Intake Form

Printable Intake Form

Printable Professional Disclosure Statement

Intake Form

Lakeview Counseling, LLC

Kristyn Hamblin MS, EMDR, NCC, QSUDP, LPC

Florence, Oregon 97439

Phone: (541) 305-55887

Consent to Treatment

I consent to take part in treatment at Lakeview Counseling, LLC.

I have received and read the Client Services Agreement and Privacy Practices and Kristyn Hamblin’s Lakeview Counseling, LLC Professional Disclosure Statement. The Notice of Privacy Practices are required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996. I have asked any questions that I have now and if I have future questions regarding Client Services Agreement and Privacy Practices, I will ask Kristyn.

I understand that I am responsible for my bill. While Kristyn and Lakeview Counseling, LLC may assist me with pursuing insurance reimbursement, I understand that unpaid bills are my responsibility. A bill of greater than $300 must be reduced before resuming counseling.

I authorize release of necessary information to my insurance company through invoice receipts. The receipts will contain service dates and diagnosis codes as required by the insurance provider. In select cases, an insurance provider may need additional information.

Consent *I consent to treatment and agree to the terms aboveYesOption 2

Signature

Date

If acting as personal representative, describe legal authority

Name

Pronouns

Phone *

Okay to leave message *YesNo

Email Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Children and Ages

Years Married

Marital Status

Referral Source

PCP Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Country

Phone

Medications

Primary Concern

Client Services Agreement and Privacy Practices

The Counseling Process

Counseling is one way to identify and resolve personal, emotional or relational issues...

However, improvement does not always occur and there may be periods of increased difficulty...

Occasionally, the help of other supportive professionals may be needed...

Confidentiality

Counseling, including all communications between therapist and client, is confidential...

Child abuse
Elder abuse
Imminent risk of harm

Scheduling and Fees

If you must cancel with less than 24 hours notice, full session fee applies...

Insurance

Responsibility for insurance rests with the client...

Privacy Practices

Your Protected Health Information (PHI) may be used for treatment, payment, operations, or as required by law.

Right to inspect and copy
Right to amend
Right to request restrictions
Right to file a complaint

If you have further questions, please ask.

I have read and agree to the Client Services Agreement and Privacy Practices *Option 1Option 2