I Shine Behavioral Health and Recovery Services

[cf7mls_step cf7mls_step-3 "Back" "Next" "Step 3"]Step 4[cf7mls_step cf7mls_step-4 "Back" "Next" "Step 4"]Step 5

How would you rate your current Physical Health *

How would you rate your current sleeping habits? *

How many times per week do you generally exercise? *

Are you currently experiencing overwhelming sadness, grief, or depression?*

YesNoMaybe

Are you currently experiencing anxiety, panic attacks or have any phobias?*

YesNoMaybe

Are you currently experiencing chronic pain?*

YesNoMaybe

Do you drink alcohol more than once a week?*

YesNo

How often do you engage in recreational drug use?*

DailyWeeklyMonthlyNever

Are you currently in any relationship?*

YesNo

Alcohol/Substance Use *

YesNo

Domestic Violence *

YesNo

Eating Disorder *

YesNo

Obsessive Compulsive Behavior *

YesNo

Suicide Attempts *

YesNo

[cf7mls_step cf7mls_step-6 "Back" "Next" "Step 6"]Step 7[cf7mls_step cf7mls_step-7 "Back" "Next" "Step 7"]Step 8

You may cancel or reschedule an appointment anytime, without any fees if you provide 24 hours notice for Medication Management and 48 hours for counseling session.*

Agree

You may call office at 815-947-4463 or Text at 815-947-4463 to make/cancel/re-schedule your appointment*

Agree

Our cancellation policy in not a penalty. We reserve the right to terminate our services for missing appointments for 3 times or more. Includes: Late cancellations/No show.*

I have read the above policy. I understand the policy and I agree to comply

[cf7mls_step cf7mls_step-8 "Back" "Next" "Step 8"]Step 9[cf7mls_step cf7mls_step-9 "Back" "Next" "Step 9"]Step 10

I, hereby consent to participate in tele-mental health with, IShine Behavioral Health, as part of my psychotherapy. I understand that tele-mental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations. I understand the following with respect to tele-mental health.

I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled. *

Agree

I understand that there are risks, benefits, and consequences associated with tele-mental health and other electronic communication including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. *

Agree

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.*

Agree

I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to tele-mental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).*

Agree

I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that tele-mental health services are not appropriate and a higher level of care is required.*

Agree

I understand that during a tele-mental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, ending and restarting the session may be needed or I may need to re-schedule the appointment.*

Agree

I may be required to perform random drug tests as per company and state policies and protocols. *

Agree

If I miss more than 3 appointments in 1 year, cancelation charges may apply as per company policies. *

Agree

I understand patient dismissal may occur due to following reasoning but not limited (i.e persistent failure to keep scheduled appointments or adhere to agreed-upon treatment plans, ongoing rude, disruptive, or unreasonably demanding behavior, habitual noncompliance, falsifying or providing misleading medical history, seductive behavior toward physician or staff, sentinel incident (eg, verbal threat, violence, criminal activity)*

Agree

I understand that my provider may need to contact my emergency contact and/or appropriate authorities in case of an emergency. *

Agree

I have read all of the above policies, and understand them and agree to comply. *

Agree

Patient Authorization *

I, Authorize the release of any medical and insurance information necessary to process any claim.I may be fully responsible to pay my balance for the visit that is not covered through my insurance.IShine Behavioral Health Inc. can submit claims to your insurance company for services rendered during appointment. Invoice may be sent to you for remaining balance not covered by insurance or deductible.All accounts over 90 days regardless of insurance payment, are subject to collection by a collection bureau.I am giving consent to authorize payment and charge the applicable fees by charging credit card/bank card for the services provided by IShine Behavioral Health Inc.

For minor: Please share contact person name and phone number, email address to send invoices. Please note if you do not provide complete information then invoices will be send out to email address/ contact number provided on the first section. *

By submitting, you agree to receive text messages at the provided number from IShine Behavioral Health. Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance.

Intake Form

Patient Details

Gender

Prefer method to be contacted *

Communication via Text Message *

Emergency Contact Information

Health History

How would you rate your current Physical Health *

How would you rate your current sleeping habits? *

How many times per week do you generally exercise? *

Are you currently experiencing overwhelming sadness, grief, or depression?*

Are you currently experiencing anxiety, panic attacks or have any phobias?*

Are you currently experiencing chronic pain?*

Do you drink alcohol more than once a week?*

How often do you engage in recreational drug use?*

Are you currently in any relationship?*

Family Mental History

Alcohol/Substance Use *

Trauma *

Anxiety *

Depression *

Domestic Violence *

Eating Disorder *

Obesity *

Obsessive Compulsive Behavior *

Suicide Attempts *

Late Cancellation/Missed Session Policy for Counseling and Medication Management

You may cancel or reschedule an appointment anytime, without any fees if you provide 24 hours notice for Medication Management and 48 hours for counseling session.*

You may call office at 815-947-4463 or Text at 815-947-4463 to make/cancel/re-schedule your appointment*

Our cancellation policy in not a penalty. We reserve the right to terminate our services for missing appointments for 3 times or more. Includes: Late cancellations/No show.*

Tele-Health Consent form and Informed Consent for Counseling and Treatment

I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled. *

I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that tele-mental health services are not appropriate and a higher level of care is required.*

I understand that during a tele-mental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, ending and restarting the session may be needed or I may need to re-schedule the appointment.*

I may be required to perform random drug tests as per company and state policies and protocols. *

If I miss more than 3 appointments in 1 year, cancelation charges may apply as per company policies. *

I understand that my provider may need to contact my emergency contact and/or appropriate authorities in case of an emergency. *

I have read all of the above policies, and understand them and agree to comply. *

Authorization Form and Financial/Insurance Policy

Patient Authorization *