Intake Form for Care Providers

Intake Form for Care Providers

Client intake Form Preview
Intake Form for Care Providers
  • Intake Form

  • Personal Information

  •  -
  • Financial Information

  • Personal Medical History

  • Legal Responsibility

  • Under the laws of the United States and the state of Mississippi your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

    Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.

  • Use and Disclosure of your Personal Health Information (PHI)

  • Communication

  • We are committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using this website; you can be assured that it will only be used in accordance with this privacy statement.

    We will not intentionally share the contents of any email or information submitted via the internet with any third party. However, due to the nature of electronic communications, we cannot and do not provide any assurances that the contents of your email will not become known or accessible to third parties. We urge you not to provide any confidential information to us via electronic communication. Should you choose to communicate via email, the provider contacted will respond to any emails sent until you request that form of communication to cease. Please take all precautions necessary to secure your email should you choose to use it to contact the provider.

  • Signature

  • Please print and sign your name below to indicate consent.

  • Should be Empty:
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