FORMS

Prior to the first appointment, each new client must complete the Intake Paperwork, Billing Form, and Receipt of Privacy Practices Form. 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.

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 couple of ways. Whichever you choose, please complete the Intake Paperwork and bring a hard copy into your session with your therapist. Thank you and we look forward to working with you!

 

The first is the full intake packet, including both required and supplemental forms.

 

Alternatively, we have deconstructed and attached the packet in chunks. Each section can be found here:

Required:

Supplemental:

Billing Form

 

The NEW CLIENT BILLING FORM should be completed and sent to our secure email at paperwork@integrativeempowerment.com.  Alternatively, you may fax your form to our billers at:

f:(734)207-5326. It is important that you include the name of the therapist that you will be seeing. 

 

 

 

 

 

 

 

Full Intake Packet

Short Intake Packet

Fee Agreement

Informed Consent

Adverse Life Experiences

Holistic and

Spiritual Health

Sexual Functioning

Privacy Notice

Notice of Privacy Practices

Acknowledgement of Receipt of Privacy Practices

Teletherapy Informed Consent
Fillable Billing Form

​​​Contact Us

122 South Main Street, Suite 200

Ann Arbor, MI 48104

 

2488 Golfside Drive

Ypsilanti, MI 48197

560 S. Main St.

Ann Arbor, MI 48104

Follow Us

  • w-facebook

More About Us

  • Instagram

On Instagram

  Tel: 734-945-6210