Intake Forms & Informed Consent
MyCounselor is a provider of “Mental Health Services”. As such we must collect some information about you and your presenting concerns for our records (Intake Forms). We also need to provide you with some information about the services you will receive (Informed Consent). You’ll need to complete each of the following documents before your first session. Completing the documents prior to your first session is very important, as we can not provide you with services without these documents complete.
If you have any questions please give us a call at 855-593-4357 and we will be happy to answer them.
Each adult participating in sessions must complete the following:
Adult Intake Form
Clients age 18 and older must complete this form prior to the first scheduled appointment with one of our counselors.
Informed Consent Documents
This form contains a Counseling Service Agreement along with important information on Christian counseling, privacy, insurance and financial responsibilities.
If you are a parent or guardian scheduling family sessions, complete the Family Intake Form:
Family Intake Form
Clients receiving family counseling must complete this form prior to the first scheduled appointment with one of our counselors.
Payment Plan & Scholarship
Payment Plan Request Form
Qualifying clients must complete this form prior to beginning weekly payments for services provided by our counselors.
If you are the recipient of an organizational scholarship you will need to complete this scholarship agreement.
Insurance Processing Request Form
Complete this form to have our medical biller submit insurance reimbursement claims on your behalf.
Authorization to Use & Release Personal Health Information (PH) Form
MyCounselor (MCO) may use or disclose your protected health information (PHI) for treatment, payment, and health care operations for the purposes within your written authorization.
Sexual Identity Therapy Advanced Information Consent
Clients receiving sexual identity therapy must complete this form prior to the first scheduled appointment with one of our counselors.
Court Service Request Form
Clients needing MyCounselor to provide reports and documentation to assist with legal matters must complete a Court Service Request form.
3rd Party Authorization to Disclose and Release PHI
The following release authorizes MCO to release and discuss that billing information to the 3rd party person designated.
3rd Party Financial Responsibility Agreement
This agreement allows a 3rd-party to provide a scholarship for clients needing counseling.