Patient Information

Today's Date:*

Clinician:

Diagnosis:

Personal Information

Client's Legal Name:*

Date of Birth:*

Home Address:*

Email Address:*

Phone Number:*

Gender:*

Payment Information

***All co-pays and private pays are due at the time of service***

Visa

Mastercard

Discover

Card Number:*

Expiration Date:*

3 Digit Code:*

Billing Zip Code:*

Primary Insurance

Primary Insurance Company:*

Subscribers Name:*

Date of Birth:*

Subscriber's Insurance ID Number:*

Relationship to Client:*

Secondary Insurance

Secondary Insurance Company:

Subscribers Name:

Date of Birth:

Subscriber's Insurance ID Number:

Relationship to Client:

Reason for seeking counseling services:*

If the client is a minor, please print the name of the parent or guardian on minor’s behalf:

Print Full Name:

Relationship to Client:

I consent to the Informed Consent and Notice of Privacy Policies

Client's Signature:*

Today's Date:

Parent or Guardian's Signature:*

Today's Date:

Thank you! Your submission has been received!

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Please Review Our New Client FAQs + Policies

Missed Appointments and No-Shows Policy

Clients are responsible for attending all scheduled appointments. To avoid charges, cancellations must be made at least 24 hours in advance.
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• Late cancellations (less than 24 hours' notice) will incur a $50 fee.
• No-shows will be charged $75.

Paperwork

Completion of paperwork for Social Security, disability, workers' compensation, or other purposes is at the provider’s discretion and must be discussed in advance. Decisions are based on treatment duration, frequency, and necessity.

• If approved, the fee is $45 per 15-minute increment.
• Paperwork will not be released until payment is received in full.

Insurance Billing

Clients authorize Whole Life Solutions, LLC to release necessary medical information to insurance providers for claims processing. Clients are responsible for notifying Whole Life Solutions, LLC of any changes to their insurance coverage.

Payment and Account Responsibility

Payment is due at the time of service. Clients are responsible for all fees not covered by insurance.

• If an account becomes delinquent after three billing statements, it may be referred to a third-party collection agency.

Clinical Consultation and Confidentiality

To support high-quality care, therapists may seek professional consultation using general clinical information. Personal details will not be discussed without a signed Release of Information form from the client.

Informed Consent and Privacy Policy

Clients consent to the following:
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• Photocopies of their driver’s license, insurance card, and credit card will be securely stored on file.
• Participation in counseling services and agreement with all Counseling Policies, including the Notice of Privacy Practices (HIPAA).
• By signing, clients confirm they have read, understood, and agree to all terms outlined in the Whole Life Solutions, LLC Policies.