Mindful Intake Form

We use Spruce to message with our patients. Registration on Spruce is required after becoming an established patient. Spruce helps us respond to questions sooner and coordinate care most efficiently. Spruce is not for medical or psychiatric emergencies: please call 988 immediately and/or go to the nearest emergency department if you are in crisis.

We may not be the ideal fit for everyone, so we reserve the right to refer active patients to other clinicians.

Every patient has the right to end their relationship with their clinician at any time. In such cases certified notice will be given to the patient in accordance with current state law.

Clinical fees

If you haven't had a chance to see our Fee Schedule, please do so now.

Payment of services

Upon scheduling your first appointment, we will collect a credit card for payment which will be kept on file. You agree that any credit card you provide to us for payment can be placed on file until your verbal or written permission to delete it. When scheduling your first appointment, half of the visit fee will be collected and the remaining balance is due at the time of service.

Scheduling and cancellation policies

• All appointments may be canceled or rescheduled free of charge if done 48 hours or more in advance of the scheduled appointment.
• If an appointment is canceled or rescheduled less than 48 hours from the appointment time, it is a "late cancellation" and will incur a fee of half the cost of the visit.
• If you do not show up for your appointment and there is no attempt to reach out to us, we will charge you the full cost of the appointment.
• If there is a reasonable excuse for missing your appointment or canceling late, we are happy to work with you. These cases are handled on an individual basis.
• We will cancel appointments, without penalty, when the local school district for an office issues a closure or delay due to adverse weather.

Medicare eligibility notification requirement

• If you are currently enrolled in any Medicare-related program (including Traditional/Original Medicare, Railroad Medicare, Medicare Advantage plans, or any other form of Medicare coverage), or if you become eligible for Medicare at any point during the course of treatment, you agree to notify us in writing within 24 business hours of becoming aware of your enrollment or eligibility status.
• Failure to provide timely written notice may result in immediate termination of the patient-clinician relationship, as this practice does not participate in Medicare and cannot legally continue care once a patient is enrolled without appropriate opt-out documentation and agreements on file. You understand that any submission of claims to Medicare or secondary insurance by you or on your behalf will result in termination of services and transition of care to a Medicare-enrolled provider.

• By signing this form, I acknowledge that I have read and understand all the terms, conditions, and information contained herein. I have been provided sufficient opportunity to ask questions and seek clarification of anything contained in the agreement that is unclear to me.

• By signing this form I acknowledge that I have read and understand all the terms, conditions, and fees outlined in our fee schedule, which may include associated fees for telephone consultations, re-writing stimulant prescriptions, completion of paperwork and special completion of letters, as well as legal fees billed by the hour.

• By signing this form I understand that all patient communication from this practice will be sent through Spruce. If I am not able to get in touch with the office staff or my clinician and need immediate medical help, I will seek care at the nearest emergency room or urgent treatment center.

• By signing this form I understand I may choose to end services with this practice and I may discontinue treatment and/or withdraw my consent to treatment at any time. I am also aware that this practice may recommend ending services for any reason and at any time with appropriate legal notifications as required by the state medical board.
• In consideration of services provided by this practice, by signing this form I understand that the care offered here may not be an ideal treatment solution for myself, my family, or my child. I understand that if the clinicians and staff feel that they can no longer provide excellent patient care, the practice will provide a list of available resources to whom care may be transferred.

• By signing this form I agree to attend all of my scheduled sessions and to notify the practice at least 48 hours ahead of time if I will not be able to attend my session for any reason. I understand I may be charged a "late cancellation" fee of half the cost of the visit if I cancel less than 48 hours before my scheduled appointment. I also understand that I will be charged the full appointment fee if I fail to show for my scheduled appointment without notice. Fees are based on our current fee schedule, which is on our website.

• By signing this form I voluntarily consent to receive medical/psychiatric services from this practice by one of our clinicians. I agree to actively participate in my treatment plan and to take prescribed medications as directed by my clinician. I have read and understand the information provided in this section.

• By signing this form I confirm that my response regarding Medicare coverage is true and correct to the best of my knowledge.
• I agree to notify this practice in writing within 24 business hours if I become eligible for or enrolled in any Medicare-related plan. I understand that this practice does not bill Medicare and that federal regulations may prohibit continued care once a patient is enrolled. I understand that failure to provide timely written notice may result in immediate termination of the patient-clinician relationship.

• HIPAA acknowledgement form
• Patient financial responsibility agreement