Behavioral Health Services Intake Form

I hereby authorize and consent to the rendering of mental health treatment and/or diagnostic procedures by Kaecyn Behavioral Health Services and its providers.

I understand that treatment may involve psychotherapy, medication management, and other therapeutic interventions. All information will be kept confidential except as required by law. I have the right to refuse treatment at any time. I am responsible for all fees associated with services rendered.

By typing my name and date below, I acknowledge that I have read and understand this consent form.

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Kaecyn Behavioral Health Services is required by law to maintain the privacy of your health information and to provide you with this notice of our legal duties and privacy practices.

We may use and disclose your health information for treatment, payment, and healthcare operations, appointment reminders and follow-up care, and as required by law or public health requirements.

You have the right to request restrictions on certain uses and disclosures, inspect and copy your health information, and request amendments to your health information.

CANCELLATION FEES:

• Initial Evaluation No-Show: $200
• Follow-Up No-Show: $100
• Extended Follow-Up No-Show: $130
• Late Cancellation (<24 hours): $75

FORMS & LETTERS: $150 each. Established patients only (3+ visits required). Forms completed within 7-10 business days.

CARE PLANS: 6-month minimum commitment required. Must maintain continuous membership for 6 months before cancellation. Insurance not accepted for membership plans.

PAYMENT: 3.5% credit card fee + taxes additional to all service prices. All fees are due at time of service.

I accept financial responsibility for all services rendered at Kaecyn Behavioral Health Services. I understand that I am responsible for payment of all services, including those not covered by insurance.

I agree to pay all co-pays, deductibles, and co-insurance amounts at the time of service. I acknowledge the 3.5% credit card fee and additional taxes on all service prices.

For care plans, I understand the 6-month commitment requirement and that insurance is not accepted for membership plans.