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Holistic Bonfire

Suruchi Saini, MA, LPC, CCTP, TMHP, CYT

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Intake Form

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  • Client Information

  • Please provide the best number to reach you
  • Emergency Contact

  • Insurance Information

  • Choose 'Other' if you are not the primary holder of the insurance policy
  • Please upload front and back pictures of the insurance card

  • Questionnaire

    Please take a moment to fill out the survey below. Any information you provide to us on this form will be kept in strict confidence. It will not be released to any outside person or agency without your permission. If you do not know how to answer these questions, ask my guidance. Please note, each item refers to your entire life history, not just your current situation, this is why each question begins – “Have you ever…..”
  • Terms and Conditions

  • Please download and review the Privacy Practices and Terms & Condition before responding to the following questions.

    Click here to download

  • I have read and received a copy of the above information and agree to abide by these guidelines. I hereby consent to my treatment if I am bringing a minor for treatment, I have the legal authority to consent to the minor's treatment and hereby do so consent if the minor is 14 years old or older I understand that the minor will also need to sign this form.
  • I have received the notice of Privacy Practices and I have reviewed it
  • All clients are seen by appointment only. Each session is usually 45 minutes. This time is set aside especially for you. We will make every effort to honor all commitments and request that you extend the same courtesy. On occasion, emergencies will arise and, when possible, you will be informed if there are any significant delays. If you are unable to keep your appointment, please give twenty-four (24) hour advance notice in order to avoid charges. If an appointment is missed or cancelled the same day, we reserve the right to charge you $75.
  • I acknowledge and have read the Financial Disclaimer and agree to its terms. I understand my obligation that payment is due at the time of treatment unless other arrangements are made. I agree that parents, guardians or personal representative are responsible for all fees and services rendered for a treatment of a minor/child or to the patient for whom I have legal responsibility. I hereby authorize Suruchi Saini, LPC, NCC, CCTP to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions, if insurance is used.
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suruchi@holisticbonfire.com

(908) 376 9036

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