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Forms and Disclosures

A More Complete Picture of You

Prior to the first appointment, each new client must complete the Intake Paperwork, Billing Form, Receipt of Privacy Practices Form, and Telehealth Consent (if applicable).

If you have not yet scheduled an appointment with one of our therapists, please do not fill out the paperwork or send in the billing form. Instead, please request an appointment.

Request an Appointment

Intake Forms

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The Intake Packet was designed to appreciate the sensitive nature of your life experiences and presenting concerns. We request that you answer the questions as best you can and as close as possible to the date of your initial intake appointment.

This packet is intended to be holistic and inclusive. The purpose is to help your therapist better understand your preferences, goals, needs, expectations, and concerns regarding therapy services at IEG. Some of these questions may bring up difficult or uncomfortable emotions. We encourage you to care for yourself while filling out this packet. Some effective examples include deep breathing, pacing yourself, pausing to take a break, self- soothing, and reaching out to supportive friends or emergency resources. This may also include skipping entire sections as needed.

Toward this end, we have attached the packet in a short and long form. Whichever you choose, please complete the Intake Paperwork and share it to your therapist before or at your first appointment.

Full Intake Packet

OR

Short Form Intake Packet

The full intake packet includes all required and supplemental intake forms. Billing form, privacy notice, and Teletherapy Informed Consent are NOT included and must be completed separately!

The short form intake packet breaks the full intake packet down into shorter forms with built-in breaks for self-care. The short form packet also mentions which forms are supplemental but not required.

Intake Fee Agreement (Required)➔

Short Intake Packet (Required)➔

Full Intake Packet➔

Intake Informed Consent (Required)➔

Holistic and Spiritual Health (Supplemental, not required)➔

Sexual Functioning (Supplemental, not required)➔

Adverse Life Experiences (Supplemental, not required)➔

Remaining Forms and Documents

Fillable Billing Form

Submit this completed form by either email paperwork@integrativeempowerment.com or fax (734)207-5526. When completing this email, be sure to include the name of your therapist.

Fillable Billing Form (Required)➔

Acknowledgement of Receipt of Privacy Practices

Submit this completed form by either email paperwork@integrativeempowerment.com or fax (734)207-5526.

Acknowledgement of Receipt of Privacy Practices (Required)➔

Tele-Therapy Informed Consent

This form is only required if receiving Tele-Therapy. Submit this completed form by either email paperwork@integrativeempowerment.com or fax (734)207-5526.

Tele-Therapy Informed Consent (Required for Tele-Therapy Clients)➔

Authorization for Use and Disclosure of Protected Health Information or "ROI"

This form is optional as needed and is also known as "ROI." Submit this completed form by either email paperwork@integrativeempowerment.com or fax (734)207-5526.

Authorization for Use and Disclosure of Protected Health Information Form (Optional as needed)➔

Notice of Privacy Practices

Please review this notice to learn how more about privacy practices around your health information.

Notice of Privacy Practices (Please Read)➔

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