Consent Form for Treatment at IPG (stand-alone) Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient InformationPatient Name *FirstLastPatient Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAuthorizations and Consent to TreatmentAll boxes are required in order to submit form. Authorizations *I have had the opportunity to ask questions about the policies and procedures of IPG, as well as about the pros and cons of receiving psychotherapy. I agree to comply with these rules and conditions, and I understand that non-compliance with them will make my treatment subject to termination. My signature below represents my authorization to partake of treatment at IPG. I understand I have a right to withdraw my consent at any time in writing.LC/NS *I understand that my scheduled time is reserved for me exclusively, and any cancellations or rescheduling must be done with at least 24-hours’ notice. I understand that if I cancel a session within 24 hours of its scheduled time, I will be charged a Scheduling Fee of $50, and if I skip a session without notice, I will be charged a Scheduling Fee of $75.1 *I understand that if my services are provided via telehealth, there are inherent risks including interruptions, unauthorized access, and technical difficulties, as well as increased challenges should a crisis or emergency arise. I will not hold IPG responsible for the technological problems it has no control over. I understand that if I or my child demonstrates an exacerbation of symptoms, or if I do not follow the above rules for telehealth services, telehealth sessions may be discontinued, and in-person treatment or a referral to a higher level of care may be necessary. In such circumstances, if IPG cannot provide in-person treatment, a referral will be made to another practice.2 *I understand that IPG will need to share confidential information with third parties, such as my insurance carrier(s), in order to authorize and reimburse my sessions. These third parties may have a right to review my treatment at any time. My signature below also authorizes the release of this information in order to process my sessions, and for payment to be made directly to IPG for services rendered.3 *I understand that I am ultimately financially responsible for my treatment services at IPG to pay any balances owed after all third-party payments have been applied, or should any third-party payer decline to pay for some or all of my treatment. I understand that IPG reserves the right to send any delinquent balances and accounts to a collections agency with whom I may not have any previous relationship. I may be billed additional fees associated with the collection of my balance. I agree to keep a valid credit/debit card on file at all times in accordance with IPG policies.4 *I have had the opportunity to review and ask questions regarding IPG’s Notice of Policies and Practices to Protect the Privacy of Your Health Information, and I understand my rights as a patient.5 *With my signature below, I agree to pay all assigned fees, copays, coinsurance amounts, deductibles for services rendered, and any Scheduling Fees for appointments not kept or any amounts due as determined by my insurance or that my insurance did not pay, for the patient listed above. By signing this payment authorization form, I certify that I am authorized to agree to the above terms on behalf of the patient listed.Signature * Clear Signature Date *Name of person signing *FirstLastRelationship to Patient *SelfParent/GuardianSpouseOtherPhone *In case we need to reach out to you with any questionsEmail *For emailed copy of this formTherapists Email *Select oneaarntz@insightpsychgroup.comativade@insightpsychgroup.combfranklin@insightpsychgroup.combvasquez@insightpsychgroup.combreilly@insightpsychgroup.comcfigueroa@insightpsychgroup.comcpallotta@insightpsychgroup.comdrhelfgott@insightpsychgroup.comdneedleman@insightpsychgroup.comewolf@insightpsychgroup.comfmartin@insightpsychgroup.comhmavashev@insightpsychgroup.comjlevy@insightpsychgroup.comjhammond@insightpsychgroup.comjgoetz@insightpsychgroup.comjjohnson@insightpsychgroup.comkestevez@insightpsychgroup.comkhoma@insightpsychgroup.comkmurphy@insightpsychgroup.comkpeck@insightpsychgroup.comksavon@insightpsychgroup.comlkearney@insightpsychgroup.comlabraham@insightpsychgroup.comlwolman@insightpsychgroup.commmorris@insightpsychgroup.commservedio@insightpsychgoup.comoelkind@insightpsychgroup.comoschutz@insightpsychgroup.comrchoquette@insightpsychgroup.comrwilson@insightpsychgroup.comsfarid@insightpsychgroup.comsshapiro@insightpsychgroup.comtfrank@insightpsychgroup.comthernandez@insightpsychgroup.comvholbrook@insightpsychgroup.comSelect your therapist's email in order to have them receive an automatic notification that you have completed this form.Submit
