PLEASE NOTE

Intake forms are ONLY for patients
who have consulted with me.

Any intake forms filled out prior to our
discussing your care cannot be processed.

PATIENT INTAKE (PART ONE)

intake-part01b

Thank you for taking the time to complete this information. Your intake will include four parts.

PART ONE: collecting general information about you and financial information for billing purposes
PART TWO: gathering biopsychosocial information (e.g., ranging from how you’re feeling today to habits and history)
PART THREE: reviewing Kizaur Counseling privacy practices
PART FOUR: consenting to being treated by Kizaur Counseling

After you complete each part of your intake and click the "SUBMIT" button, you will then be taken to the next part.

All the information you share during this process remains completely confidential and helps me better help you.

How Insurance Works
Insurance pays for diagnosable conditions. If you have a diagnosable condition, I can ethically bill insurance until that condition is remedied, or until your insurance says that they will no longer pay. If you want to continue to see me for other life goals or concerns, I would be happy to continue to help you and bill you for my hourly rate.

Payment
For a list of insurances currently accepted, please click HERE. For your convenience I bill your insurance company directly. If however, one of those insurances is a secondary insurance, I ask that you pay upfront and I will provide a bill for you to submit for reimbursement. Your responsibility is to meet your deductible (if you have one) and pay your copay (if you have one), which is due the day of service. If you are paying out-of-pocket for counseling, payment is due each session.

Session Cost
Unless insurance covers your sessions, my fee for counseling is $150 per session. For those in financial need, please inquire about a sliding scale.

No-Show and Cancellation Policy
You will be responsible for a $100* charge if you cancel within 24 hours, or don’t show the day of the appointment. *I reserve the right to charge less depending on circumstances. If you have to reschedule, please give as much notice as possible – as least a few days if you can. This allows me to give your time slot to someone else who might be waiting to get in, and it helps me run my practice. If you have an emergency or are suddenly ill, of course you will not be charged.

Insurance Co-pay Amount
Please call your insurance company prior to counseling to find out if you have a copay and a deductible. You might have to pay for counseling sessions if you still have a deductible, which is important for you to know. Also, behavioral health often has different co-pay amounts than medical co-pays. Copays are due at each visit. I accept cash, credit card, Paypal, or check.

CLIENT INFORMATION
please list name, relationship to client,
and provide two contact phone numbers
please list name, relationship to client,
and provide two contact phone numbers
INSURANCE AND FINANCIAL INFORMATION
Only enter if different from what you entered above
in the "Client Information" section
Only enter if different from what you entered above
in the "Client Information" section
Only enter if different from what you entered above
in the "Client Information" section
Only enter if different from what you entered above
in the "Client Information" section
Only enter if different from what you entered above
in the "Client Information" section
Only enter if different from what you entered above
in the "Client Information" section

By printing my name in the signature field below, I authorize the release of any medical or other information necessary to process insurance claims. I further authorize payment of medical or insurance benefits to Wendy Nathan, MA, LPCC-S (Matthew Kizaur, MA, LPC, MEd, LPSC) and authorize the collection and release of therapy records and treatment plans to my insurance company for the purposes of evaluation, treatment, and payment.

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