Office Forms

Modern Mental Health will require that you complete forms prior to your first therapy appointment. You will have to complete a standard intake questionnaire with demographic information such as name, date of birth, gender, preferred pronouns, address, marital status, email address. Once we determine that Modern Mental Health is a good fit for your therapy needs, we will invite you into our HIPPA compliant secure patient portal where you will complete new patient paperwork online.

We will want to know how you prefer to be contacted for reminders about upcoming appointments and how you would like us to communicate best with you. We will need consent to leave voice mail messages, text messages, and email messages to reach out to you. We will want you to provide consent of an emergency contact name, relationship to you, and contact number in case of an emergency. We will want to know what medical insurance you have and if we are in your network. We will want the name of the primary subscriber to the insurance, employer, the employer ID #, Group #, Medicare/medicaid secondary insurance ID# group #, Guarantor- person who will guarantee payment for services, Guarantor Date of Birth address and phone number. Who referred you to Modern Mental Health or How did you hear about us?

Once you complete the demographics section. You will need to complete basic questions surrounding symptoms that you are experiencing and some of the barriers or stressors that you may be going through. What brings you to therapy now? We will want to know what are some of your initial goals for therapy. Have you had therapy in the past? If yes, what was that experience like for you?

We will want a list of all your medical providers from who you currently receive care from. We will want a listing of all your current medications and supplements that you are currently taking and for what reason. We will want to know of any allergies you may have or any drug reactions you have had in the past.

We will want to know what your current medical conditions are and if you have had any surgeries, hospitalizations, psychiatric hospitalizations, and drug and alcohol treatment in the past. We will want to know about your family history of psychiatric and medical concerns. We will want to know if you are in crisis or having any suicidal thoughts currently or in the past.

We will want to know if you drink alcohol or use any recreational drugs. We will want to know if you are having any legal concerns. We will want to know if you are currently in any child custody or marital disputes, attempting to apply for a medical or psychiatric disability, or currently in need of legal help?

We will want to know if you work part-time, full-time, are retired, or on any medical disability. We will want to know your highest level of education and if you have a military background.

We will want to know if you engage in any spiritual activities.

We will require that you complete a treatment and fee agreement for clinical services. Fees for service will depend on the type of service delivered. There will be a $75 fee for an appointment canceled without 24 hour cancellation notice. You will sign a credit card authorization agreeing for Modern Health to charge credit card for any fees rendered and this would include the cancellation fee.

We will have you sign forms indicating practice policies. This will outline appointments and cancellations procedures, Telephone accessibility, social media and telecommunication, Electronic communication, Minors, and Termination.

We will provide a Notice of Privacy and Practices form to sign. This will tell you how health information may be used and disclosed and how you can get access to this information.

Will provide informed consent for psychotherapy and a form to sign. This will include informed consent for psychotherapy to include general information. The therapeutic process, Confidentiality, billing, and fiscal responsibility understanding and signature.

You will sign consent for telehealth consultation.