Contact Information & Communication Consent

NOTICE: If this an emergency, call 911.

Our Phone: 701.478.7199

1. Hello! Let's get started!

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 email/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)

Provider Request:

Anxiety/Trauma Specialist:

Erin Hagen, LPCC

Complex Anxiety Specialist:

Kama Jensen, LPCC

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

BCBS ND or BCBS PPO

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Sanford Health

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BCBS MN

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Private Pay

ID number on your insurance card. * Enter "NA" if private pay.

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.