Holistic Minds Collective | Intake Form
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First Name of Client Receiving Service *
Last Name of Client Receiving Service
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Parent/Guardian of client (17 and under) 
Phone Number
 *
Email *
Date of Birth
 *
Insurance or Payment Form
 *
Member/Group ID or Open Path ID *
Where did hear about us?
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Are you seeking a specific therapist? Please provide their name below. If there is no therapist in mind, please respond N/A.
**Keep in mind that if that therapist has a waitlist, we may refer you to another in-house therapist**
Will this be In-Person or Virtual *
What Time of Day will You be receiving services? *
Required
Language of Preference
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Have you had therapy before? *
Is there anything you'd like for us to know?
** STUDENT INTERN CLAUSE **

We are excited to inform you that some of our services will be provided by student interns under the careful supervision of Licensed Clinical Social Worker (LCSW) supervisors. This collaboration allows us to offer comprehensive care while providing valuable learning opportunities to aspiring mental health professionals. At our organization, safeguarding your privacy and confidentiality is of utmost importance. That's why we adhere strictly to the Health Insurance Portability and Accountability Act (HIPAA) regulations. HIPAA ensures the protection of your personal health information, preventing unauthorized access, use, or disclosure. This commitment to HIPAA compliance means you can trust that your sensitive information remains secure at all times. It's our priority to maintain your trust and confidence as we deliver our services, and HIPAA compliance plays a crucial role in upholding these standards. Rest assured, our interns undergo rigorous training and are closely monitored by experienced supervisors to ensure the highest quality of service delivery. We appreciate your support and understanding as we continue to strive for excellence in providing compassionate and effective care to our community.

Please sign your name below stating you understand that your case may be selected for a student interns training.

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Nos complace informarle que algunos de nuestros servicios serán brindados por estudiantes en prácticas bajo la cuidadosa supervisión de supervisores de trabajadores sociales clínicos autorizados (LCSW). Esta colaboración nos permite ofrecer atención integral y al mismo tiempo brindar valiosas oportunidades de aprendizaje a los aspirantes a profesionales de la salud mental. En nuestra organización, salvaguardar su privacidad y confidencialidad es de suma importancia. Es por eso que cumplimos estrictamente con las regulaciones de la Ley de Responsabilidad y Portabilidad del Seguro Médico (HIPAA). HIPAA garantiza la protección de su información de salud personal, evitando el acceso, uso o divulgación no autorizados. Este compromiso con el cumplimiento de HIPAA significa que puede confiar en que su información confidencial permanecerá segura en todo momento. Nuestra prioridad es mantener su confianza mientras brindamos nuestros servicios, y el cumplimiento de HIPAA juega un papel crucial en el mantenimiento de estos estándares. Tenga la seguridad de que nuestros pasantes reciben una capacitación rigurosa y son supervisados ​​de cerca por supervisores experimentados para garantizar la más alta calidad en la prestación del servicio. Apreciamos su apoyo y comprensión mientras continuamos esforzándonos por lograr la excelencia en brindar atención compasiva y efectiva a nuestra comunidad.

Firme con su nombre a continuación indicando que comprende que su caso puede ser seleccionado para una capacitación de estudiantes pasantes.
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