Basic Information & Communication Consent

COVID-19 UPDATE

The current global health crisis has changed how we live and work. All medical providers are needed at this time. In order to keep staff healthy, we're offering telehealth visits using a HIPAA-compliant platform, Zoom Medical. In-Office appointments are available with approval.

1. What's your appointment preference?

When would you like to schedule your appointment?

I prefer mornings.

I prefer afternoons.

I prefer the lunch hour.

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

Anything else you'd like us to know about your schedule?

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 email/text, and call you at this number?

Yes

AVAILABILITY:

Provider Kama Jensen is currently full. Providers Erin Hagen and Amy Runcorn are accepting new patients. Payment is collected at the time of the appointment. Intake: $150.00 (50 minutes) Return Session: $120.00 (50 minutes)

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 and the above terms.

Your information will be encrypted.

Kama Jensen

Intake Team, Conscious Living Counseling & Education Center

HI! My name is Kama. Privacy is everything to us. Hushmail is a recognized company and is HIPAA compliant. This means it offers the highest level of security for online communication and monitors security closely.

701-478-7199