407 E 2nd Ave Ste 250 Spokane WA 99202 | (509) 315-9776

Before your first session

What Forms do you need?

All Clients must fill out and/or sign:

  • Notice of Privacy Practices
  • Financial Disclosure
  • Disclosures and Consent
  • History and Symptom Checklist
  • Good Faith Estimate – Sent after first appointment

See below on additional information

  • Disclosure and Consent form – Regardless of Marital/Custody status:
    EACH Biological Parent/Legal Guardian MUST SIGN.
    • Documentation to support a single signature MUST BE RECEIVED PRIOR to the first session:
      e.g. incarceration, parenting plan for 100% decision making, active restraining order, birth certificate with only one parent listed.
  • Financial Disclosure form – The Financially Responsible Party/Guarantor MUST SIGN.
    • If there is more than one financially responsible person (e.g., parenting agreement stipulates costs be split and we will be collecting from more than one party) each guarantor should sign.
  • The named client (teen/adolescent/adult) is the person who signs all forms.
  • Financial Disclosure – If the client is not the financially responsible guarantor, the named guarantor will also sign this form. This gives us permission to speak with the named guarantor about financial related matters.
  • ROI-General (Release Of Information)- We additionally recommend this to specifically stipulate what we can share with the guarantor and any other involved person (family member, caregiver, other professionals, etc) including what information is available to them on the patient portal.
  • NOTE: In Washington State, clients over the age of 13 consent to their own mental health care.
  • NOTE: The Cures Act mandates that clients have electronic access to medical records through their client portal beginning August 31st, 2023.
  • NOTE: Some insurances contractually require that clients being treated by Associate level providers have their initial intake assessment session and treatment plan reviews with a Clinical Supervisor. Furthermore, billing for services rendered by an Associate will be through their supervisor who provides supervision and direct oversight to your care.
  • Group Therapy Disclosure
  • Animal Assisted Psychotherapy Disclosure

NOTE: Those who have in-person appointments, your therapy is conducted in a room where a dog is, or was present, and you may be exposed to allergens.

  • Couple/Relational Disclosures and Consent – Signed by all enrolled.
  • Family Therapy Disclosure – signed by all individuals over the age of 13 who are not the direct client.

Fill out History on the patient portal.

Navigate to the HISTORY menu on the left side of the patient portal.

  • Fill out and save (button at the bottom) the History tab
  • Fill out and save (button at the bottom) the Symptom Checklist tab

NOTE: For couples/relational clients, fill out the tabs for each “Partner” instead of the “Individual Therapy” tab.

NOTE: if using a mobile device, you may need to rotate the screen to see all available tabs.