Intake Form
Thank you for your interest in OnyiaMind Counseling.

Please complete all questions. We will review your responses and connect you with a therapist that suits your needs. In the event that we cannot staff a therapist for you, we can assist in referring you to alternative resources. Please send a copy of your insurance card (front and back) along with a copy of your identification/driver's license to info@onyiamind.com. Please include your full name on the email subject line.
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Email *
                                                                     OnyiaMind Counseling, Inc
First Name *
Last Name *
Date of Birth *
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Gender *
Preferred Language *
Social Security Number *
Mandatory for Insurance billing and Identification purposes.
Email Address *
Phone Number *
Address *
Previous Psychotherapy/Psychiatric Treatment *
 (If yes, please provide details in the following section)
(Previous Psychotherapy/Psychiatric Treatment)             *
If previous response was "Yes" please enter the name of the service provider, when services were provided and duration of services.  If you have not received therapy services in the past please type "N/A" below and continue to the next section.
Are you taking medication? *
Please list all medications *
If you're not taking medications please type "N/A" below and continue to the next section.
Reason for Consultation (Check all that apply) *
Required
Other (Response)
 
 *
Required
Preferred Days *
Required
Preferred Appointment Time *
Required
Preferred Session Type *
Preferred Therapist *
What are your goals for your therapeutic sessions? *
How did you hear about us? *
Therapy Agreement and Consent
OnyiaMind Counseling has contracts with most insurance carriers to provide services to their members. In these contracts we accept assignment of benefits from them and you as a member agree to accept responsibility of copayment, co-insurance and/or deductible at the end of each session. Please note that our office has made every effort to verify insurance benefits, coverage and eligibility, however, verification does not guarantee payment, and you are responsible to pay session fees. You are responsible to be sure your coverage is active. If for any reason an insurance claim is denied you assume the responsibility for payment and any balance not covered by your insurance.
Disclaimer
1.
My therapist must honor court subpoenas that require the release of specified information. My therapist may take professional action to protect those in immediate danger of physical harm. My therapist is mandated by Florida Law to report suspected child or elderly abuse or neglect. My therapist may share information with me from my children's therapy session if he or she believes that my children are in imminent danger.
2.
I agree to notify my therapist at least 24 hours in advance should I need to cancel an appointment. If I fail to do so, I understand that I will be charged for the time I had booked, payable at my appointment at a rate of $50.00 which is not billable to my insurance with the exception of an emergency. If you are not able to make your appointment you may have the option of either a FaceTime, Telehealth or a phone session. Please consult your therapist to see which option may be available.
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