Patient's Name *

First Name

Last Name

Date of Birth *

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Phone Number *

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Policy Holder's Date of Birth

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Policy Holder's Phone Number

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RELEASE OF iNFORMATION & ASSIGNMENTS OF BENEFITS *

I hearby authorize IGT to provide clinical information requested by insurance companies to pay my therapist directly.

Yes, I understand that I am responsible for any charges not covered by my insurance company.

CANCELLATION POLICY *

Please understand that your appointment time is held for You! 24-hour cancellation notice is required to avoid being charged for your session fee.

I acknowledge this policy.

CREDIT CARD AUTHORIZATION *

I authorize IGT to charge my credit card below for individual and group services. I understand that my information will be saved on file for future transactions on my account.

Card Holder's Name (as shown on card) *

First Name

Last Name

Name *

First Name

Last Name

Date *

MM

DD

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IN THE PAST WE HAVE FOUND IT BEST TO HAVE OUR PRACTICE POLICIES CLEARLY UNDERSTOOD AT THE BEGINNING. IF YOU HAVE ANY QUESTIONS, PLEASE DO NOT HESITATE TO ASK BEFORE CHECKING EACH POLICY. *

1. SERVICES: Psychotherapy sessions are 45 minutes. Payment is due at time of service.

2. INSURANCE COVERAGE: It is your responsibility to know and keep track of your insurance coverage limitations. If your insurance coverage changes, please inform us intermediately. Be aware that charges in insurance coverage may increase or decrease the amount which you are responsible for at anytime during your treatment. We reserve the right to bill or credit you should this be the case.

3. BROKEN APPOINTMENTS: Consistent appointment attendance is important both for optional therapeutic benefit and sound practice management. 24-hour notice is required when canceling an appointment. If 24-hour notice is NOT given, you will be responsible for your full therapy fee.

4. CONFIDENTIALITY: Use of insurance may require disclosure of diagnosis and treatment focus; otherwise, issues explored during psychotherapy sessions are treated with professional confidentiality. Exceptions to this policy are legally mandated disclosures when self-harm or injury to others appears possible. Appropriate steps will be taken to insure the safety of anyone at risk. It’s a Girl Thing! uses text, phone, and email communication and cannot guarantee HIPPA compliant servers. All precautions are otherwise taken to keep information confidential according to HIPPA.

5. CONSENT FOR EXPRESSIVE ARTS USAGE: It’s a Girl Thing! reserves the right to use audio and visual material of clients and their artwork for display and teaching purposes. Client can revoke this at any time with written communication to It’s a Girl Thing!

6. DOCUMENTATION: Any request for paperwork/reports outside of billing requirements will be billed at a professional hourly rate directly to the patient.

I authorize my behavioral health provider at It’s a Girl Thing! to exchange information, with the person(s) named below, regarding my mental health treatment for continuity of care purposes as may be necessary for the administration and provision of my healthcare. The information exchanged may include my medical history or mental health issues that are pertinent throughout the course of this treatment, whichever is longer. I may revoke this authorization at any time by written notice to It’s a Girl Thing. This information has been disclosed to you from records where confidentiality is protected by federal law. Federal regulation (42 CFR-Part 2) prohibits you from making any further disclosure of it without specific written consent of the person for whom is pertain,or as otherwise permitted by such regulation. A General Authorization for the release of medical or other information is NOT sufficient for this purpose. *

Checking this box indicates my consent or consent of parent or guardian if patient is a minor.

Patient or Guardian *

First Name

Last Name

Person to Exchange Information Regarding My Health *

First Name

Last Name

Date *

MM

DD

YYYY

CREDIT CARD AUTHORIZATION *

I authorize IGT to charge my credit card below for individual and group services. I understand that my information will be saved on file for future transactions on my account

Card Holder's Name (as shown on credit card) *

First Name

Last Name

Card Holder's Phone Number *

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