New Client Registration

Name*

First NameLast Name

Birth Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Phone Number*

Area CodePhone Number

Preferred nickname?

Preferred pronouns:*

Relationship status:*

Please list all of your household members

Please list your partner's name (if coming for couples therapy)

First NameLast Name

Your goals for therapy:*

Do you plan to file out-of-network insurance claims for any of your treatment?*

YesNoI do not have insurance

Good Faith Estimate

As a self-pay client you are entitled to a Good Faith Estimate (GFE) of your treatment costs. At the start of therapy, we provide you with a GFE for the assessment process. Once we have completed your assessment and have a better understanding of your history and treatment goals, we can provide you with an updated GFE for any ongoing therapy.

Our assessment process is typically 4 sessions conducted over a period of 4 weeks. Individual clients may progress a little more quickly, and couples might take one or two sessions longer. However, on average, we assume 4 sessions at a total cost of $920.

Here is a breakdown of the potential charges:

-Initial appointment (costs $275 and lasts 60-minutes)

-All subsequent assessment sessions (cost $215 and last 52-minutes)

During the assessment process, all clients are subject to a late cancel/no show fee of $50 per session. You can learn more about this fee in our financial policy.

Please note, GFE's are estimates and not binding contracts. They do not commit you or us, as your provider, to any course of treatment, and they are based on the information available at the time of their writing.

Should you feel that you are billed in excess of the GFE, you may appeal the bill directly with us. You can also contact the Department of Health and Human services for further information or aid in disputing your bill.

Should you have any questions regarding this GFE, please contact your provider before the first appointment, if at all possible. Your provider will review this information again during the intake appointment.

Please sign below to confirm receipt of your GFE.

Signature*

Have you ever sought help for your mental health?*

YesNo

Please tell us a bit about the mental health symptoms for which you sought help, including when they began, how long they lasted, and any current symptoms.*

On a scale from 1 to 5, how much of a role does this mental health condition play in your current reason for seeking treatment here at Mend?

	1	2	3	4	5

1 is Zero, 5 is The main reason

What types of treatment have you received? Please check all that apply.*

Are you currently undergoing any of the treatment options you listed above? *

YesNo

Current provider information:

New Client Registration

Mental Health History