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Adult Intake Form

Child/Adolescent Intake Form

Couple Intake Form

Release of Information Form

HIPAA Notice of Privacy Policies and Practices

At Horizons, we use a packet of intake forms to gather information and to clarify procedures before we see you for the first time. You may fill out the forms at the office (please come 15 - 20 minutes early to do so) or you may print out the forms, fill them out and bring them with you.

If the client (the person in whose name services will be billed and perhaps insurance billing submitted) is an adult coming for an individual appointment, use the Adult Intake Form.

For couples, use the Couples Intake Form. The person in whose name services will be billed should complete the first three pages. The client AND the spouse/partner should read and sign pages 3-6 (Services and Fee Agreement.) Spouse/partner should also complete the last two pages (Additional Information for Spouse/Partner.)

If the client (the person in whose name services will be billed and perhaps insurance billing submitted) is under 18, use the Child-Adolescent Intake Form.

Insurance companies often have negotiated rates with Horizons or with individual therapists. At times, therapists make arrangements with clients for reduced fees. Your fee agreement will reflect agreements with your insurance provider or made directly by you with your therapist.