- Youth Intake Form (ages 12-17 years) – Use this form if you are looking for individual services for an adolescent in your home.
- Adult/Family Intake Form – Use this form if you are looking for individual adult or family services.
What Are Intake Forms?
- Asks general client information including medical insurance information.
- Describes current situation and gives Equity Associates needed information to match a therapist to your family.
- Provides background information.
What is PHI? And What Does the Form Do?
- PHI is protected health information for you and your family.
- Authorizes Equity Associates to email or text you with appointment/scheduling reminders, information related to billing and payments and other information that you designate as appropriate.
- Notice of Privacy Policies and Practices – Click to view our HIPAA document.
What Is This?
- Explains how medical information may be used and disclosed, as well as how a client can get access to that information, and follow the privacy practices listed in the document.
- Explains our responsibility to secure a client’s medical information.
- Provides a notice about our privacy practices.
- Allows Equity Associates to bill your insurance company for services rendered.
- Release of Information form – Once Equity Associates matches you with a therapist, we will send you a Release of Information form to fill out.
What Is A Release of Information?
- Please fill out this form if you would like your therapist to speak to a previous therapist, your medical doctor, family member or another individual regarding your care.
- Complete the Disclosure Statement – Once Equity Associates matches you with a therapist, we will send you a Disclosure Statement to fill out.
What Is A Disclosure Statement?
- Informs clients about the professional background of Equity Associates therapists and explains the rights of clients.
- Describes the limitations of the professional relationship between client and therapist.
- It is sometimes referred to as a document of informed consent.