New Client Forms

Welcome! To help us serve you better and streamline your first appointment, please download and complete our new client forms in advance. This allows us to focus our time together on your needs.

Choose How to Complete Your Forms

Download PDF Forms

Download and print the forms to complete by hand. Bring the signed forms to your first appointment.

Download Forms

Complete Forms Online

Fill out the forms digitally on this page. You can save as PDF or submit electronically.

Client Info

Insurance

Consent

Authorization

Client Information

Full Name *

Date of Birth *

Age

Gender

Address *

City *

State *

ZIP Code *

Phone Number *

Email Address

Emergency Contact Name *

Emergency Contact Phone *

Relationship

Insurance Information

Insurance Provider *

Policy/Member ID *

Group Number

Policy Holder Name (if different from client)

Policy Holder Date of Birth

Relationship to Client

Informed Consent for Mental Health Treatment

Paula S. Gordy LISW, LLC - Informed Consent

I agree to obtain mental health treatment on a voluntary basis. I understand that I may end treatment at any time, but that my mental health provider may want to discuss this with me. I also understand that I have the right to discuss any recommendations that are made regarding diagnosis and treatment.
I will be given a description of the types of treatment recommended, such as individual/family therapy, group therapy, and other programs offered by this organization. The least restrictive level of care will be strongly considered. In addition, the frequency and length of each appointment will be determined by me and my mental health provider. I also understand that my mental health provider cannot promise certain results or outcomes from treatment.
My mental health provider and I will discuss problems to be addressed, my strengths and needs/wants, and treatment interventions that may be used throughout the treatment process. We will also mutually agree upon and develop goals and objectives for continuing/discontinuing mental health treatment.
I understand there may be some risks involved in participating in mental health treatment, such as being challenged on difficult or sensitive issues or addressing painful emotions related to past trauma or past losses. I am aware that I can discuss any risks with my mental health provider at any time.
I understand that this Informed Consent for Mental Health Treatment is not intended to be absolute, but instead it is intended to provide helpful information before making a decision whether or not to be involved in mental health treatment. I am also aware that at any time, I have the opportunity to ask questions and have them answered satisfactorily.

Confidentiality

What is said in mental health sessions is confidential with the following exceptions:

You are assessed to be a danger to yourself
You are assessed to be a danger to others
Child or dependent adult abuse is occurring
Records or testimony is subpoenaed from the court

I have read and understand the informed consent for mental health treatment *

Client/Guardian Signature *

Today's Date *

Authorization for Third Party Billing and Assignment of Benefits

I authorize Paula S. Gordy LISW, LLC to furnish my third-party payer (e.g., insurance company, county of legal residence, etc.) all necessary information (per Iowa Code) that may be required in processing claims for service rendered. I hereby assign to Paula S. Gordy LISW, LLC all money to which I am entitled for expenses relating to services performed, not to exceed my indebtedness to Paula S. Gordy LISW, LLC.

I understand that any money received from my third-party payer, over and above my indebtedness, will be refunded to me when my bill is paid in full. I also understand that any co-pays, co-insurance, deductible, or any other uncovered charges are my responsibility.

Photocopies of this authorization shall have the same force and effect as the original and may be attached to any claim form required by my third-party payer. This authorization shall be in effect until revoked by me in writing.

Payment for Services is expected at the time service is provided.

I authorize third party billing and assignment of benefits *

I understand that payment is expected at time of service *

Client/Guardian Signature *

Today's Date *

How to Complete Your Forms

Download the PDF: Click the download button above to save the forms to your device.
Print the forms: Print all pages of the document on standard letter-size paper.
Complete all sections: Fill out the forms completely using blue or black ink. Please write legibly.
Sign and date: Don't forget to sign and date where indicated. A parent or guardian must sign for clients under 18.
Bring to your appointment: Bring the completed forms to your first visit, along with your insurance card and photo ID.

Save Time

Completing forms in advance allows us to maximize your appointment time for discussing your needs and treatment goals.

Privacy Protected

Your information is kept strictly confidential in accordance with HIPAA regulations and professional ethical standards.

What to Bring

Please bring your completed forms, insurance card, photo ID, and a list of current medications to your appointment.

Need Help with Forms?

If you have questions about the forms or need assistance, please don't hesitate to contact our office. We're here to help make your first visit as smooth as possible.

(641) 856-2688

[email protected]

501 N 12th St, Centerville, IA