Getting ready for your first appointment:
If you received this link from Mindfully Balanced Therapy, please complete each form below at least 48 hours before your scheduled appointment. There are 4 required forms, and 1 optional form you can choose to add if it applies to you.
If you’ve been redirected to this page upon completion of a form, please move to the next one on the list until all forms are completed. Once you have finished, you may close this window.
Forms to be completed:
Client Information - This form is for you to share your contact information, demographic information, and a few history questions
Informed Consent Agreement - This form explains all about my practice, how things work, and the risks/benefits of therapy. There are places within the form for you to enter your emergency contact information and communication preferences (you can check off as many as you'd like).
You can download a copy of the privacy practices here. You don't need to print or sign it, there is a spot in the Informed Consent form where you mark to acknowledge you've received a copy.
Financial Agreement - This form breaks down the costs and payment information and has you confirm a couple things.
In the email Kimberleigh sent with the link to this page, you will also find a copy of your Good Faith Estimate. The Good Faith Estimate is part of the No Surprises Act law, which gives you the right to receive as estimate of the cost of your treatment when you're not using insurance benefits. The estimate you received is for the intake appointment itself. During the intake we will discuss how often we plan to meet and then I will provide you with an updated one for ongoing therapy services over the course of this calendar year. The cost estimates provided are based on the same rates shown in the Financial Agreement. You don't need to print or sign it, there is a spot in the Financial Agreement where you mark to acknowledge you've received it.
Partnering for Safety Plan - This is a safety plan form I have all my clients complete ahead of time. Even if you didn't mention any specific concerns, I have everyone complete one so that if a crisis were to occur in the future I know what local crisis services or hospitals are in your area since I work with clients throughout the states of North Carolina, South Carolina, and Illinois.
Optional Form to Complete:
Release of Information - This is a “permission slip” that gives permission for me to be in contact with someone else and share/receive information regarding your care. If you have other providers you’d like me to collaborate with (doctors, dietitians, couple’s counselors, etc), please complete one form for each provider.
If you have any questions or need to reschedule your appointment, you’re welcome to send an email to khagar@mindfullybalancedtherapy.com or call/text (847) 447-2919.