New Client Intake Form (Adult)

Conscious Living Counseling & Education Center, West Fargo

Please correct the errors described below.

Your Name

Medical & Psychosocial Information

Hello. The purpose of this form is to collect important information about your history and current symptoms, in your own words.

Emergency Contact Information

Add another emergency contact

Relationship History

Trauma & Loss History

Learning & Education

Employment History

Social Relationships

Depression Assessment

Anxiety Assessment

Medical & Mental Health History

Hormone/Reproductive Health

Self-Care Habits

Sleep Health

Medications

Primary Medical Provider

PAYMENT STUFF All self-pay are due at the time of service. We can provide you with an itemized receipt for submission to a health savings account, by request.
 


INSURANCE CLAIMS If your coverage requires a co-payment please bring a means of payment (cash, check, or credit card) to your appointment. Co-insurance or deductible amounts are due after your insurance processes and you receive the explanation of benefits from your insurance carrier. You will receive a bill from Conscious Living Counseling stating the amount due and due date. Our staff will file a claim with your insurance carrier. We will work with you to obtain the benefits you deserve; but, remember, you are accountable for the “patient responsibility” portion of our charges.

QUESTIONS Call the office between 9:00 am and 5:00 pm Monday through Friday. Thank you!

COMMUNICATION CONSENT:

We use HIPAA-compliant technology to reduce wait times, improve the intake process, and ensure that you have access to your provider when needed. We need your consent in order to move forward. Your provider will explain each service in detail. Please call or email if you have questions now.

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