Medical Forms

This Client In-take Form is required prior to paying for your therapy sessions, either with or without insurance coverage. You will then be directed to the Therapy Services page. For those clients without insurance, please choose the therapy session you wish and pay for it there. Once you have completed payment, you will be redirected to the Session Booking page for selecting your 1st of 3 sessions time and date.
If you have medical insurance, please follow the instructions next to the Session product description or read our FAQ’s.

Client Intake Form

"*" indicates required fields

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Name*
Address*
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Dou You Have Insurance?*
If you have insurance, you must contact your insurance company, get an authorization # and Co-pay amount prior to submitting this form.
Dr. Harris will not accommodate me with completing any disability claims including FMLA.*
I authorize payment of medical benefits to the named provider for professional services rendered*
I authorize the release of medical information necessary to process this request*

If you have insurance you must upload the front and back, a copy of your insurance card. Failure to do so will invalidate the insurance process.

Drop files here or
Accepted file types: jpg, pdf, Max. file size: 256 MB, Max. files: 2.
    CLIENT INFORMED CONSENT Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are lengthy and somewhat complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future. SERVICES Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. As your therapist, I have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. The first session will allow us to get to know each other just a bit and give me the opportunity to offer you an initial impression of what our work may include. At this point, we will also discuss your goals and create an initial treatment plan. This complimentary session will allow for you to be able to decide if you feel comfortable working me and if you would like to move forward with therapy. APPOINTMENTS Appointments will ordinarily be 45 - 50 minutes in duration and vary depending upon the package you select. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is that there will be no refund owed to you [unless we both agree that you were unable to attend due to circumstances beyond your control], at which time, we can reschedule that appointment. You are responsible for being present for your sessions on time. If you are late, your appointment will still need to end on time. PROFESSIONAL FEES The initial session is 1 of 3 and may be paid in full (without insurance) or a co-pay (with authorized insurance). Once you’re ready to secure services, you will have the opportunity to choose a package that best fits your needs. Prices vary depending upon the specific package you select. Once you select a package, you are responsible for paying at that time and prior to the start of therapy. Payment must be made by PayPal or Venmo. I do not process credit card charges as payment (we use a 3rd party vendor). If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. PROFESSIONAL RECORDS I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location in my office. I keep brief records noting if you were present, your reasons for seeking therapy, the goals and progress we have set for treatment, your progress and various topics we have discussed as well as history of therapy and medical history if related to your presenting problems. CONFIDENTIALITY & TECHNOLOGY I will make every effort to keep your personal information private. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. As your therapist, I take every precaution to safeguard your information, but cannot guarantee that unauthorized access to electronic communications could not occur. If you wish to have information released to another party, you will be required to sign a consent form before such information will be released. Counselors are required by law to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly.
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