Note: please do not submit any intake form until your initial appointment has been scheduled

Adult Intake Form: Submit Online | Download PDF

Child/Adolescent Intake Form: Submit Online | Download PDF

Couple Intake Form: Submit Online | Download PDF

Release of Information Form

Telehealth Informed Consent

Paula Adkins, Office Manager

Welcome to Horizons! We want to make sure your experience here is a great one and that you are treated with courtesy and compassion.

Before you come, we ask that you look into what mental health benefits your insurance covers. Please bring  your health insurance card to your first visit. We also need you to complete one set of intake forms listed above.  Our Services and Fee Agreement, including confidentiality and privacy practices, is included in each set of intake forms.

You can download the intake forms, print them out, complete them, and bring them to your first appointment. Or you can fill out the intake forms at the office, prior to the appointment. But if you choose to do that, please come 15 – 20 minutes before the scheduled appointment time.

If the client (the person in whose name services will be billed and perhaps insurance billing submitted) is an adult coming for an individual appointment, use the Adult Intake Form. Please read and sign the Services and Fee Agreement.

For couples, use the Couple Intake Form. The person in whose name services will be billed and perhaps insurance billing submitted should complete pages 1-3. The client AND the spouse/partner should read and sign the Services and Fee Agreement (pages 3-6). Spouse/partner should complete Additional Information for Spouse/Partner (pages 7-8).

If the client (the person in whose name services will be billed and perhaps insurance billing submitted) is under 18, use the Child/Adolescent Intake Form. Parent(s) or guardian(s) must sign the Services and Fee Agreement.

Insurance companies often have negotiated rates with Horizons or with individual providers. At times, providers make arrangements with clients for reduced fees. Your fee agreement should reflect agreements with your insurance provider or agreements made directly by you with your provider.

Services and Fee Agreement (including confidentiality and privacy practices)