Patient Intake & Consent Form
Welcome to IShine Behavioral Health.
We are committed to providing compassionate, high-quality mental health care in a respectful and confidential environment. This intake form allows our clinical team to better understand your medical history, concerns, and treatment goals so we can provide the most effective care.
All information you provide is confidential and protected under HIPAA regulations.
Please complete this form as accurately as possible.

Step 1: Patient Information

Full Name

Date of Birth

Phone Number

Email Address

Address

City

State

Zip Code

Step 2: Reason for Visit

What brings you in today?
AnxietyDepressionADHD / Attention IssuesMood Swings / Bipolar SymptomsTrauma / PTSDSleep ProblemsMedication ManagementTherapy / CounselingOther

Please briefly describe your concerns

Step 3: Insurance Information

Insurance Provider

Member ID

Group Number

Self Pay Patient?
YesNo

Upload Insurance Card (Front)

Upload Insurance Card (Back)

Step 3b: Government ID Upload

Upload Government ID (Front)

Step 4: Mental Health History

Have you previously received mental health treatment?
YesNo

Previous Diagnoses (if known)

Current Psychiatric Medications

Have you ever been hospitalized for psychiatric reasons?
YesNo

Step 5: Safety Screening

Have you had thoughts of harming yourself?
NeverIn the pastRecently

Have you had thoughts of harming others?
NoYes

Step 6: Telehealth Consent

I understand that IShine Behavioral Health provides mental health services via telehealth (video or phone). I understand that telehealth involves the use of electronic communication to enable healthcare providers to diagnose, consult, treat, and educate patients remotely. I acknowledge that: • Telehealth services may involve risks such as technical difficulties or interruptions. • I have the right to withdraw consent for telehealth services at any time. • My information will remain confidential and protected under HIPAA regulations. By signing below, I consent to receive telehealth services from IShine Behavioral Health.

Step 7: AI-Assisted Documentation Notice

I understand that there will be no recording of any online sessions by either party for personal use. To ensure accurate documentation and better quality of care, I acknowledge that the provider may use a secure, HIPAA-compliant service that temporarily captures audio from the session to automatically generate clinical notes. This process is solely for documentation purposes, and no audio recordings are stored or shared. All information will be handled with strict confidentiality in compliance with privacy laws.

Step 8: Financial Responsibility

I understand that I am financially responsible for all charges related to services provided. Insurance coverage will be verified as a courtesy; however, final responsibility for payment remains with the patient. Any balance not covered by insurance, including deductibles, copayments, or coinsurance, will be billed to the patient. Payment may be required prior to future appointments if balances remain outstanding.

Step 9: Appointment Cancellation Policy

I understand IShine Behavioral Health’s cancellation policy: I agree to provide at least 24 hours notice for cancellations or rescheduling. I understand that missed appointments or late cancellations may result in a fee.

Step 10: HIPAA Privacy Acknowledgment

I acknowledge that I have been provided access to the Notice of Privacy Practices explaining how my medical information may be used and disclosed. I understand that I may request a copy of this notice at any time.

Step 11: Consent for Treatment

I voluntarily consent to receive mental health evaluation, treatment, and related services from the providers at IShine Behavioral Health. I understand that: • Treatment may include therapy, medication management, or other clinical services • I may ask questions at any time regarding my treatment • I may withdraw consent for treatment at any time

Step 12: Emergency Notice

I understand that IShine Behavioral Health does not provide emergency services. If I am experiencing a mental health emergency, I will call 911, go to the nearest emergency room, or contact the 988 Suicide & Crisis Lifeline.

Patient Signature

Type Full Name as Signature

Date