How did you hear about us?*
Please specify how you heard about us if you selected 'Other' or write N/A.*

Agreement and Understanding
Appointment Confirmations: I understand that I may be contacted via text or phone 24-48 hours in advance to confirm a scheduled appointment.
Your insurance company may require us to consult with a client’s primary care physician or psychiatrist whenever symptoms of a mental health diagnosis are present. The purpose of such consultation is to determine if there may be a medical condition or medication that may be causing or contributing to the client’s symptoms. The client/parent/legal guardian may also choose to waive such consultation. The clinician may provide treatment or evaluation until such time that the medical consultation is obtained or waived.
Please check.*

At this time, I waive the consultation with my primary care or psychiatrist, understanding that I may at anytime complete a release of information to the physician of my choice.
Notice of Privacy Practices*

I understand that I may download a copy of Notice of Privacy Practices at TCAcounseling.com/Forms.
Initials*

Financial Agreement
I understand that it is my responsibility to disclose to TCA if I am using a HSA/FSA payment as TCA does not have the ability to access their information. I also understand that TCA has the right to refuse HSA/FSA as these payments are difficult to obtain. If my HSA/FSA card has a visa/mc logo, it is most likely that TCA will accept it*

I accept
How I plan to pay for therapy:*

I plan to use my insurance.I want to pay for my therapy (Private Pay).
Member's ID Number*
Take Photo of Front of Insurance Card*
Take Photo of Back of Insurance Card*
Service Costs*

If I am not a private pay client, I understand that TCA Counseling Group will attempt to bill my insurance company, but if for any reason the service is not covered, I will be responsible for payment of that service at the rate of $150 for the first visit and $135 for each subsequent visit. I understand I will pay the amount due, including copayments and deductibles, before the session on the day of my scheduled appointment. I also understand that if I do not adhere to this agreement, services maybe suspended. If I'm a private pay client, I understand the cost for services is $150 for the first session and $135 for each additional visit.
Cancellation and Excessive Absenteeism Policy*

I understand that a twenty-four hour notice is required for the cancellation or rescheduling of an appointment. Appointments changed with less than 24 hour notice will incur a $80 charge, which will be applied to my credit card as insurance cannot be billed. I also understand that my treatment may be terminated if I miss more than 2 scheduled appointments in any given 4 week period.
Credit Card Requirement and Authorization*

I understand that a credit card is required to hold my appointment time. The card will not be charged unless I have a deductible, copayment or cancellation/late reschedule fee. I agree to allow TCA Counseling Group to remotely and automatically charge my credit or debit card for any costs for services not paid by my insurance, including counseling fees, co-payments, private pay services, cancellation fees and no-show fees.
Therapists Solutions*

I understand that Therapist Solutions is contracted by TCA to handle billing and claims services. I may be contacted by Therapists Solutions when an issue with my insurance or payment arrises. The information I provide to them is strictly confidential.
Convenience Fee*

I understand that TCA Counseling Group uses a cashless system to ensure safety. My credit card will be remotely charged ahead of my visit. As such, there is a 4.5% convenience fee for each transaction.
A valid credit or debit card is required to hold your appointment. Please upload your credit card information below. If you are unable to do so, please call us Monday - Friday between 10 am and 6 pm at 617-861-0370.
Take Photo of Front of Credit Card
Take Photo of Back of Credit Card
Initials*

Signature
Please type and sign your name below to indicate consent to treatment and acknowledgement of Informed Consent, Privacy Policy and financial agreement.
Patient's Name*
Patient's Signature*

Clear
Date

MonthDayYear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Guardian's Name
Guardian's Signature

Clear
Should be Empty:

Intake Form

Personal Information

Medical and Mental Health Information

Social Information

Family History

Wellness Survey

Informed Consent & Confidentiality Policy

Agreement and Understanding

Financial Agreement

Signature