This page contains all of the information you will need to begin the intake process. Please only complete and submit these documents once you have a scheduled initial appointment. If you are looking to make an appointment, please call Nate at 480-332-4397 or email at firstname.lastname@example.org
Thank you for choosing to begin counseling with Nate Marshall Counseling, PLLC. On this page you will find the documents for you to fill out before your first visit. Please be aware that these forms can take up to several hours to complete, so please plan accordingly. Having these documents completed before your first session will greatly speed up the process of getting you enrolled for services and allow us to have more time to focus on beginning your counseling services at our first appointment. All documents are available in 2 forms: one to fill out and submit electronically through this website; the other for you to print out, complete by hand, and bring in with you to your first appointment. Please do not submit or print and fill these documents unless you already have a scheduled appointment.
Please fill this form out as thoroughly as possible. If a particular field does not apply, please indicate this by submitting an “N/A” in that field. If you are using your insurance to pay for your sessions, you will need to complete the part labeled “Section 2” with your insurance info. If submitting electronically, there is also an option to upload a picture of the front and back of your insurance card. If you do not use this option, I will need to get a physical copy of your insurance card at our first appointment. If you are not using insurance, neither “section 2” nor the picture of an insurance card need to be completed, but the rest of the document will need to be completed. Please ensure that you either electronically sign if submitting online or physically sign if you are printing this form out.
This document thoroughly describes the counseling process and other policies of Nate Marshall Counseling, PLLC. If submitting this form electronically, all fields must be completed. If you are printing this out and completing it by hand, you will need to write your name on the top of each page and initial the bottom of each page, which indicates that you have read the information contained on that page. In the middle of page 4, there is a spot that requires another initial, indicating that you have been given access to the HIPAA Notice of Privacy Practices Statement (available below). Towards the top of page 7, there are three sections to initial to ensure that you have reviewed these particular policies, as they are very important. Towards the bottom of page 7 your signature, printed name, and date are required. Finally, page 8 is an overview of the fee schedule for different services offered through Nate Marshall Counseling, PLLC. On the bottom of this page is the final place where you will need to sign, print your name and provide the date.
Comprehensive Background Information
This document will assist in the process of gathering information about you, your background, and the nature of the issues that bring you in for treatment. Please fill out as much as possible in as much detail as possible. This form is a very valuable tool that helps speed up the process of evaluation and treatment planning. Be prepared that this is a lengthy and thorough document, so please allow appropriate time to fill it out as completely as possible.
HIPAA Notice of Privacy Practices Statement
This 2 page document does not require a signature or any submission, it is just for your information. This form describes how confidentiality is handled by Nate Marshall Counseling, PLLC. You do not need to print this out, unless you want it for your records.
This questionnaire asks about difficulties due to the mental health conditions/concerns for which you are seeking help. Think back over the past 30 days and answer these questions thinking about how much difficulty you had doing the following activities. For each question, please select the response that best describes your situation.
Thank you for taking the time to complete these forms and I look forward to meeting you in our first session!