Intake Form
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Client Last Name *
Client First Name *
Client DOB *
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Client Street Address *
Client City *
Client State *
Client Zip *
Client Email *
Client Phone
Parent/Guardian Last Name (if client is under 18 y/o or completing for client)
Parent/Guardian First Name
Parent/Guardian Relationship with Client
Parent/Guardian Street Address
Parent/Guardian City
Parent/Guardian State *
Parent/Guardian Zip
Parent/Guardian Email
Parent/Guardian Phone
How did you learn about Motivate Counseling or Rob Danzman?
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Billing Street Address (if different from above)
Billing City
Billing State
Billing Zip
Billing Email
Who will be the financially responsible party? (Client, Parent, Guardian, Other - Please put their name below) *
Payment Authorization
For your convenience, we require an active credit card to be kept on file that will only be charged for sessions, agreed-upon deposits, late fees or other service fees discussed and agreed upon during intake. Credit card information is maintained in our secure and encrypted payment management system. The credit card information provided by you to Motivate Counseling, LLC will be stored in a confidential manner. Our employees may access such information only when there is an appropriate business reason to do so, such as when a refund must be issued back to the credit card. Motivate Counseling, LLC maintains physical, electronic and procedural safeguards to protect your information, and our employees are required to follow these privacy standards.
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Card Type *
Card Number *
Card Expiration Date *
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Cardholder Name (exactly as written on card) *
Cardholder Street Address (if different from Billing address)
Cardholder City
Cardholder State
Cardholder Zip
Digital Signature *
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Client Information
Client Work/School Status
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Requested Services
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Reason for Seeking Services
Symptoms/Behaviors/Issues
Medications (Name, Frequency, Dose, Prescribing Provider)
Diagnoses (Mental Health, Medical)
Treatments and Assessments (Please list all treatments, interventions and assessments and include dates of service and names of providers if known)
Consent for Treatment
Consent for Treatment: Please indicate below that you understand and authorize Motivate Counseling staff to provide the service(s) you indicated above in the Requested Services section and that additional services may be recommended in the future. *
Required
Please indicate below that you understand and agree to be charged and pay, within the timeframe indicated within each invoice or service agreement, the fee of $179 per hour charged by Motivate Counseling as described to you either during your initial session, intake session, or complimentary consultation. I understand that results, outcomes, and any information gathered or generated during this service is confidential as defined in the Motivate Counseling policies on confidentiality listed within the Motivate Counseling Intake Form I reviewed and signed. *
I agree to allow Motivate Counseling to communicate with my insurer regarding treatment provided by Motivate Counseling for the purposes of securing either reimbursement or payment of insurance monies for services rendered.
Confidentiality: The law protects privacy and all communications between a patient and a clinician. In most situations, we only release information about your treatment to others if you sign a written authorization form. There are other situations that require that you provide written, advance consent. Your digital signature on this intake form provides consent for those activities. We occasionally consult with other health/mental health professionals. The other professionals are legally bound to keep the information confidential. If we believe that a patient presents an imminent danger to his/her health or safety, we may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where we are permitted or required to disclose information without your consent:  • If you are involved in a court proceeding and a request is made for information concerning the services we provided you, such information is protected by the therapist-patient privilege law. We cannot provide any information without your written authorization or a court order.    • If a government agency requests information for health oversight activities, we may be required to provide it for them.  • If a client files a complaint or lawsuit against us, we may disclose relevant information regarding that client in order to defend ourselves.  • If we have cause to suspect that a child under 18 is abused or neglected, or if we have reasonable cause to believe that a disabled adult is in need of protective services, the law requires that we file a report with the Department of Social Services.   • If we believe that a client presents an imminent danger to the health and safety of another, we may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim (if identifiable), and/or calling the police.  We will make every effort to fully discuss any need to breach confidentiality with you before taking action. We will limit disclosure to what is necessary. *
Required
All other Policies
This contract contains information about our services and the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is a federal law that provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. The law requires that we obtain your acknowledgement that we provided you with this information. Checking the box below indicates this agreement represents an agreement between us (Motivate Counseling LLC and you, the client or you as representative of the client). You may revoke this contract in writing at any time which will be binding on us unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process claims; or if you have not satisfied any financial obligations you have incurred. APPOINTMENTS Your appointment represents time reserved for you. As scheduling permits, we work out the most convenient time for you. We reserve the right to charge the full session fee for missed appointments and cancellations made less than 24 hours in advance of your appointment time. Please help us serve you better by keeping scheduled appointments. We reserve the right to reschedule your appointment if you arrive late/are not home, dependent upon the schedule that day. PAYMENT OF FEES. Payment of $179 per hour is to be made in full at time of service and/or as determined by Motivate Counseling LLC specific to the service(s) provided with the exception of clients receiving invoicing. We only accept credit cards. In the event we accept a check, we may charge up to $50 for Returned Check Fee in addition to the original check amount that was charged. Failure to pay the Returned Check Fee and the Account Balance may result in termination or delay in service. A full session fee may be charged if you do not show for a scheduled appointment and/or you cancel with less than 24 hours before your scheduled appointment. Unpaid balances older than 30 days may be subject to an interest charge of 5% per month (15% annually). Payments are non-refundable. You will be liable for all costs if your account defaults and requires the use of a collection agency. In addition, you will be liable for all other costs incurred in their service including, but not limited to, corporation fees, attorney’s fees and all court related expenses. Services may be interrupted until payment is made. Fees are subject to change without prior notice. INSURANCE. Please email a copy of your active insurance card prior to service. You are responsible for all deductibles and copays. We do not accept insurance though we regularly assist clients in filing direct claims with their insurance company. You are responsible for all balances, deductibles and co-payments not covered by your insurance company. Your insurance policy is a contract between you and your insurance carrier. It is your responsibility to determine whether your insurance company requires prior authorization for the initial visit and/or subsequent sessions. CONTACTING YOUR Motivate Counseling LLC STAFF MEMBER In the event that your Motivate Counseling LLC Staff Member is unavailable to take your call, you may leave a confidential voice message and s/he will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please leave times when you will be available.  PROFESSIONAL RECORDS The laws and standards of the helping profession require that we keep PHI about you in your Medical Record. Except in circumstances that involve danger to yourself and/or others, or the record makes reference to another person and we believe that access is likely to cause harm to such other person, you may examine and/or receive a copy of your Medical Record if you request it in writing. We may charge as much as $5.00 per page of patient record for related administrative expenses. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. We recommend that you review them in our presence or have them forwarded to another professional so you can discuss the contents. If we refuse your request for access to records you have a right of review, which we will discuss with you upon request. PATIENT RIGHTS HIPAA provides you with several rights with regard to your Medical Records and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Medical Records is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this contract and our privacy policies and procedures. We are happy to discuss any of these rights with you. READ CAREFULLY AND COMPLETE I have read, understand and agree to comply fully with the above policies. I recognize and accept full financial responsibility for all professional services rendered. I agree to accept services from Motivate Counseling LLC and any staff and/or contractors working for or under contract with Motivate Counseling LLC.
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