Wellness- Intake Form (Emind)

Wellness- Intake Form (Emind)

Intake form for mental health Form Preview
  • Emind Wellness & Training Institute

    Online Intake Form

  • Welcome to the Emind Wellness & Training Institute's Intake form for therapeutic services. Before you begin completing this form, Click and review the information under:

    1. The disclosure link that is relevant for the services you will receive(online or in-office)

    2. The HIPAA information

    These documents share information related to what to expect while engaging in therapeutic sessions and your rights, responsibilities and expectations. It is your responsibilty to read, understand and ask any questions you may have related to engaging in online session therefore be sure to read the disclosure carefully!

    EWTI DISCLOSURE -Online Session

    EWTI DISCLOSURE - In-office (includes programs and groups)

    HIPAA INFORMATION

    Be sure to complete this form completely and accurately. Providing inaccurate or incomplete information will delay the intake and appointment setting process.

    Prepare to complete this form in one-sitting, for some it may be necessary to set aside approx. 15-20 minutes to complete.

  • For therapeutic services & programs, we accept Aetna, Aetna EAP, BCBS (NC Only), BHS, Cigna, Cigna EAP, HealthChoice, Medicaid & Quantum EAP!

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