FORMS
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.
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About The Intake Packet: 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.
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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.
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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. Thank you and we look forward to working with you!
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Fillable Billing Form
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required
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Submit completed form by either
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fax (734)207-5326.
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Include the name of your therapist
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required
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required
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required
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supplemental, not required
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supplemental, not required
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supplemental, not required
Notice of Privacy Practices​
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Review this!
Acknowledgement of
Receipt of Privacy Practices
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Sign this!
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Required
Tele-therapy Informed Consent​​
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Required only if receiving tele-therapy.
Authorization for Use and Disclosure of Protected Health Information
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optional, as needed
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also known as an "ROI"