Confidential Client Information - Individual
Christine and Bret Eartheart, MSW LCSW
3449 W Ooley Dr
Bloomington, IN 47403
Date of Birth:
Required for Insurance Clients
Required for Insurance Clients
(Home) (Work) (Cell)
Best way of contact:
Insurance Company and Insurance Policy Number:
Please include the name of the policy holder if different as well as any relevant information from the back of the card
Preferred Billing Method:
Payment is due at the time of service. However, in the case of insurance processing. phone sessions, or unusual circumstances, it may be necessary to bill you. Please indicate your preferred method for receiving your invoice/statement.
Charge card on file (Please complete the Credit Card Authorization Form)
Occupation & Workplace:
How did you hear about our services?
Children's Names and Ages:
Why are you seeking services?
Have you had any past experience with counseling or coaching?
If so, please describe.
What do you want more of in your life?
What gets in the way of having this?
What do you want less of in your life?
What do you value most in life?
What are your greatest gifts/strengths?
Which relationships in your life are most important to you? Please list those individuals here. Then, next to their names, on a scale of 1-10, please rate how healthy and connected you feel in each of these (10 being the healthiest and most connected).
Please describe your physical health, how you feel about it, and how you'd love for it to look.
Please describe your mental and emotional health, how you feel about it, and how you'd love for it to look.
Please describe your spiritual health, how you feel about it, and how you'd love for it to look.
Are you currently seeing a therapist, counselor, healer, massage therapist, nutritionist, chiropractor, life coach, etc.?
If so, for what are you seeking their services?
Do you or your family members have any history with mental illness?
If so, please describe.
Are you currently on any medications?
If so, please list them AND what they are prescribed for.
EFT (Emotional Freedom Technique)
Not sure/Curious (tell us more in the 'Other' box!)
Is there anything you'd like me to know about you so that I can best serve and support you?
Client Commitments and Financial Policy
• We will come to our sessions with our open hearts and minds and will hold our sessions in 100% loving compassion. This is a judgment-free space where you are fully free to be YOU. • We celebrate and deeply honor you for accepting the invitation to grow, heal, transform, and thrive. When we say YES to these things, to the life and relationship we really want, abundant opportunities open up, and amazing things happen! • Coaching and counseling works like so many other things in life – the more you put into it, the more you get out of it. We lovingly invite you to open your mind and heart to all the new possibilities available to you, to stay present with the process, to be willing to change and grow and see things differently, to ask for whatever you need, to share your most honest thoughts and feelings, and to put into practice what we explore together. We know your time is precious, and we want to make the absolute most of our moments together and to serve and support you as best as possible. This will allow you to receive the maximum benefits! • We will keep everything shared in total confidentiality (unless required by law to report it). By accepting below, you consent to the release of personal information required for insurance and billing purposes. You can find a complete copy of our Notice of Privacy Practices at
which outlines your rights and our responsibilities under HIPAA. • Please let us know, at the beginning of the session, if you need to leave right after the designated amount of time we’ve set. Insurance sessions must be kept to only one hour per covered individual. For cash clients, if scheduling allows, you do have the option of allowing your session to extend past the scheduled amount of time. In these cases, you will be charged for the actual total time of the session. • Although Christine Eartheart is a Counselor, Certified Life and Relationship Coach, skilled facilitator of healing and transformation, and has extensive training and certification in a wide variety of modalities (such as EFT, Matrix Reimprinting, Reiki, hypnotherapy, etc.) you understand she is not a medical doctor or licensed mental health professional. (Bret is a Licensed Clinical Social Worker and psychotherapist.) • You agree to assume and accept full responsibility for any and all risks associated with utilizing the techniques presented to you. You understand that Eartheart LLC accepts no responsibility or liability whatsoever for the use or misuse of the information presented or any techniques, processes, suggestions and activities that occur within or beyond a session. • After your session, you might appreciate having some scheduled time for rest, journaling, connecting, and/or doing some nurturing activity to help you integrate all that occurred for you. This isn’t necessary but highly recommended. • Please have your payment with you, as it is required at the time of service unless other arrangements have been made prior to your session. Payment can be made as cash, credit card, or check. In the case of insurance, it may be necessary to bill you. Please ensure you have selected a preferred billing method on the Client Information Form. Thanks so much! • Please provide at least 24 hours’ notice if you need to cancel. If you cancel less than 24 hours before your appointment, you will be charged $35. If you miss an appointment without contacting us at least two hours beforehand, you will be charged the full session fee. This time slot was not available to be filled by another client, and preparations and scheduling considerations were made based on your session. Thanks very much for honoring this. • We may have clients scheduled directly before you. Please let yourselves in the white door with the stained glass window and make yourselves at home in the waiting room. We will be out to greet you.
I have read and accept the financial and scheduling policy. I have been made aware of the Notice of Privacy Practices and how I may obtain a copy.
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