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Forms

Thank you for choosing Seasons Counseling of Michiana. If you are coming for the first time or after a long absence, please print ALL forms and bring them to your first appointment.

New clients must fill out all forms, even if they are selecting “no” (like on authorizations to release information) as we need to have the completed form on file with appropriate signatures.

Client Registration Form

All new clients and clients returning after more than six months since last session must complete this form. Please print and bring to your first appointment.

Counseling and Fee Agreement Form

This is for your information. You don’t need to bring it to your appointment, but be aware that by signing the Client Registration and Insurance Agreement forms, you are agreeing to the policies detailed here.

Insurance Agreement Form

If you would like us to bill your insurance company for services, please print this form. Bring the completed form and your insurance card to your first session.

Authorization to Disclose Information Form

This forms grants us permission to disclose information regarding your appointment to your primary care physician or referring professional.

Authorization to Release Appointment and Billing Information Form

If you would like someone close to you (such as a spouse, parent, etc.) to be able to call and schedule or cancel appointments on your behalf or talk with us concerning billing matters, please print and complete this form.

General Release of Information

This optional form provides you the opportunity to 1) send your records to another care provider and/or 2) request records from another provider be sent to Seasons Counseling of Michiana.

HIPAA Notice to Clients

This notice tells you how we make use of your health information at our Center, how we might disclose your health information to others, and how you can get access to the same information.  There is no signature required on this form.

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