New Client Intake form
Please download both the Intake, Telehealth Consent, and Credit Card Authorization forms by clicking on the individual boxes below. In order to receive counseling you must complete all required fields in the Intake, Telehealth Consent and Credit Card Authorization forms. These requirements pertain to new clients, and those that seek counseling on behalf of the client. Once complete, email your forms to us at: firstname.lastname@example.org
Unify Behavioral Health's policy requires all clients to have a valid credit card on file, in case of "no show" or untimely cancellation. Your card will not be charged until your scheduled appointment. In the event that your insurance company denies your claim, Unify Behavioral Health reserves the right to charge your card for the therapist's self-pay rate.
Once we receive your Intake and Credit Card Authorization forms our administrative staff will respond within a few business hours to confirm your appointment and let you know about your insurance coverage, if applicable. All of our client data is highly protected and kept confidential in compliance with HIPAA standards.