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Client Intake Form

Full Name Date of Birth Email Phone

Insurance Information

Insurance Provider Policy Holder Name Relationship to Client Insurance Company Member ID / Policy Number Group Number Insurance Phone Number Do you have secondary insurance? Reason for Seeking Counseling Electronic Signature I consent to the terms, privacy policies, and electronic transmission of submitted data.

Release of Information

Client Name Organization or Individual Receiving Information Purpose of Disclosure Electronic Signature I authorize the release of information and consent to electronic submission of this form.

HIPAA Notice of Privacy Practices

I acknowledge that I have received and reviewed the Notice of Privacy Practices for Thrive Trauma-Informed Care, LLC.

Client Name Date Electronic Signature I consent to the privacy policies and electronic submission of this acknowledgement.

Telehealth Consent

I understand that telehealth services involve electronic communication and there are potential risks and benefits associated with telehealth counseling.

Client Name Date Electronic Signature I consent to telehealth services and electronic transmission of my information.

Financial Policy Agreement

I understand that I am responsible for payment of services provided by Thrive Trauma-Informed Care, LLC.

Client Name Date Electronic Signature I agree to the financial policies and consent to electronic submission.

Carrie Moore, LICSW, PIP

Counseling Services of Dothan
334-794-2113

Business Cell
334-980-2520

Email
carrie.moore@thrivetraumainformedcare.org

Dothan, Alabama

© Thrive Trauma-Informed Care, LLC