Contact Information & Communication Consent

Please read the Provider Availability Notice.

Did someone refer you, or are you making the request yourself?

Please describe your primary concern(s):

First Name

Middle Initial

Last Name

Gender

Date of Birth

Month

Day

Year

*Complete Street Address

City

State

Zip

Email (double check, please)

Cell Phone

May we text and call you at this number?

Yes

My preferred communication is:

Text (CLCEC uses HIPAA-compliant texting)

(please look for a reply in you inbox/spam folder)

REQUEST

Dr. Erin Hagen, Anxiety & Trauma Specialist:

This provider is the best fit for me.

General anxiety concerns, Relational trauma (EMDR or CPT), Panic episodes.

Kama Jensen, Complex Anxiety Specialist:

This provider is the best fit for me.

General anxiety issues, Social anxiety, Fears about health, OCD/Obsessions, ADHD, Panic episodes, Sleep problems.

Educational Group(s):

spaceOUT Online Group

Personal management & time awareness group for the chronically overwhelmed and stressed. Begins August 31, Every Tuesday @ 10 am. Zoom meeting. Membership $160.00 month.

PAYMENT REQUEST

Please check insurance/payment preference: (We are not enrolled in government-issued medicaid)

BCBS ND or BCBS PPO

Please upload your insurance card below.

Sanford Health

Please upload your insurance card below.

Private Pay

*If using your insurance, please include a picture of the front side of your card.

* UPLOAD PICTURE HERE

Add file

Please upload a file

NON-TRADITIONAL 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.

I consent to receive text and email notifications for my appointments, invoices, and receipts.

I consent to HIPAA-compliant texting, when necessary or appropriate.

I consent to provide/allowing charges on my credit card for the balance due at the time of the appointment (self-pay clients only). If using insurance, I consent to charges for my co-payment, and co-insurance once my claim has been processed.

Lastly, by sending this, I consent to the use of digital forms.

Your information will be encrypted.