Intake Form

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Client Information

Medical History

Emergency Contact Information

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By E-signing this form I consent to allow A Time for Peace Inc. to contact me regarding scheduling an appointment and I consent to receive mental health treatment either in office or via tele-health. I consent to allow A Time for Peace Inc. to bill my insurance on my behalf for compensation for claims and I understand that co pays, deductibles or self pay balances are due at time of services. Self pay rates are $150 per hour but discounts are available based on household size and income. A copy of a financial aid application can be request from office staff. I understand there is a $25.00 no show fee for all missed therapy appointments and a $50.00 no show fee for missed medication/eval appointments. All or part of the no show fee may be required prior to scheduling a follow up appointment. I understand that A Time for Peace Inc. follows the HIPAA law and may only disclose PHI with my written consent or when permitted/required by law. More detailed consent forms and a copy of the privacy policies can be found in my patient portal.

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