Intake & Consent Form for GMH Clients
Please fill out the following information prior to your first appointment with Good Mental Health LLC.
(Please Answer N/A in fields that do not apply)
Client Name *
Date of Birth *
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If Minor Child, Parent Name *
Address *
City *
State *
Zip Code *
Phone/Cell# *
Email *
Emergency Contact Person *
Emergency Contact Relationship to Client *
Emergency Contact Phone/Cell# *
Reason for Seeking Services *
How Were You Referred? *
Do you consent to receive: *
Required
Mental Health History? *
Do you see a psychiatrist? *
If Yes, who is your psychiatrist? *
Meds currently taking: *
I hereby authorize Good Mental Health LLC to speak to the following people regarding my care, payments, and upcoming appointments (please specify names): *
Please read and consent to the following statements: *
You are responsible for keeping track of and coming to your appointments at the scheduled time. Sessions last for 50 minutes. If you are late, we will end on time and not run over into the next person’s session. *
Due to the unique nature of teletherapy (meeting via telephone or video chat), you are responsible for communicating your physical location at the beginning of each meeting. In the event you are experiencing a crisis, this information will allow me to access the proper intervention necessary to support your well-being. *
Your appointment is set especially for you. If you cannot make your appointment, please notify me as soon as possible at office@goodmentalhealthllc.com or 904-325-6105. This allows me to fill the appointment and prevents long wait times between appointments. For appointments canceled less than 24 hours in advance, a telephone or telethealth appointment will be made available for you at the appointed time, however you will be charged your normal session rate whether or not you choose to attend. *
If you miss an appointment without notification, you consent to a $95 no show fee due before you are seen again. If you miss 2 or more appointments without notification you will be referred to a new provider and I will no longer provide you services. *
You agree to pay for your portion in full at the beginning of your appointment. My fees are listed on my website (goodmentalhealthllc.com) and include $95/session for teletherapy, $95/session in office. I can accept payment online through the secure payment portal on my website or in-person via check, cash, or credit card. At this time, I do not accept private insurance but I am willing to work on a sliding fee scale for those in need. I require an authorized credit card on file to ensure against missed appointments and will always notify you when charging your card. *
Card Type for authorized payments: *
Required
Cardholder Name (as shown on card) *
Card Number: *
CVV Code *
Expiration Date (mm/yy): *
Cardholder ZIP Code (from credit card billing address) *
By entering my name below, I authorize Diana Brummer with Good Mental Health LLC to charge my credit card for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account. *
Please print and return a signed copy of the payment authorization form found here: https://bit.ly/2Z7yo20 *
I am not willing to have clients run a bill with me. You agree to pay any and all monies owed. If you refuse to pay any debt with Good Mental Health, LLC, you consent to have your name given to a collection agency to recover any debt, and services will be terminated. *
Please review our HIPAA disclosure here: https://bit.ly/2Axo75b *
If you would like clarification of any of the above listed requirements for treatment, please send an email to: office@goodmentalhealthllc.com or call 904-325-6105 to discuss your concerns. We are happy to answer any questions you may have. *
Your current consent for treatment is valid for 1 calendar year and must be updated on or about January 1st unless treatment lapses for 90 days or more, or your personal information substantially changes. *
I agree I have received and read this Consent for Treatment outlining my responsibilities as a participant in treatment and have had any questions answered to my satisfaction. By my signature below, I verify that I understand the Disclosure Statement and my responsibilities as a client and consent to participate, or have my child participate, in treatment with Good Mental Health, LLC. If attending Couples Therapy, I understand that my/spouse’s signature(s) indicate that I/we give consent to release to my spouse any and all information discussed in session with my spouse present. I consent to the disclosure of necessary information to my insurance company for billing purposes if applicable. *
By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
For identity verification purposes, please provide the last 4 digits of your social security number: *
Today's Date *
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Thank you for your submission. Follow this link to schedule an appointment online: https://bit.ly/GMHappt *
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