THANK YOU FOR SCHEDULING WITH I CHOOSE CHANGE!

So we can spend more time talking, please fill our your new client paperwork prior to your session. Guardians of minors under age 17 should fill this out for the child. Please also read the below documents before filling out paperwork. Thank you!

HIPPA Compliance (Your Rights as a Patient)

Counseling Packages (Buying in Bulk to Save Money)

If you would rather not submit information online, simply click this link, fill out, and bring to your first appointment.

Date *

Personal Information

Full Name *Name

Address *

Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Contact Phone *

Alternate Phone

Email *

Birth Date *

Employer *

Marital Status *

Married In a Relationship Separated Divorced Single

Spouse and Childrens Names

How did you hear about I Choose Change? (Click all that apply.) *

Psychology Today Living Magazine Suburban Parent Physician Relative Relative Friend Internet Search

Would you like to be signed up to receive our blog articles and/or newsletters with up-to-date mental health news and articles? *

Yes No

Insurance Information

Insureds Name

Insureds Birthdate

Insureds Employer

Insurance Company

Group #:

ID#

Payor ID#

Mental Health Number (on back of card)

Authorization

I give consent to I Choose Change to perform necessary procedures to diagnose, treat and care for the mental health needs for my child or me. *

Yes No

I understand that all receipts will be emailed to the address above, but I can request a paper copy anytime. *

Yes No

I understand that I Choose Change is an out-of-network provider who will submit for insurance reimbursement upon my request. Interns are not eligible for insurance reimbursement. *

Yes No

Should I authorize I Choose Change to submit claims to my insurance company, I hereby authorize the release of any information relating to insurance claims, and I authorize payment of my group insurance benefits directly to I Choose Change which may be us *

Yes No

I understand that my insurance company may pay less than the actual bill for services and that I am fully responsible for payment in full at the time of my appointment. *

Yes No

Privacy and Fees

I have read and am aware of my rights of confidentiality as a mental health consumer. *

Yes No

I have read and understood Professional Disclosure Statement, and I have received answers to any questions I have about this statement, and they been answered to your satisfaction *

Yes No

I understand there is a 24-hour cancellation by phone (214-548-1318) policy, and that if I do not cancel within 24-hours of my appointment, I am liable for full cost of this appointment, and my credit card on file will be charged without notice.s normal. *

Yes No

How will you be paying for your sessions? *

Cash Check Visa MasterCard American Express Discover

If Paying By Credit Card

Name on Card

Credit Card Number

Expiration Date

I authorize my credit card to be used for counseling services, unless another form of payment is given at the time of service.

Yes No

Verification

Please enter any two digits with no spaces (Example: 12)*

If you’re interested in attending the Women’s Circle, please fill out this form:

Women’s Circle Intake

Other useful forms:

Consent to Exchange Information or Records - useful when your counselor needs to speak with your physician, past counselors, or other helpful people in your life.

Consent to Treat Persons Under Age 17 - parents fill out on behalf of their child’s care.

Informed Consent to Work with Counselor Intern – Interns are Master level counselors, and have passed the State of Texas LPC licensure exam, working to complete their required supervised internship hours.

How To Guide: Google Chat & Video – Setup instructions for Google Video or Chat sessions.

Evaluation Survey – Your feedback matters! – We value your opinion. Fill out anytime and fax, email, or mail – confidentially!

You’ll need Adobe Reader to download the above documents. Click this button to download now:

Call I Choose Change / Allen Counseling Center to schedule your free consultation now: 214-547-1318

THANK YOU FOR SCHEDULING WITH I CHOOSE CHANGE!

Personal Information

Insurance Information

Authorization

Privacy and Fees

If Paying By Credit Card

Verification

If you’re interested in attending the Women’s Circle, please fill out this form:

Other useful forms:

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