Therapy Intake Form 🧠✨

New Client Intake Form

Please fill out this form to help us understand your needs and preferences for therapy.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about The Healing Hill Collective?

Other
Reason for Seeking Therapy
Current Concerns or Symptoms
Have you previously attended therapy?
Preferred Session Times
Please list any current medications or relevant medical conditions.
Is there anything else you would like your therapist to know?
INFORMED CONSENT FOR THERAPY

Dr. LaTronna Hill, LCSW provides psychotherapy services to support clients in addressing emotional, behavioral, and mental health concerns. Therapy is a collaborative process and may involve discussing sensitive topics. While many clients benefit from therapy, outcomes cannot be guaranteed.

Confidentiality will be maintained except in situations required by law, including risk of harm to self or others, abuse or neglect of a child, elderly, or disabled person, or court order.

By proceeding, you acknowledge understanding of the nature of therapy and consent to participate in services.
I have read and agree to the informed consent above
I currently accept the following insurance plans:

Horizon Blue Cross Blue Shield of New Jersey

Independence Blue Cross Pennsylvania

Blue Cross Blue Shield

Cigna

Aetna

Quest Behavioral Health

Carelon Behavioral Health

Ascension (Texas only)
How will you paying for services?
Insurance Company
Member ID
Upload Insurance Card

Cancelof
Payment is required at the time of service for clients not using insurance. Your card will NOT be charged until your session has started.
Please upload a picture of your Debit/Credit Card to put on file

Cancelof
INSURANCE & PAY AGREEMENT

Services provided by Dr. LaTronna Hill, LCSW may be covered by insurance for clients located in Texas and Louisiana. Accepted insurance plans currently include Cigna, Aetna, Quest Behavioral Health, Carelon Behavioral Health, and Ascension (SmartHealth – Texas only).

Clients who wish to use insurance are responsible for providing accurate insurance information prior to their appointment. Coverage and benefits will be verified; however, clients are responsible for any copays, coinsurance, or deductibles required by their plan.

If a client does not have active insurance coverage, chooses not to use insurance, or services are not covered, sessions will be considered private pay. Payment is required at the time of service. Sliding scale rates may be available based on need and availability.

Cancellations must be made at least 24 hours in advance. Late cancellations or missed appointments may be subject to a fee.
I I understand and agree to the payment, insurance, and cancellation policy.
TELEHEALTH CONSENT

Therapy sessions may be conducted via secure video platforms. While efforts are made to protect confidentiality, there are inherent risks with electronic communication.

By agreeing below, you consent to participate in telehealth services.
I consent to Telehealth services.
EMERGENCY NOTICE
This service is not intended for crisis or emergency situations. If you are experiencing a mental health emergency, please call 911 or go to the nearest emergency room.
I understand this is not a crisis service.
Signature
Date

MonthDayYear
Date
All information submitted is kept confidential and used solely for the purpose of providing therapy services.
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New Client Intake Form