Intakes Forms

Review and print forms to save time before your first appointment.

YOU MAY COMPLETE THE INTAKE FORMS IN ONE OF TWO WAYS

1. In Advance: Print and complete the top three forms and bring them to your first appointment

2. At Your First Appointment: Plan to arrive 10 to 15 minutes early to complete the necessary forms. 

Intake Form

Personal History Form

Acknowledgment of Receipt Form

Informed Consent Notice Form

 ---

Other forms

Notice of Privacy Practices

Client Privacy Rights Form

 

 


USING INSURANCE TO HELP PAY FOR COUNSELING?

Questions to Ask Your Insurance Provider

Concerning Mental Health Benefits
*Do I have behavioral/mental health coverage?
*How many outpatient psychotherapy sessions am I allotted in my plan?
*Are there any limitations, requirements, or restrictions in accessing my plan?

Additional questions for more detail:
Do I need a referral from my Primary Care Physician?
Do I need to have pre-authorization from my insurance company?
Is my therapist in your network? If not, what are my out-of-network benefits?
Am I authorized to see only a particular kind of therapist? (psychiatrist, psychologist, licensed mental health counselor, licensed marriage and family therapist, licensed clinical social worker, etc.)?
What is the effective date of my insurance coverage?
Am I limited to a dollar amount per year ($500, $250 etc.) that will be covered?
What is the amount of my deductible, co-pay, and co-insurance amounts after insurance adjustment is applied?

Get in Touch

1000 characters left

We Can Help

We provide affordable counseling to adults, teens, children, couples, families, and groups.

Your Therapy is

  • Completely confidential
  • A safe way to address problems
  • A helpful means to explore life choices

Convenient Location

Based in Winona, MNWe provide our services in and around Southeastern Minnesota.

Winona, MN

COUNSELING ASSOCIATES, LLC | 111 Market Street, Suite 4A, Winona, MN | Monday - Friday 9:00am - 5:00pm   Call (507) 452-5033