Helpful Forms

On-Line Forms

Forms are available for new clients to fill out and submit online. Synergism Counseling will send you a Client Portal invitation via email before your first appointment with instructions to complete the required forms. Please upload or bring a photo copy or picture of the front and back of your health insurance card(s) to your first appointment if applicable.

Printed Forms

If you can't fill out the required forms online, please print the first seven forms below, fill them out completely and bring them with you to the first appointment. Choose either the Adolescent or Adult Intake Information depending on the client's age.

Adolescent & Child Intake Information

Adult Intake Information
Insurance Information
Electronic Payment Authorization
Limits of Confidentiality
Cancellation Policy

Professional Service Agreement
HIPAA Patient Privacy Policy
Restraint Agreement
Authorization To Use and Disclose Protected Health Information
Letter of Revocation for Authorized Protected Health Information

Additional Forms (if applicable)

If you would like us to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), please complete the Authorization To Use and Disclose Protected Health Information form.

If the patient is a child and under certain circumstance you feel they might need restraining, please fill out the Restraint Agreement and bring that with you too.

Please Note:
If you wish to use health insurance, our services may be covered in full or in part by your health insurance provider or employee benefit plan. Please call your insurance company or employer in advance of receiving services to check your coverage. It is important that you understand what your costs may be for each session. Here are some helpful questions you may want to ask:

  • Do I have mental health insurance benefits in my plan?
  • What is my deductible and has it been met? If not, what will be my estimated out of pocket expenses?
  • How much will my co-payment be for each session once my deductible is met?
  • How many sessions per year does my health insurance provider allow?
  • Is an authorization required to receive services?
  • Do I have any EAP (Employee Assisted Program) sessions available?

As a convenience to you, we can bill your insurance company for the services we provide to you. You are financially responsible for charges that are not covered under your insurance plan. All required co-payments, co-insurance and deductible amounts are due at the time of service or when we are notified by your insurance company.

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Helpful Forms

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