Mt. Hebron Counseling Services

Intake Form

Please list other household members:

In case of Emergency


EMPLOYEE ASSISTANCE PROGRAM (EAP) (In most cases, the client has to call the EAP program to activate benefits)



Please read the New Client Information, Professional Disclosure Statement Act, Your Rights under HIPAA, Consent to Treatment, HIPAA Privacy Practices notice, No Surprises Act notice, and acknowledge by writing your name in the "Signed By" field below.

Consent to Treatment

  • I have read the following documents:
    • New Client Information
    • Professional Disclosure Statement
    • HIPAA Client Rights Statement
    • HIPAA Privacy Practices Notice
    • No Surprises Act Notice
  • I am aware that I may terminate treatment with my provider at any time.
  • I authorize the release of treatment information to my insurance company upon request, and as needed for the purpose of filing insurance claims.
  • I authorize Mt. Hebron Counseling Services to receive payments directly from my Insurance company, or Employee Assistance Program.
  • I understand that I am responsible for any portion of my fee for therapy which is not covered by insurance.
  • Legal Policy - I understand and agree that all information, communication, observation and opinions deriving from my treatment will be considered private and confidential between me and my therapist.  My therapist is a licensed professional and trained to work with me on resolution of my presenting issues and does not claim to be a legal expert witness of any type. My therapist feels that litigation is by nature an adversarial process and is incompatible with the goals of therapy.  My therapist does not wish to be involved in litigation of any type, and my acknowledgement of these terms indicates my understanding of this.
  • Our Clinicians are committed to spending your time actively engaged in therapy.  Therefore, any out-of-agency paperwork including disability, legal or FMLA, etc. should be directed to your Primary Care Provider.
  • Not showing up for a scheduled appointment, without a prior cancellation of 24 HOURS, will result in my being charged a $40.00 NO SHOW FEE.
  • Unless otherwise indicated, I understand my case will be considered inactive if I have not had any contact with you after 60 days.
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