Intake Form - Military

Please complete this form prior to our first session.  All information is protected by confidentiality. 
** This is a Secure form.  All information sent will be encrypted.  
    Military
    Education
    Employment
    Medical
    Symptoms / Behaviors
    Legal
    Notice to clients and prospective clients:
         Under the law, health care providers need to give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. 
         You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. 
         You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service, or at any time during treatment.  
         If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.  
         For questions or more information about your right to a Good Faith Estimate, or how to dispute a bill, see your Estimate, or visit www.cms.gov/nosurprises. 

    The above statement is now required by law to be posted effective January 1, 2022. This new law protects consumers from "surprise" bills from any health care provider which is great for all of us.  In my practice, I do not bill for services. Each session is to be paid in full prior to you receiving the session. Whether you are not using insurance and paying in full for your session, or paying your insurance co-pay, payment is to be received prior to session.  This avoids any client holding any type of monetary balance. 


    Thank you for taking the time to complete this form. You will have an opportunity to discuss/clarify any information on this form. Please complete as much as possible.

    ​When you click Submit a copy will be sent to me.  ~ Liz Birch, LMFT