Therapist Intake Form

If you have been approved to be a therapist at Guttman and Pearl Associates for mentorship, coaching or supervision services, please fill out this form and acknowledge receipt of all notices here within. We look forward to working with you.

Email(Required)

Name(Required)

First Last

Date of birth(Required)

Month

Day

Year

Sex(Required)

Female

Male

Prefer not to say

Other

Gender Identity(Required)

She/Her

He/Him

They/Them

Other

Cell/Main Phone Number(Required)

Work Phone Number

Home Phone Number

Address(Required)

Street Address Address Line 2 City State ZIP Code

Emergency Contact(Required)

First Last

Emergency Contact Relationship(Required)

Emergency Contact Phone(Required)

Section Break

ESign, Cancellation Policy, Privacy Practices, Self-Pay Agreement

E-SIGN ACKNOWLEDGEMENT AND AGREEMENT(Required)

You agree that your signature for this electronic document is valid and will be enforceable as and to the full extent of a hand-written signature as an original for this entire New Client Intake Form, including all sections and checkboxes here within. BY TYPING YOUR FULL NAME BELOW, you agree to this E-Sign Acknowledgement and Agreement.

Cancellation Policy(Required)

Cancellation Policy: Your appointment time is reserved specifically for you. If you are unable to keep your scheduled appointment, or need to re-schedule for any reason, please give us 24 hours notice. Cancellations must be made either by phone or email. With this notice, we have the opportunity to fill your open session. Without this notice, you will be billed for the session. In case of snow, there will be no charge for cancelled appointments as long as you phone or email your cancellation in advance. By CHECKING THE BOX BELOW, I e-sign and acknowledge that I have read and agree to the Cancellation Policy as stated here within.

Yes, I acknowledge and agree to the Cancellation Policy.

SELF-PAY AGREEMENT(Required)

All services at Guttman & Pearl Associates are self-pay and due at the time of service. Superbills are sent out on a monthly basis on or after the 15th for the previous month and include all information needed for you to request reimbursement from your insurer for covered services. GPA does not and will not submit bills to insurance companies on clients' behalf for reimbursement. All insurance reimbursements for services will be the clients responsibility. Please confirm your coverage, benefits and reimbursement process prior to your first appointment and arrive prepared to pay for your session. BY CHECKING THE BOX BELOW, I e-sign and acknowledge that have read and agree to the Self-Pay Agreement.

Yes, I have read and agree to the Self-Pay Agreement.

NOTICE OF PRIVACY PRACTICES (EMAILED TO YOU UPON SUBMISSION OF THIS FORM): THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.(Required)

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law, the NASW Code of Ethics, and the American Psychological Association Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI. I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or providing one to you at your next appointment. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultant only with your authorization.For Payment. I may use and disclose PHI so that I can provide the necessary information for your insurance carrier, explaining the treatment services you received. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.For Communication with you. When I need to contact you by telephone I will use the phone numbers you have given me on the signature form to do this. Required by Law. Under the law, I must make disclosures of your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule. Without Authorization: Applicable law and ethical standards permit me to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:• Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work or psychology licensing board or the health department) • Required by Court Order • Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. Verbal Permission: I may use or disclose your information to family members that are directly involved in your treatment with your verbal permission. With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked. Your treatment will not be affected if you choose to not sign an authorization. YOUR RIGHTS REGARDING YOUR PHI You have the following rights regarding PHI I maintain about you. To exercise any of these rights, please submit your request in writing to me.• Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. • Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although I are not required to agree to the amendment. • Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that I make of your PHI. • Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. I are not required to agree to your request. • Right to Request Confidential Communication. You have the right to request that I communicate with you about medical matters in a certain way or at a certain location.• Right to a Copy of this Notice. You have the right to a copy of this notice. COMPLAINTS: f you believe I have violated your privacy rights, you have the right to file a complaint in writing to me or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. I will not retaliate against you for filing a complaint. BY CHECKING THE BOX BELOW, I e-sign and hereby acknowledge that I read the Notice of Privacy Practices and I am aware that I may request a copy of the current Privacy Practices at any appointment.

Yes, I have a read of the Privacy Practices and am aware I may request a copy at any future appointment with my therapist.

Consent(Required)

By SIGNING YOUR FULL NAME BELOW, you e-sign and agree that all information is yours, true and accurate. You also e-sign and agree to all acknowledgements and agreements within this document. Lastly, you e-sign and consent to therapy services as discussed with your therapist, including therapy session fees.

Date of Signature(Required)

MM slash DD slash YYYY