REBUILD YOUR LIFE ON A SOLID FOUNDATION

CLIENT FORMS…

The following forms are essential paperwork required by law that I must have before we can begin our work together. Please print one copy of each document, (note that there are separate adult and child forms for the Developmental Inventory and Information Forms), read each one thoroughly, complete and sign. You are encouraged to complete and bring all of the new client forms with you to our first meeting so we do not have to use precious time from our session filling them out.

It is important that you fully understand what you are signing, so please feel free to ask any questions about the paperwork.

Here is Everything You Need to Bring With You to Your First Appointment…

Mental Health Benefits Worksheet

It is important to know what your benefits are. Use this form when calling your insurance company to obtain information regarding mental health coverage. Additionally, you can use this worksheet when you call the billing manager, Kristi, prior to your first appointment to discuss your insurance benefits, co-pay, etc. Kristi’s number is 509.725.0236 and her office hours are Monday – Thursday 10am-4pm. Bring this completed worksheet to your first appointment.

Agreement of Professional Services and Business Policies

This document contains important information about my professional services, business policies including use of social media and electronic communications. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), limitations of confidentiality, my fee structure and billing practices, my treatment philosophy, and other crucial information pertaining to your health care.

Notice of Privacy Practices

This document describes in more detail how your health information may be used and disclosed and how you can access your treatment/record information.

Insurance and Authorization Form

This document explains what you need to know about billing, payment requirements and use of insurance.

Adult Information Form

The Information Form provides demographic information, your referral source, previous counseling history and current medical complications.

Adult Developmental Inventory

The Developmental Inventory documents the significant events in your life. The aim is to get an overview of who you are and what you have experienced in life, both good and bad, including major stresses and transitions.

Authorization for Release of Information Form

You can complete this form if there is anyone that you would like me to share information with, or receive information from. For example, if you were referred to my practice by your physician, a Release of Information is needed so I can provide updates regarding your counseling.

Notice to TRICARE Clients

Only those utilizing TRICARE insurance are required to complete this form.

 

Wendy Biondi

Wendy Biondi, LMHC

E: wendy@wendybiondi.com
T: 509.590.6339

Leave a quick Message

1 + 5 =

IMPORTANT!
By using this web form you acknowledge that the Internet is a NON-SECURE way to communicate and therefore we strongly recommend that if you use this form of contact, you limit it to general subject matter only. Thank you for understanding.

"Life isn't about finding yourself. Life is about creating yourself."
- George Bernard Shaw
"Never be bullied into silence. Never allow yourself to be made a victim. Accept no one's definition of your life; define yourself."
- Harvey Fierstein
"Your task is not to seek love, but to seek and find all the barriers within yourself that you have built against it."
- Rumi
"I was always looking outside myself for strength and confidence but it comes from within. It is there all the time."
- Anna Freud
"Life is not about waiting for the storms to pass. It's about learning how to dance in the rain."
- Vivian Greene
Shadow
Slider

Make Appointment

Smartphone users tap to dial
Call Now!