Intake Forms - Insights Wellness Center LLC

Intake Form

Patient Name*
First Last
*
- male
- female
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
ie. (123)456-7890
Email*
Date of Birth*
MM slash DD slash YYYY
Social Security Number*

ie. 000-00-0000
Policy Holder’s Name*
First Last
Relationship to the Patient*
Insurance Carrier Name*
Insurance Carrier Customer Service Number
ie. (123)456-7890
Policy Holder Date of Birth*
MM slash DD slash YYYY
Policy ID Number*
Policy Group Number*
Date*
MM slash DD slash YYYY

Policies Form

FEES and APPOINTMENTS

Payment is due at time of services rendered.
Cancellations must be made with a 24 hour notice to avoid the $100 late cancel fee. This is a FIRM policy aside from the exceptions listed below. Thank you for your cooperation and consideration.
EXCEPTIONS to the late cancel fee
*A signed doctors note is provided
*If there is an available appointment during the same week, the client may reschedule and the cancellation fee is waived. Please note the weekly calendar is often full. Also note there will be an automatic fee of $100 should a client cancel a rescheduled appointment, no exceptions.
*If the therapist can fill the cancelled appointment time with another client session.
Sessions are 50 minutes, if a client is late for a session the session will still end promptly (50 minutes after the scheduled appointment).
Please present fee at the start of each session.
Fee is payable by cash, checks Venmo or Apple Pay. Checks can be made out to “Insights.”
If a check is returned there is a penalty fee of $30.00 in addition to the unpaid session fee due at the start of the next session.
This is a home office. When you arrive you may park in the driveway. Text "here" and I will "like" your text to indicate you may come in.
Insights is NOT a 24 hour facility. In case of an emergency please call 911 or go to the nearest emergency room. If you do not have an emergency, take note of your concern and bring it to your next session. You may leave a message on the voice mail if you would like your therapist to call you. Messages are kept confidential.

CONFIDENTIALITY
By law all psychotherapists are mandated reporters. This means that the therapist is obligated to notify the appropriate authorities if the therapist suspects abuse, neglect or danger to a client or persons mentioned during treatment.
Other than the above, all treatment services are held confidential. There may be a time the therapist may ask the client to sign a release of information to collect information to better treat the client i.e. former therapists, primary care physicians, schools.

TREATMENT
Clients will not be treated while under the influence of alcohol or illegal substances. Therapist(s) reserve the right to reschedule a session if a client seems to be under these influences.
Parents must NOT leave minor children unattended at “Insights.”
Clients participating in family, couples or group therapy should not call to discuss therapy matters over the telephone. Discussions should be held during sessions to avoid any imbalance in treatment.
Families going through a divorce will be offered family therapy with each parent on an alternating weekly basis.

COMMUNICATION/SOCIAL MEDIA
All scheduling changes must be done 24 hours in advance by text message or voice mail. No exceptions.
Texting on therapeutic matters must be left for session time. If you need to speak to your therapist please schedule an appointment.
Communicating through any form or action of social media does not support professional and therapeutic boundaries between therapists and clients. Therefore clients are asked to maintain those boundaries honoring the privacy of both the client(s) and the therapist.

Policies Signature Form

Policies Form

Liability Waiver

Due to the variety of healing modalities and wellness offerings used (reiki, yoga therapy, psychotherapy, spiritual counseling, home and family energetics, 12 step therapy, psychoeducational and psychospiritual consultations and wellness programs, EMDR, healing retreats) at on and off-site locations, all individuals seeking any services must sign a waiver. Thank you.

Due to the variety of healing modalities and wellness offerings used (reiki, yoga therapy, psychotherapy, spiritual counseling, home and family energetics, 12 step therapy, psychoeducational and psychospiritual consultations and wellness programs, EMDR, wellness groups, healing retreats) at on and off-site locations, all individuals seeking any services must sign a waiver. Thank you.

Date*
MM slash DD slash YYYY
Name*
First Last
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
Minor Participants*
Please list any minors and their dates of birth whom you give consent to participate in services at Insights, A Wellness Center, LLC. Write none if not applicable.
Emergency Contact*
First Last
Emergency Contact Phone*
Are you or any minor participants listed currently suffering from a medical condition, illness or injury?*
Please elaborate in full.
Read thoroughly and check below to confirm agreement.*
You hereby acknowledge and agree that Insights, A Wellness Center, LLC will not be liable for any injury, including, without limitation, personal, bodily or mental injury, economic loss or any damage to you, your spouse or partner, guest, unborn child or relatives resulting from the negligence of Insights, A Wellness Center, LLC, anyone providing services on Insights, A Wellness Center, LLC's behalf or anyone else using Insights, A Wellness Center, LLC facilities or providing livestream or pre-recorded content and you release Insights, A Wellness Center, LLC from any liability related to any such injury, including any transmission of sickness, virus, pathogen, or disease. All sessions, classes, performance of any activities provided by Insights, A Wellness Center, LLC whether in person, online, through video or stream or otherwise, or use of Insights, A Wellness Center, LLC’s studio and office facilities (or entry/exit of such facilities), live-streaming or video, use of Insights, A Wellness Center, LLC’s office or studio-provided equipment or apparatus (whether during a class or otherwise), or use of any other Insights, A Wellness Center, LLC service shall be at your sole risk. You understand that the decision to use any equipment or apparatus, or the selection of programs, methods and types of equipment, shall be solely your responsibility, and at no time may you use any equipment without supervision by an Insights, A Wellness Center, LLC’s teacher or therapist, and Insights, A Wellness Center, LLC shall not be liable to you for any claims, demands, damages or causes of actions due to injury to you or your property arising out of or in connection with your use of the services or facilities of Insights, A Wellness Center, LLC, or any occurrence in or around an Insights, A Wellness Center, LLC facility, regardless of whether the injury or damages were caused by the negligence of Insights, A Wellness Center, LLC, its employees or its agents.
This waiver of liability and release specifically applies to claims of negligent instruction, maintenance, cleaning, and/or supervision that may arise as a result of injuries sustained before, during, or after classes or individual training and/or healing sessions. Although Insights, A Wellness Center, LLC instructors and therapists may provide guidance during a class or individual session, it is your sole responsibility to discontinue participation in any activity you feel is beyond your capability to safely perform and Insights, A Wellness Center, LLC will not be responsible for any injuries or damages arising from your engagement in any activities at any Insights, A Wellness Center, LLC office or studio regardless of whether they were caused by the negligence of Insights, A Wellness Center, LLC, its employees or its agents, trainees, assistants, or mentees. You acknowledge and agree that this waiver of liability and release applies to any and all incidents occurring on any Insights, A Wellness Center, LLC owned, operated or controlled premises, including slip or trip and fall incidents, regardless of the cause. You further acknowledge and agree that Insights, A Wellness Center, LLC is not liable and does not assume responsibility for any claims, losses, damages, costs or expenses arising out of any inconvenience, loss of enjoyment, upset, disappointment, distress or frustration, whether physical or mental, resulting from any act or omission of Insights, A Wellness Center, LLC or any other party. The scope of this waiver of liability and release specifically includes any and all injuries sustained in or about the premises of any Insights, A Wellness Center, LLC facility and during any event or program organized or operated by Insights, A Wellness Center, LLC away from its facilities, including, without limitation, parks, beaches, community centers and schools.
You expressly acknowledge and understand that you will be automatically opted into communications from Insights, A Wellness Center, LLC with regard to the services provided, branding, marketing, or anything else and that it is your duty to opt out through the procedures outlined in such communications. You further expressly acknowledge and understand that your photo and/or video likeness may be used, without limitation (with exception to private and confidential psychotherapy and yoga therapy sessions), in connection with publicity, copyright, marketing, web content, social media, live stream, recorded classes, or other uses and that permission is expressly granted for such uses, and that no additional consideration outside of the services provided by Insights, A Wellness Center, LLC will be provided.

**I have read, understand, and agree to the above rules and conditions**
Signature*

I understand typing my signature and submitting this form indicates full agreement to all terms within this liability waiver for myself and on behalf of all minor children listed herein, as parent or legal guardian.
Name
This field is for validation purposes and should be left unchanged.

Hippa Form

What You Should Know about Confidentiality in Therapy

I will treat what you tell me with great care. My professional ethics (that is, my profession’s rules about moral matters) and the laws of this state prevent me from telling anyone else what you tell me unless you give me written permission. These rules and laws are the ways our society recognizes and supports the privacy of what we talk about – in other words, the “confidentiality” of therapy. But I cannot promise that everything you tell me will never be revealed to someone else. There are some times when the law requires me to tell things to others. There are also some other limits on our confidentiality. You need to know about these rules now, so that you don’t tell me something as a “secret” that I cannot keep secret. These are very important issues, so please read these pages carefully. A copy of this will be given to you. We can discuss any questions that you might have.

1. When you or other persons are in physical danger, the law requires me to tell others about it. Specifically:

a. If I come to believe that you are threatening serious harm to another person, I am required to try to protect that person. I may have to tell the person and the police, or perhaps try to have you put into a hospital.

b. If you seriously threaten or act in a way that is very likely to harm yourself, I may have to seek a hospital for you, or call on your family members or others who can help protect you. If such a situation does come up, I will fully discuss the situation with you before I do anything, unless there is a very strong reason not to.

c. In an emergency where your life or health is in danger, and I cannot get your consent, I may give another professional some information to protect your life. I will try to get your permission first, and I will discuss this with you as soon as possible afterwards.

d. If I believe or suspect that you are abusing a child, an elderly person, or a disabled person I must file a report with a state agency. To “abuse” means to neglect, hurt, or sexually molest another person. I do not have any legal power to investigate the situation to find out all the facts. The state agency will investigate. If this might be your situation, we should discuss the legal aspects in detail before you tell me anything about these topics. You may also want to talk to your lawyer.

In any of these situations, I would reveal only the information that is needed to protect you or the other person. I would not tell everything you have told me.

2. In general, if you become involved in a court case or proceeding, you can prevent me from testifying in court about what you have told me. This is called “privilege,” and it is your choice to prevent me from testifying to allow me to do so. However, there are some situations where a judge or court may require me to testify:

a. In child custody or adoption proceedings, where your fitness as a parent is questioned or in doubt.

b. In cases where your emotional or mental condition is important information for a court’s decision.

c. During a malpractice case or an investigation of me or another therapist by a professional group.

d. In a civil commitment hearing to decide if you will be admitted to a psychiatric hospital.

e. When you are seeing me for court-ordered evaluations or treatment. In this case we need to discuss confidentiality fully, because you don’t have to tell me what you don’t want the court to find out through my report.

3. There are a few other things you must know about confidentiality and your treatment:

a. I may sometimes consult (talk) with another professional about your treatment. This other person is also required by professional ethics to keep your information confidential. Likewise, when I am out of town or unavailable, another therapist will be available to help my clients. I must give him or her some information about my clients, like you.

b. I am required to keep records of your treatment, such as the notes I take when we meet. You have a right to review these records with me. If something in the record might seriously upset you, I may leave it out, but I will fully explain my reasons to you.

4. Children and families create some special confidentiality questions.

a. When I treat children under the age of about 12, I must tell their parents or guardians whatever they ask me. As children grow more able to understand and choose, they assume legal rights. For those between the ages of 12 and 18, most of the details in things they tell me will be treated as confidential. However, parents or guardians have the right to know if the child is considering harm to self or others.

b. In cases where I treat several members of a family (parents and children or other relatives), the confidentiality situation can become very complicated. I may have different duties toward different family members. At the start of our treatment, we must all have a clear understanding of our purposes and my role. Then we can be clear about any limits on confidentiality that may exist.

c. If you tell me something your spouse does not know, and not knowing this could harm him or her, I cannot promise to keep it confidential. I will work with you to decide on the best long-term way to handle situations like this.

d. If you and your spouse have a custody dispute, or a court custody hearing in coming up, I will need to know about it. My professional ethics prevent me from doing both therapy and custody evaluations.

e. If you are seeking me for marriage/couples counseling, you must agree at the start of treatment that if you eventually decide to divorce, you will not request my testimony for either side. The court, however, may order me to testify.

f. At the start of family treatment, we must also specify which members of the family must sign a release form for the common record I create in the therapy or therapies. (See point 6b, below.)

5. Other points:

a. If your account with me is unpaid and we have not arranged a payment plan, I can use legal means to get paid. The only information I will give to the court, a collection agency, or a lawyer, will be your name, address, and contact numbers, as well as the dates we met for professional services, and the amount due to me.

b. I will not record our therapy sessions on audiotape or videotapes without your written permission.

c. If you want me to send information about our therapy to someone else, you must sign a “release of records” form.

d. Any information that you share outside of therapy, willingly and publicly, will not be considered protected or confidential by a court.

The law and rules on confidentiality are complicated. Situations that are not mentioned here come up only rarely in my practice. Please bear in mind that I am not able to give you legal advice. If you have special or unusual concerns, and so need special advice, I strongly suggest that you talk to a lawyer to protect your interests legally.

Intake Form

Policies Form

Policies Signature Form

Policies Form

Liability Waiver

Hippa Form

HIPPA Form