Counseling Intake Forms ~ Tri-Lakes Relational Center Springfield Missouri

Download Intake Forms

This page will provide you with the appropriate forms for our Springfield location.
If your appointment is at the Branson location please click here TRC Branson Intake Forms.

When you schedule your first appointment for a counseling session, you are required to fill out and read forms regarding personal information, payment information and HIPPA regulations.

You can print out the required forms, fill them out at home or work and bring them with you to your first appointment. This should save you time at your first appointment and make the process flow more smoothly.

Click on the links below to download the pdf forms. You must have Adobe Reader to view the forms. You can download adobe reader for free at www.adobe.com

If you have any questions as to which form you should be using, please contact our office. We'll be happy to assist! Please be assured that all personal information will remain strictly confidential.

If you are unable to print the required forms your counselor will provide them for you at the beginning of your first appointment.

READ the "Notice of Policies & Practices" and the "Counseling Services Agreement."

PRINT, FILL-OUT, SIGN, AND BRING TO THE FIRST SESSION the "Signature Form", "Intake Information Form", and "Financial Responsibility Statement" below. A separate "Intake Information Form" is required for each person that will see the counselor.

Tri-Lakes Relational Center is a non-profit counseling center. The standard fee for a 1st evaluation appointment is $125 and the standard fee for ongoing counseling is $95 per 45 minute session. The 1st evaluation appointment for couples may be scheduled for 2 sessions (90 minutes; fee $190).

TRC is now able to provide insurance claim submission. If you would like for TRC to submit your insurance claim on your behalf please complete the Insurance Claim Processing Request Form and give it to your counselor with your insurance card at the time of your appointment.

INSURANCE CLAIM PROCESSING REQUEST FORM

We have a reduced fee scale and special payment options. If you would like to request a reduced fee or interest-free payment option please fill out the "Reduced Fee Request Form" and bring it with the indicated documentation to your first appointment. Do not let financial limitations keep you from getting help; we have options that will work with your budget.

REDUCED FEE REQUEST FORM

2131 S Eastgate Ave, Springfield, MO 65809


					Download Intake Forms This page will provide you with the appropriate forms for our Springfield location. If your appointment is at the Branson location please click here TRC Branson Intake Forms. When you schedule your first appointment for a counseling session, you are required to fill out and read forms regarding personal information, payment information and HIPPA regulations. You can print out the required forms, fill them out at home or work and bring them with you to your first appointment. This should save you time at your first appointment and make the process flow more smoothly. Click on the links below to download the pdf forms. You must have Adobe Reader to view the forms. You can download adobe reader for free at www.adobe.com If you have any questions as to which form you should be using, please contact our office. We'll be happy to assist! Please be assured that all personal information will remain strictly confidential. If you are unable to print the required forms your counselor will provide them for you at the beginning of your first appointment. READ the "Notice of Policies & Practices" and the "Counseling Services Agreement." NOTICE OF POLICIES & PRACTICES COUNSELING SERVICES AGREEMENT MINORS PRIVACY POLICY PRINT, FILL-OUT, SIGN, AND BRING TO THE FIRST SESSION the "Signature Form", "Intake Information Form", and "Financial Responsibility Statement" below. A separate "Intake Information Form" is required for each person that will see the counselor. SIGNATURE FORM INTAKE INFORMATION FORM FINANCIAL RESPONSIBILITY STATEMENT Tri-Lakes Relational Center is a non-profit counseling center. The standard fee for a 1st evaluation appointment is $125 and the standard fee for ongoing counseling is $95 per 45 minute session. The 1st evaluation appointment for couples may be scheduled for 2 sessions (90 minutes; fee $190). TRC is now able to provide insurance claim submission. If you would like for TRC to submit your insurance claim on your behalf please complete the Insurance Claim Processing Request Form and give it to your counselor with your insurance card at the time of your appointment. INSURANCE CLAIM PROCESSING REQUEST FORM We have a reduced fee scale and special payment options. If you would like to request a reduced fee or interest-free payment option please fill out the "Reduced Fee Request Form" and bring it with the indicated documentation to your first appointment. *Do not let financial limitations keep you from getting help; we have options that will work with your budget.* REDUCED FEE REQUEST FORM 2131 S Eastgate Ave, Springfield, MO 65809 .