Growing Harmony Services: Intake Form

The above information is correct to the best of my knowledge. I agree to pay the full fee for services. I agree to authorize Growing Harmony Services and/or Linda Tremblay to release any and all information pertinent to billing and managed care. I agree to pay for all evaluation services in full prior to any records or evaluation results being sent to the requesting entity. I understand that no records will be sent out until my fee is paid in full. I understand that I must provide Growing Harmony Services and/or Linda Tremblay with at least 24 hours' notice of cancellation for any scheduled appointment. I agree to pay for any session cancelled without 24 hours' notice.

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Consent to Receive Services:

• I understand the risks and benefits of therapy as discussed.

• I have reviewed and received the PHI/HIPPA handout.

• I understand and have received my rights and responsibilities.

• I understand the limits of confidentiality as discussed.

• I understand that I will be charged for a session if I do not give at least 24 hours notice of cancellation.

• I understand that any 90-day-plus outstanding balance may be submitted to collections and I give consent for this confidential information to be released to the collections agency.

• I understand that by using my insurance health benefits, Linda will need to give me a behavioral health diagnosis which, at a later time, may inhibit me from obtaining life or other types of insurance.

• I understand email or phone communication will be billed in fifteen-minute increments at $30 per fifteen minutes; $55 per thirty minutes; $80 per forty-five minutes. A five-minute-or-less telephone conversation will be complimentary once a month. Payment for your email or phone session will be expected at your next scheduled session or mailed within thirty days of the service.

• I understand email and texting are used at times for scheduling purposes only. Facebook and other social media will not be used.

I/We, the undersigned, consent to receive services from Growing Harmony Services/Linda Tremblay according to the terms described and discussed.