Pink Positive Psychology
Call Us Today: (586) 209-7092
Royal Oak, MI 48067

Client Intake Forms

Please complete the following three required (electronic) forms before your first appointment:

 

Form 1: New Client Registration Form

 

This form is used to gather a basic profile of client’s contact information to register client in our system; assess your match to clinician(s) based on reason(s) for seeking counseling; and to gather insurance information so we can verify your benefits before your 1st session.  Ultimately this form serves to streamline client onboarding.

 

*IMPORTANT:  Please complete this form BEFORE booking an appointment. Thank you.

 

Form 2: Consent for Treatment/Office Policies/Procedures/Emergency Contact/HIPPA

 

This form explains our expectations of you as a client, your protections and rights as a client, and our fees. Please read, and fill out client name, and emergency contact.

 

Form 3: Payment Authorization Form

 

This form serves as an authorization to input your credit card information

into our secure system and charge it when a balance on your account exists.

Thank you!

 

*All electronic forms are HIPPA compliant and ENCRYPTED which means your information is safe and secure.

Pink Positive Psychology

Located inside The Center for Natural Healing

1103 S. Washington Ave.

Royal Oak, MI 48067-3219

 

Appointments Available

Day • Evening • Weekend

Copyright © 2017 Pink Positive Psychology. All Rights Reserved.

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