Client Intake Form
Please read all information pertaining to limits if confidentiality, insurance and cancellation policy before proceeding to the online intake form provided below.
Limits of Confidentiality
Confidentiality between client and therapist is of the utmost importance. Your verbal communication and clinical records are strictly confidential except for the following:
1. Information you and /or your child or children report about physical of sexual abuse of a minor or an elder person; in such cases I am obligated by Connecticut State Law to report this information to the CT Department of Children and Families.
2. If you provide information that informs me that you are in danger of harming yourself of others.
3. Where you sign a release to have specific information shared.
4. Information shared with your insurance company to process your claims.
I agree to the above limits of confidentiality, understand their meanings and ramifications, and acknowledge the electronic signature affixed below carries the full weight of my handwritten signature.
For your protection and confidentiality we recommend that, if possible, you pay for your counseling without using insurance. Insurance companies require us to disclose highly personal information about you. The confidentiality and privacy of this
information cannot be guaranteed. They also often restrict the number of sessions they will authorize, even if we agree that you still need help.
If you choose to use your insurance, most insurance plans that provide out-of-network benefits will provide coverage for our services. We can provide you with a monthly invoice to submit to your insurance company for reimbursement.
Please check your insurance coverage carefully. Some services may be covered in full and some in part by your health insurance or employee benefit plan. In the event that your insurance does not cover the cost of your session(s), you, the client, will be wholly and fully responsible for any remaining balances on your account not covered or unpaid by your insurance company.
Appointments cancelled less than 24 hours before the scheduled appointment time, or missed altogether, are subject to a cancellation fee equal to the amount of a full fee appointment. The amount due will be charged to the credit card on file.
You will be asked to provide credit card information for our files below.