MARRIED COUPLE'S INTAKE FORM for Marriage & Family Wellness Ctr., Inc.

Welcome, and thanks for selecting Marriage & Family Wellness Ctr., Inc. for your counseling needs. We will strive to provide you with the best possible care. To help us meet your needs, please complete all parts of this form. If you have any questions or need assistance, please call 507-288-3118 or email us at marriagefamily19@yahoo.com.

           

  


  


MEDICAL & MENTAL HEALTH HISTORY

  

  

INSURANCE INFORMATION

It is necessary to obtain health insurance information from all of our clients. Please bring your insurance card with you so The Center can make a copy. This information will include the following: ID Number and address for submitting claims to the insurance company.


PAYMENT INFORMATION

Marriage & Family Wellness Ctr., Inc. is asking for the deductible and co-pay to be made at the first appointment. The agency will also expect the co-pay to be made at the time of arrival. Please call your insurance company and say, "I am seeking individual counseling. What is my deductible and co-pay for each visit, and how many visits per year am I allowed?" Please come with your check, cash, or credit card information ready. The Center will use an Intuit swiping device and will NOT be storing your credit card information.

CO-PAYMENT

The Center will collect the co-pay at the time of the visit. Please bring cash, check, or credit card to each visit.

DISCLAIMER

By submitting this form you agree to the following terms:

  • I understand I am financially responsible for all charges whether or not these charges are covered by my insurance.
  • I understand in cases of divorce, both parties are responsible for the remaining balance. The balance divided equally between the husband and wife.
  • I understand I will be charged half the fee for appointments that are not canceled 24hrs in advance.
  • If used, I will be charged for Psychological testing.
  • I certify that the above information is correct to the best of my knowledge. I will not hold my therapist or Marriage & Family Wellness Ctr., Inc. responsible for any errors or omissions that I may have made in the completion of this form.
  • I authorize the release of any medical and/or other information necessary to process all 3rd party claims and insurance payments to be sent to Marriage & Family Wellness Ctr., Inc.