slogan
Blue Mountains
Blue Mountains

Forms




Wellness Solutions

Live Mindful. Feel Better.









Please complete the following forms and bring them to your first therapy session.
If you forget to bring your forms Wellness Solutions, LLC will provide them to you at the time of your appointment. Please keep in mind the forms may take 15 minutes to review.



Client Forms:

1. Client Registration Form-This form provides all demographics to register a client, check eligibility, submit claims for insurance, identify guardians and guarantors, and establish appropriate means of contact for administrative purposes. (Required to be Completed and Submitted at First Appointment)

Client Registration Form


2. Informed Consent and Disclosures- The information in this form includes the following: Informed Consent for Outpatient Psychotherapy, Notice of Limitations of Confidentiality, Notice of Billing Practices and Policies, Notice of Client Financial Responsibilities, and Permission to Treat for Outpatient Psychotherapy. Please initial and sign where indicated. (Required to be Completed and Submitted at First Appointment)

Informed Consent and Disclosures


3. Notice of Privacy Policies and Practices- This information is a detailed description of the HIPAA compliant privacy policies and practices of Wellness Solutions, LLC. It is strongly recommended that you read it thoroughly. The Notice of Privacy Policies and Practices information is also available on this website under the "Privacy Policy" tab and it is also in Dani's office at Wellness Solutions, LLC. (Please read this form. It is not required that you print this form and turn it in.)

Notice of Privacy Policies and Practices


4. Acknowledgement of receipt of Privacy Policies and Practices- This form is an acknowledgement that you received the information in the above Notice of Privacy Policies and Practices, understand the contents of the above form, and agree to the privacy policies and practices. (Required to be Completed and Submitted at First Appointment)

Acknowledgement of receipt of Privacy Policies and Practices


5. Consent to Release Information- This form allows Wellness Solutions, LLC staff to discuss your care with the indentified individuals of your choice. Wellness Solutions, LLC requires that a consent to release information be on file for your primary care physician (if you have one), your psychiatrist (if you have one), and an emergency contact. If you have any other individuals, healthcare providers, or social service organizations you would like Wellness Solutions, LLC to coordinate care with then we will also need an additional consent to release information on file for those contacts. (Required to be Completed and Submitted at First Appointment)

Consent to Release Information


Note: To download Adobe Acrobat Reader for free, click here.





"Although the world is full of suffering, it is also full of overcoming it."
Helen Keller


Schedule Appointment

Start your new path in life and be the change today!

CLICK HERE
Helpful Forms

Click here to view and print forms for your appointment.

CLICK HERE