CONSENT TO TREATMENT AND PAYMENT AUTHORIZATION FORM

Prior to your first session, you will need to fill out the form below in which you agree to:

  1. The policies and procedures for treatment (link) at IPG
  2. Acknowledge how IPG preserves your privacy and confidentiality (link), and
  3. Authorizes payment through your Credit, Debit, or HSA/FSA benefits card

This form is only to be filled out once you have been assigned a therapist. Please select the email address of your therapist in the form below so that they will automatically receive notification that this form has been completed, and your treatment can begin.

Patient Information

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Credit/Debit Card Information

IPG processes payments using only cashless, electronic methods, even when treatment occurs in-person. As such, in order to reserve appointments with our therapists, IPG requires all clients to keep a valid credit/debit card securely stored on file with our Billing Department. Therapy is a weekly process, which is continuously billed to you or your insurance, generating ongoing cost-sharing balances. To keep this process as smooth as possible, our Billing Department seamlessly charges your card your ongoing balances as they become due. You can change the card kept on file at any time. You may also make alternative payment arrangements through our Billing Department.

Authorizations and Consent to Treatment

All boxes are required in order to submit form.
In case we need to reach out to you with any questions
For emailed copy of this form
Select your therapist's email in order to have them receive an automatic notification that you have completed this form.