Name of Patient *

First Name

Last Name

Parent or Guardian of patient (only if patient is under 18)

First Name

Last Name

Other Parent or Guardian of patient (only if patient is under 18)

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Home Phone *

(###)

###

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Name of Primary Insured (if different than patient)

First Name

Last Name

Conditions and Terms of Therapy *

Please click on each to show understanding

I understand that this form represents permission for Innovate Mental Health Services and Dwight Hurst, CMHC to provide the identified Patient with mental health therapy, and to seek payment for those services. I understand that I am financially responsible for all charges whether or not paid by insurance, and I give permission for all third party or insurance payments to be made to Innovate Mental Health Services.

It is your responsibility to check with your insurance provider in regards to reimbursement, pre-approval requirements, and terms and limits of coverage.

Your portion of payment (co-pay if insured, cost of session if not) is due at the time of service, the beginning of each session. If no payment is made, you may be unable to schedule another appointment until payment has been made.

You are responsible for any portion of the bill not covered by your insurance company or any other third party.

Failure to attend a scheduled appointment without cancellation (a “no show”) will be billed as one full clinical session. This will need to be paid before being allowed to schedule another appointment. After 2 instances of “no showing,” your file may be closed.

Please cancel appointments with as much notice as possible, 24 hours minimum. Cancellations made with less than 24 hours of notice will be charged a $35 fee.

The first session may be charged at a higher rate due to a higher paperwork requirement in the creation of a new case.

Therapy sessions last 45-50 minutes to allow for time to satisfy legal requirements of documentation following the appointment.

Should you be more than 20 minutes late for an appointment you may be asked to reschedule.

Fees for sessions (unless under insurance ocntract or other arrangements have been made) are $180 for the Intake Session, $120 for each individual session. Group Sessions have individualized Pricing depending upon the group.

Authorization for Release of Confidential Information

Please check the following ot demonstrate understanding. Then provide the name and contact information of whichever individuals, agencies, or Insurance Companies that you authorize your Therapist to communicate with.

I authorize Innovate Mental Health Services and the persons listed below, or their representatives, to mutually release and disclose my health information. Other than parties or agencies identified by myself on this document I understand that my information will be kept confidential from all others except for Innovate MH Solutions, their office, billing, or accounting staff, and members of the Group Practice Aspire.

I understand that by signing this form I am authorizing Innovate MH Solutions to disclose my health information to the persons or entities listed below. I also understand that any confidential or health information possessed by the persons or entities listed below may be disclosed to Innovate MH Solutions.

My health information includes, without limitation, records, reports, assessment or test results, opinions, assessments, and any other information related to any medical, psychological, emotional, vocational, or educational conditions. Disclosure may also include reports of my condition, attendance, or progress in treatment.

I understand that I may revoke this authorization at any time by sending a written notice of revocation to Innovate MH Solutions at 2363 North Hillfield Rd, suite 7, Layton, Utah 84041. I understand that revocation will not prevent or affect any disclosure made while the authorization is in effect.

I understand that Innovate MH Solutions is not responsible for re-disclosure or use of information by the recipient identified below. I waive any right to privacy in connection with the disclosures hereby authorized.

This authorization is valid until revoke by me in writing or until 6 months following my final psychotherapy session.

Electronic Signature *

I understand that typing my name in this field and clicking "Submit" I am allowing this field to represent my signature. This field must be filled out by the identified patient, or that patient's legal guardian if patient is under 18 years of age. I understand that if I am not that person than filling out this field and clicking "submit" represents fraud.

First Name

Last Name