Peace & Harmony Client Consent Form

We are only licensed in the state of Michigan.*

Please note: We are only licensed in the state of Michigan. For Telehealth services you must be a resident and currently in the state of Michigan during your sessions.

Is Client 18 Years of Age or Older?*

Yes, Client is 18 Years of Age or Older

No, Client is Under 18 Years of Age

Name of Therapist*

Name*

First Name Last Name

Date of Birth*

Gender*

SSN*

Age*

Client Name*

First Name Last Name

Client's Date of Birth*

Client's Gender*

Client's Age*

Address*

Street Address City & State ZIP Code

Home/Cell Phone Number*

Work Phone*

Email*

Client's SSN*

Parent/Legal Guardian Name*

First Last

Grade*

Name of School:*

In case of an Emergency, Contact:*

Emergency Contact Phone Number*

Primary Physician*

Primary Physician Phone Number*

Address*

Street Address City & State ZIP Code

Home/Cell Phone Number*

Work Phone

Email*

Occupation*

Employer*

In case of an Emergency, Contact:*

Emergency Contact Phone Number*

Primary Physician*

Primary Physician Phone Number*

Insurance Information

How Do You Plan To Pay For Care?*

Insurance

MedicAid

Self Pay

Opt-Out

By selecting 'Self Pay' you are opting out of paying through insurance and choosing to pay out of pocket

Birth Date of Primary Policy Holder*

Name of Primary Insurance Company:*

Name of Primary Policy Holder:*

Employer of Primary Policy Holder*

Relationship to Primary Policy Holder*

Self

Spouse

Child

Other

Primary Policy Holder Address*

Street Address City & State ZIP Code

Primary Insurance ID Number*

Primary Group Number*

Using Secondary Insurance?*

Yes

No

Name of Secondary Insurance Company:*

Name of Secondary Policy Holder:*

Birth Date of Secondary Policy Holder*

Employer of Secondary Policy Holder*

Relationship to Secondary Policy Holder*

Self

Spouse

Child

Other

Secondary Policy Holder Address*

Street Address City & State ZIP Code

Secondary Insurance ID Number*

Secondary Group Number*

Upload Image of Front & Back of Insurance/Medicaid Card*

Drop files here or

Max. file size: 512 MB.

Upload Image of Front & Back of Secondary Insurance/Medicaid Card*

Drop files here or

Max. file size: 512 MB.

Upload Identification*

Please upload front and back of state issued identification

Drop files here or

Max. file size: 512 MB.

Consent*

I have read the above and accept this policy as outlined.*

I authorize payment of medical benefits to the provider for services rendered, if applicable. I further authorize the release of information to the above-designated insurance carrier. Confidentiality procedures of the managed care and/or insurance company cannot be guaranteed by Peace & Harmony Counseling Services, LLC. Information may be shared with the collection department, outside collection agency, company attorney, credit bureau, law enforcement, or IRS.

Signature*

Signature of Guardian*

Signature of Therapist__________________________ DATE____________

Diagnosis Codes:1.____________ 2.____________ 3.________

Please upload front and back image of insurance or MediAid Card*

Drop files here or

Max. file size: 512 MB, Max. files: 2.

Family Health History:

Please note any family history (in direct bloodline) of depression, anxiety, psychiatric problems, substance abuse, and alcoholism

First Name

Relationship to Client

Nature of Problem

Were/Are You In the Military?*

Yes

No

Military*

Branch

Rank

Beginning Date of Service

End Date of Service

Active?*

Currently Active

Veteran

Type of Discharge*

Medical History*

Please list all of your medical conditions-- Include a brief description of the treatment. To add more use the (+) button.

Condition

Treatment

Medical History*

Please list all of your child's medical conditions-- Include a brief description of the treatment. To add more use the (+) button.

Condition

Treatment

Please list all illegal substances that you have used over your lifetime:*

To add more use the (+) button.

Please list any alcohol or illicit drugs that your child has used in the past 12 months:*

To add more use the (+) button.

Have you been in counseling previously?*

Yes

No

Has your child previously been in counseling?*

Yes

No

Please indicate approximate dates of treatment, reason for treatment, your satisfaction with treatment outcome and therapist’s name (if known):*

Describe any hospitalizations (medical or psychiatric). Give approximate dates and reason for treatment:*

Do you have any physical disabilities and/or limitations?*

Yes

No

Does your child have any physical disabilities and/or limitations?*

Yes

No

Please Specify:*

Years of education completed:

Degrees Earned or Other Specialized Training:*

To add more use the (+) button.

Please note any involvement with the legal system:*

Today's Date*

Signature*

Signature of Guardian*

Thank you for taking the time to fill out this client intake form for Peace and Harmony LLC in its entirety. By clicking the “Submit” button below you verify that all the information entered is true to the best of your knowledge.

Email

This field is for validation purposes and should be left unchanged.

Peace and Harmony Consent Form

Peace & Harmony Client Intake Form

Insurance Information