FORMS 2018-09-04T15:50:11+00:00

Forms can either be brought into first session or scanned and emailed to intake@headhearttherapy.com. Please also provide a photo of the front and back of your current insurance card.

For all clients, please print a copy of your rights to privacy for your personal records:

HIPAA

For new clients, please download the following forms and complete them before your first session:

Assessment
Informed Consent
Insurance Verification
Notice of HIPAA
Credit Card Authorization Form
Release of Information

Explanation of Benefits – This information can be obtained by calling the benefits number on the back of your insurance card. This document will help us predict your expected out of pocket costs for therapy. (You can often request for this document to be sent directly to us, or you can forward it to us when it is sent to you.)

For clients utilizing adjunct therapies:

Yoga Waiver
Reiki Waiver
Hypnosis Waiver