Counseling Service Forms

Before beginning, please make sure you have all of the following documents to ensure a streamlined scheduling process.

STEP 1: Please be sure you have the following items available:

• Your Health Insurance Card (if using benefits for services) - front/back pictures
• Relevant Court Documents (if applicable) for any individual subject to a court order or custody document
• Minor child(ren) - divorce, custody decree, child support orders, etc.
• Adults - guardianship orders
• Current list of Medications and Allergies (we are required to ask for this information)
• Contact information for your Primary Care Physician (as insurance and best practice guidelines require that we coordinate care)

STEP 2: In addition, we will ask several Pre-Screening questions to ensure we are the best fit.  If at any point you receive a pop-up that we are not a good fit, please do not proceed with signing consent forms or adding additional information to the process.  These questions center around several key items including:

• We do NOT accept EAP plans (unfortunately, we still show up on a number of insurance websites - we're sorry about this!)
• We can NOT prescribe medications.
• We do NOT complete psychological evaluations to determine learning disabilities.
• We DO have in-person appointments, but not all providers will be in-network.
• All appointments must be open to weekday, daytime appointments as we do not hold intakes for evenings or weekends.

Please be sure to read each question carefully before moving forward with your intake for services. We provide these pre-screening questions to be respectful of your time as you look for a provider.

STEP 3:  Select the button to complete forms for the Client (individual, couple, family) that will be receiving services.

Release of Information

We encourage collaboration between our agency/therapists and other professionals involved in your care.  You can now complete our Release of Information electronically in order to disclose information between our agency and another provider.

Please be prepared to upload a copy of your photo identification upon completion of the form. Clicking the button below will redirect you to our HIPAA compliant form to complete online OR you can choose to download then send. If downloading the PDF version of the form, please note that you will need to send the fully completed forms along with a copy of your Photo Identification via fax to 817-405-3364 or via e-mail to referrals@empathyhq.org.

2023 Consent Forms/Policies

2023 CONSENT FORMS/POLICIES

Custody Clarification Forms

CUSTODY CLARIFICATION FORM

Agency Policies & Procedures

These forms are referenced in our updated New Client Forms and are available for review here on our website at any time.  Clicking on the button will download a PDF copy of the current form.

EmpathyHQ PRACTICE POLICIES

For Existing Clients signing into the Client Portal:
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IntakeQ Client Portal

For Clients needing to upload forms to their New Client Forms *OR* through this portal, existing clients can make or reschedule an appointment, access forms sent by your Therapist, or send a message to our Staff.