Consent for Treatment & Practice Policies
Please fill out the following information prior to your appointment with Good Mental Health.
All fields are required. Please answer N/A in fields that do not apply.  (*Please note: this digital form has been created and and is stored within Google Workspace for Good Mental Health LLC which is a HIPAA compliant and secure platform*)
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Client Name *
Date of Birth *
MM
/
DD
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YYYY
If Minor Child, Parent Name *
Address *
City *
State *
Zip Code *
Phone/Cell# *
Email *
Emergency Contact Person *
Emergency Contact Relationship to Client *
Emergency Contact  Phone/Cell# *
Reason for Seeking Services *
How Were You Referred? *
Do you consent to receive: *
Required
Mental Health History? *
Do you see a psychiatrist? *
If Yes, who is your psychiatrist? *
Meds currently taking: *
I hereby authorize Good Mental Health LLC to speak to the following people regarding my care, payments, and upcoming appointments (please specify names): *
Please read and consent to the following statements: *
You are responsible for keeping track of and coming to your appointments at the scheduled time. Sessions last for 50 minutes. If you are late, we will end on time and not run over into the next person’s session. *
Due to the unique nature of teletherapy (meeting via telephone or video chat), you are responsible for communicating your physical location at the beginning of each meeting. In the event you are experiencing a crisis, this information will allow me to access the proper intervention necessary to support your well-being.   *
Your appointment is set especially for you. If you cannot make your appointment, please notify me as soon as possible at office@goodmentalhealthllc.com or 904-325-6105. This allows me to fill the appointment and prevents long wait times between appointments. For appointments canceled less than 24 hours in advance, a telephone or telethealth appointment will be made available for you at the appointed time, however you will be charged your normal session rate whether or not you choose to attend. *
If you miss an appointment without notification, you consent to a $165.00 no show fee due before you are seen again. If you miss 2 or more appointments without notification you will be referred to a new provider and I will no longer provide you services. *
You agree to pay your fee in full at the time of your appointment. My fees are listed on my website (goodmentalhealthllc.com). I can accept payment online through the secure payment portal on my website or in-person via check, cash, or credit/debit card. At this time, I do not accept private insurance. I require an authorized credit card on file to insure against missed appointments and will always notify you when charging your card. *
The initial in-person or online ninety-minute assessment and session are $200.00. Subsequent 50-minute sessions are $165.00, in-person or online. Please choose the option you wish to purchase below. *
Individual sessions can be paid for by cash, check, or credit/debit card, and payment is required at the time of service. An authorized credit card is required to reserve appointments and insure against missed appointments. If you would like to submit for out of network insurance reimbursement, a superbill may be requested and provided at the later end of the sessions purchased or on/about December 31st of the year of purchase. HSA/FSA reimbursement eligible but please refer to your individual health plan for confirmation.   *
Card Type for authorized payments: *
Required
Cardholder Name (as shown on card) *
Card Number: *
CVV Code *
Expiration Date (mm/yy): *
Cardholder ZIP Code (from credit card billing address) *
By entering my name below, I authorize Diana Brummer with Good Mental Health LLC to charge my credit card for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account. *
Please print and return a signed copy of the payment authorization form found here: https://bit.ly/2Z7yo20  *
Bills for service are due at the start of each session, and you agree to pay all monies owed at that time. If payment is declined, rejected, or if you do not have a valid, current payment method on file, you consent to your name being given to a collection agency to recover any debt. You also agree that if additional collection actions are required, you will be responsible for any and all attorney fees and costs incurred by Good Mental Health in the collection of the debt. *
If you would like clarification of any of the above listed requirements for treatment, please send an email to: office@goodmentalhealthllc.com or call 904-325-6105 to discuss your concerns. We are happy to answer any questions you may have. *
Your current consent for treatment is valid for 1 year and must be updated on an annual basis unless treatment lapses for 90 days or more, or your personal information substantially changes. *
I agree I have received and read this Consent for Treatment outlining my responsibilities as a participant in treatment and have had any questions answered to my satisfaction. By my signature below, I verify that I understand the Disclosure Statement and my responsibilities as a client and consent to participate, or have my child participate, in treatment with Good Mental Health, LLC. If attending Couples Therapy, I understand that my/spouse’s signature(s) indicate that I/we give consent to release to my spouse any and all information discussed in session with my spouse present. I consent to the disclosure of necessary information to my insurance company for billing purposes if applicable. *
By entering your name in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
For identity verification purposes, please provide the last 4 digits of your social security number: *
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