Client Forms & Getting Started

Everything you need to begin our journey together

New Client Intake Form

Client Name*
First Last
Gender Identity*
- Female
- Male
- Nonbinary
- Transgender
- Prefer not to say
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
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*
Emergency Contact Name*
Emergency Contact Phone*
Date*
MM slash DD slash YYYY

Client Policies & Practice Information

CLIENT POLICIES & PRACTICE INFORMATION

Insights Wellness Center, LLC

Please review the following practice policies carefully. These guidelines are intended to support a clear, respectful, and consistent therapeutic relationship.

FEES & APPOINTMENTS

Payment

Payment is due at the time services are provided.

Payment may be made by cash, check, or Venmo. Checks may be made payable to Insights Wellness Center, LLC.

Cancellation & Rescheduling Policy

A minimum of 24 hours of notice is required to cancel or reschedule an appointment.

Appointments cancelled with less than 24 hours of notice are subject to a $125 late cancellation fee.

The late cancellation fee may be waived under the following circumstances:

A medical circumstance occurs and appropriate documentation is provided when requested.
An available appointment can be rescheduled within the same calendar week. Please understand that availability is often limited. If the rescheduled appointment is subsequently cancelled, the $125 late cancellation fee will apply.
The cancelled appointment time can be filled by another client.

Thank you for respecting the time that has been reserved specifically for you.

Session Length & Late Arrival

Standard therapy sessions are approximately 50 minutes.

If you arrive late, your session will still end at the originally scheduled time so that subsequent appointments can begin as scheduled.

Returned Checks

A $30 returned-check fee, in addition to the unpaid session fee, will be due before or at the next scheduled session.

IN-PERSON APPOINTMENTS

Insights Wellness Center operates from a private home-office setting.

When you arrive for an in-person appointment, please park in the designated gravel parking area and text “here.”

Your therapist will acknowledge your message when it is time for you to enter.

Please do not enter the office until you receive confirmation.

EMERGENCIES & CRISIS SUPPORT

Insights Wellness Center is not a 24-hour emergency or crisis service, and messages may not be reviewed immediately.

If you are experiencing an immediate or life-threatening emergency, please call 911 or go to the nearest emergency department.

If you are experiencing a mental health or emotional crisis, you may also call or text 988 to reach the Suicide & Crisis Lifeline.

For concerns that are not emergencies, please bring the matter to your next scheduled session or leave a message requesting a return call.

CONFIDENTIALITY

Your privacy and confidentiality are important parts of the therapeutic relationship.

Information shared in therapy is generally confidential and is protected in accordance with applicable federal and Connecticut law and professional ethical standards.

There are circumstances in which information may be disclosed when permitted or required by law, including certain situations involving abuse or neglect, significant safety concerns, emergencies, court or legal requirements, or other legally recognized exceptions.

Additional information regarding confidentiality, privacy rights, and the use and disclosure of health information is provided in the Insights Wellness Center Notice of Privacy Practices & Confidentiality.

When communication with another professional or organization may be helpful to your treatment, such as a physician, previous therapist, school, or other provider, you will generally be asked to complete a written Release of Information before information is exchanged.

PARTICIPATION IN TREATMENT

Alcohol & Substance Use

Clients should not attend therapy while significantly impaired by alcohol or other substances.

If your therapist believes that you are unable to participate safely or meaningfully in the session, the appointment may need to be ended or rescheduled.

Minor Children

Parents and guardians may not leave minor children unattended at Insights Wellness Center unless specific arrangements have been made as part of the child’s treatment.

Couples, Family & Group Therapy

When participating in couples, family, or group therapy, substantive therapeutic matters should generally be addressed during scheduled sessions rather than through private telephone, text, or email conversations with the therapist.

This helps maintain appropriate therapeutic boundaries, clarity, and fairness among those participating in treatment.

Additional expectations regarding confidentiality and communication may be discussed at the beginning of couples, family, or group treatment.

COMMUNICATION

Scheduling

Text messages and voicemail may be used for scheduling and brief administrative matters.

Appointment cancellations and rescheduling requests should be made with at least 24 hours of notice in accordance with the cancellation policy above.

Therapeutic Matters

Text messaging, email, and voicemail are not intended to replace psychotherapy sessions.

Clinical concerns and therapeutic discussions should generally be addressed during scheduled sessions. If you need additional therapeutic support between regularly scheduled appointments, please contact your therapist to discuss scheduling an additional session when available.

Electronic communications may carry privacy risks and should not be used for emergencies.

SOCIAL MEDIA & PROFESSIONAL BOUNDARIES

Maintaining appropriate professional boundaries helps protect both your privacy and the therapeutic relationship.

Insights Wellness Center does not conduct psychotherapy through social media or enter into personal social-media relationships with current therapy clients.

You are never expected or required to follow, connect with, comment on, or interact with Insights Wellness Center or your therapist through social media.

Public educational or wellness content provided by Insights Wellness Center is not a substitute for individualized psychotherapy or professional advice.

ACKNOWLEDGMENT

By signing below, I acknowledge that I have read and understand the Client Policies & Practice Information of Insights Wellness Center, LLC.

I understand the policies regarding fees, cancellations, appointments, communication, emergencies, confidentiality, treatment participation, and professional boundaries and agree to follow these policies while receiving services.

Name:

Date:

Electronic Signature:

Typing my name electronically and submitting this form serves as my electronic signature and acknowledgment of these policies.

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.

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This field is for validation purposes and should be left unchanged.
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.

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.

Client Forms & Getting Started

Everything you need to begin our journey together

New Client Intake Form