Client Intake Forms

Demographic Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Is client a minor child, dependent, or disabled adult with a power of attorney?
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Administrative Sex (for insurance purposes only)
Gender Identity
Gender Identity - Other
Race
Race - Other
Pronouns
Pronouns - Other
Ethnicity
Ethnicity - Other
Marital Status
Marital Status - Other
Employment
Employment - Other
Employer/School
How did you hear about us?
How did you hear about us - Other
What doctor referred you to us?
Emergency Contact Information
Emergency Contact Name

First NameLast Name
Relationship to Client
Relationship to Client - Other
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Legal Guardian

For minors, dependents, or disabled adults with a power of attorney
Name of Parent/Legal Guardian

First NameLast Name
Relationship to Client
Relationship to Client - Other
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
If there is a power of attorney for a disable adult, please upload here. This document is required BY LAW to allow us to provide services.

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Divorced/Separated Parents

If you share custody with another parent, please include their information below and ensure you upload your divorce decree, child custody evaluation, etc below or email the information to our office at sagecounselingpllc@gmail.com. Failure to provide these documents will result in the cancelation of your appointment.
Name of parent sharing custody

First NameLast Name
Relationship to Client
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please upload your divorce decree, child custody evaluation, power of attorney here. This document is required BY LAW for services to be rendered.

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Client Questionnaire
What is the primary reason for seeking services?
You can select more than one option
Other
If this matter is related to custody, divorce, or other court related matters will you need a counselor to testify, provide documents to your lawyer or the court, or any other legal proceedings?
NOTICE

If you are seeking services in relation to a custody dispute, divorce, or other court-related matter that may require a provider to testify, provide documentation or records to an attorney or court, participate in legal proceedings, or provide any other forensic services, Sage Healing Counseling Services, PLLC does not provide forensic services and these matters may fall outside the scope of our practice.

If necessary, we will contact you and provide appropriate referrals to another provider or facility that offers these services. If you would like to discuss your situation further, please contact our office at 956-413-7005.

By continuing with this document, you acknowledge and understand that you may be referred to another provider if your needs involve forensic or court-related services that are outside our scope of practice.
Are you currently taking any medications?
If yes, please list them:
Will you need any FMLA or disability paperwork completed?
Please be advised that any documentation requested from your provider to be filled out will be subject to a $50 fee. Additionally, if a request for your records is received, there is a $35 administration fee. These fees are NOT covered by insurances and are due before paperwork can be completed and records released to you.

PCP Release of Information
PCP Release of Information

This section will be skipped if a PCP did not refer you for services. If you would like to complete a release of information for your doctor or other service provider in the future, please call us at 956-413-7005 or inform you provider so we can assist you in completing a release of information in the future.
By signing below, I authorize Sage Healing Counseling Services to release pertinent medical and mental health information, as necessary, to my primary care physician (PCP) or other healthcare providers involved in my care. I also consent to Sage Healing Counseling Services contacting my PCP to discuss my treatment, if needed, for the purposes of coordination of care. This release of information will only include relevant details that are necessary to support my treatment and overall health. You can end this authorization any time by contacting 956-413-7005.
Clinic Name/Doctor Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Doctor/Clinic Address
Client/Guardian Name

First NameLast Name
Client/Guardian Signature

Client Insurance Form

Please complete all information below if you will be using insurance for your visits. Additionally, please upload a copy of your insurance card.
Will you be using insurance for your services?
Insurance Name
Insurance - Other
Insurance ID Number/EAP Authorization Number
Insurance Group Number
Are you the primary cardholder for your insurance?
Primary Cardholder Name

First NameLast Name
Primary Cardholder SSN
Primary Cardholder DOB

MonthDayYear
Date
Insurance Card (Front)
Insurance Card (Back)
Do you have a secondary insurance?
Secondary Insurance Name
Secondary Insurance - Other
Secondary Insurance ID
Secondary Insurance Group Number
Secondary Insurance Card (Front)
Secondary Insurance Card (Back)
EAP Sessions & Authorization Policy

Employee Assistance Program (EAP) sessions are limited to one authorization per person. If you wish to continue therapy after your EAP sessions have expired or you have used all your sessions, you may do so by using your medical insurance or by paying privately. By continuing, you acknowledge that you understand this policy and understand that we will not allow more than one EAP authorization per person.
EAP Acknowledgement Signature
Insurance Authorization to Release Information

I authorize Sage Healing Counseling Services, PLLC to release information to my insurance companies to submit claims on my behalf, including details on mental health, substance use, or HIV diagnoses if required. I assign all benefits to Sage Healing Counseling Services, PLLC and authorize payments to be made directly to them. I understand I am responsible for any remaining amounts, including copays, coinsurance, deductibles, non-covered services, and fees for services not deemed medically necessary or without prior authori
Name

First NameLast Name
Date

MonthDayYear
Date
Signature
Private Pay Agreement

Please sign this section ONLY if you will not be using insurance for your visits.
I understand that Sage Healing Counseling Services, PLLC is accepting me as a private-pay client, and I am responsible for payment of all services I receive. No claims will be submitted to Medicaid, Medicare, or private health insurance for services provided under this agreement.

I understand that fees may vary based on the length and type of service provided and the provider's credentials, experience, and qualifications. I will be informed of applicable fees before receiving services whenever reasonably possible.

I understand that I am responsible for payment at the time of service, as well as any applicable cancellation or no-show fees in accordance with the Practice's policies.

I understand that I may request a receipt for services paid privately. Sage Healing Counseling Services, PLLC does not guarantee that my insurance company will reimburse me for any services I independently submit for reimbursement.

By signing below, I acknowledge that I have read, understand, and agree to the terms of this Private Pay Agreement.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature

Cancelation Policy
At Sage Healing Counseling Services, we strive to provide the highest quality mental health services to our clients, and you commitment to the therapeutic process is essential to the success of your treatment.

As a part of our commitment to creating a supportive and effective therapeutic environment, we want to bring your attention to some important office procedures that ensure a smooth and respectful experience for all our clients. Please take a moment to carefully read and acknowledge the following points:
1. Punctuality and Consistency.
  We kindly ask that you arrive on time for your scheduled appointment to ensure you receive the full benefit of your session. We understand that unexpected circumstances may arise, and a 15-minute grace period is provided. If you arrive more than 15 minutes late, your appointment will need to be rescheduled.
2. Cancelation or rescheduling with 24-hour notice.
  If you need to cancel or reschedule your appointment, we require at least 24 hours’ notice. This allows us to offer your appointment time to other clients who may need services. Please note that three (3) consecutive missed or late-cancelled appointments, or more than three (3) consecutive cancellations, may result in termination of services due to non-adherence to recommended treatment and scheduling expectations.
3. Cancelation Fee.
  In the event of a late cancellation (less than 24 hours’ notice) or a missed appointment, a $50 fee will be charged. This fee helps compensate your Provider for reserved time and supports fair scheduling for all clients. Insurance does not cover this fee. The charge will be applied to the debit or credit card on file. If no payment method is available, an invoice will be issued and must be paid through the client portal or by contacting the office. Future appointments may not be scheduled until any outstanding balance is resolved.
4. For your convenience.
  We offer a multitude of ways for you to reach us to cancel or reschedule an appointment to prevent the fee:
- Contact us at 956-413-7005, Monday through Friday 9am to 5pm.
- Email us at sagecounselingpllc@gmail.com
- Login to your patient portal and cancel/reschedule online.
Your cooperation in adhering to these guidelines is crucial for maintaining a positive and effective therapeutic experience for everyone. If you have any questions or concerns about these policies, please feel free to discuss them with your counselor.
Signature

Acknowledgment of Receipt and Understanding of Documents
Instructions:

Before moving forward, please click the blue links below to access and read the “Consent for Services” and “Notice of Privacy Practices” documents in their entirety.

Please take the time to review the information carefully and ensure that you understand the contents of both documents.

If you have any questions about the information provided, please contact the office before proceeding. Once you have reviewed both documents, please check the “I Agree” box below to confirm your acknowledgment and continue.

If you would like a copy of these documents, please let our front desk personnel or your counselor know.
I acknowledge that I have accessed the links provided to me for the Consent for Services and Notice of Privacy Practices documents. I confirm that I have read each document in its entirety, understand the information contained within them, and have had the opportunity to ask questions.

I confirm that I have no questions at this time regarding the content of these documents. I understand that I may request copies of these documents from Sage Healing Counseling Services, PLLC at any time and that I may be notified if changes are made to these documents.

By signing below, I acknowledge that I have accessed, read, and understood the documents provided to me.
Name

First NameLast Name
Date

MonthDayYear
Date
Signature
Should be Empty:

Demographic Information

Emergency Contact Information

Parent/Legal Guardian

Divorced/Separated Parents

Client Questionnaire

PCP Release of Information

PCP Release of Information

Client Insurance Form

Private Pay Agreement

Cancelation Policy

Acknowledgment of Receipt and Understanding of Documents