Call Us! 515-270-0280

Client Intake Form

  • ILEARN Client Intake Form

    2130 Grand Ave.Suite B Des Moines, IA 50312 Phone: 515-270-0280
  • RELATIONSHIP STATUS

  • PARENT/ GUARDIAN INFORMATION

    If applicable.
  • Emergency Contact

  • Primary Insurance

  • Secondary Insurance

  • Verification of Receipt of Psychotherapy Practice Information, Informed Consent Information, Consumer Rights Statement, & Notice of Privacy Rights

    I verify that I have been provided with a copy of informed consent for educational and psychological/ behavioral/mental health services including information regarding risks and benefits of services, limitations of confidentiality, and information about my rights and responsibilities as a client. I also verify that I have been provided a copy of Notice of Privacy Rights under HIPAA, a general statement about consumer rights, and information regarding emergency contact procedures. Written copies of each document are available in the waiting room, an electronic copy is available on the company website (www.innovativelearningpros.com/forms.cfm), and a personal written copy is available upon request. I understand that Innovative Learning Professionals staff is willing to answer any questions I may have about these written documents at any time. Your signature below indicates you have received, or have been provided the opportunity to review, these documents, agree to the terms described therein, and provide consent for evaluation and/or treatment for yourself or your dependent. You may revoke this Agreement in writing at any time. Revocation is binding on me unless we have taken action in reliance on it.
  • Authorization for Release of Information to Insurance Company

  • I understand that I have the right to inspect the information released through this authorization and such an inspection will occur in a meeting with Innovative Learning Professionals staff. I understand I may revoke this authorization by providing written revocation. I also understand any information released prior to the revocation may be used for the purpose(s) listed above. A photocopy of this authorization shall have the same force as the original. This release shall be valid for six months following our last appointment, unless otherwise restricted.
  • Advanced Care Directive

    Although not directly relevant to outpatient mental health care, some insurance companies are requesting that we document an individual’s advanced care directive status and wishes. Moreover, we wish to advocate for those clients who would like information about such directives. Advanced directives are a set of written instructions that specify what actions should be taken for the individual’s health if s/he is no longer able to make decisions due to illness or incapacity. The instruction may appoint someone to make such decisions on one’s behalf (aka power of attorney), and a living will leaves specific instructions for treatment.
  • Insurance Notice

    It is your responsibility to know if pre-authorization is required per your insurance policy, and it is your responsibility to seek pre-authorization from your insurance company by calling the number on the back of your insurance card.

    It is your responsibility to contact your insurance company prior to your appointment so you will understand your benefits and your portion of fees. Any and all fees not reimbursed by insurance policy are your responsibility. Mental health and medical benefits may differ, so it is important for you to understand what benefits you have.

    If your insurance company determines any services as not payable for any reason (not a benefit or deemed not medically necessary), you are responsible for the full payment at the time of service. Copayments, coinsurance, deductibles are to be paid at the time of service. We accept major credit/debit cards, checks, and cash. We are not able to process health savings account cards. Appointment times are reserved for you. If you are unable to keep a scheduled appointment, please give a 24-hour notice. Voicemail is available 24 hours a day seven days a week—515-270-0280.

    Failed appointments mean a loss of productivity for our providers. Providers are rarely able to fill a session canceled shorter than 24 hours in advance. If you do not give a 24-hour cancellation notice you will be charged a no-show fee of $35.

    Insurance companies do not typically reimburse for missed appointments. If appointments are failed repeatedly, clients may be asked to find a new provider. You are ultimately responsible for the cost of our services. In the case of shared custody, the parent who brings a child in for services is responsible for fees incurred. Please let the provider know if you have questions or call and speak to Mary Kay 515-270-0280 ext 0.
  • By signing below, I have read and understood that I am responsible for all fees for service. I have decided to receive services at Innovative Learning Professionals, and I understand some services are not, or may not, be covered by my insurance. I understand if I choose to use an insurance benefit, there is no guarantee any portion will be covered and I agree to pay any remaining portion. Failure to pay my portion of fees could result in a fee collections agency being contacted on behalf of ILearn.
  • Authorization for Release of Confidential Information

    In the interest of integrative health care (which is meant to provide you or your child the best possible overall care), it is often important that your primary care provider (e.g., family doctor, pediatrician) be able to access your records. In addition, if you have a psychiatrist, it is important to be able to coordinate with him or her. Please indicate your desires below. One form must be completed for every individual/agency for whom you wish to release information. Additional forms can be provided as needed.
  • This release shall be renewed on an annual basis, unless further restricted as indicated.

  • I understand I have the right to inspect any written information released through this authorization and such an inspection, if requested, will occur in a meeting.

    I understand I may revoke this authorization by providing written notice of revocation. I also understand any information released prior to the revocation may be used for the purpose listed above.

    I understand I do not have to sign this authorization. Treatment, payment, enrollment, or eligibility for benefits cannot be conditioned upon the signing of this authorization.

    I understand if the person or organization that receives my information (described above) is not a health care provider or health insurer the information may no longer be protected by federal or state privacy regulations (e.g., HIPAA and other privacy regulations).

    I understand and agree that a copy of this authorization (including electronic copy, fax, or photocopy) shall have the same force as the original.

    NOTICE TO PERSON/AGENCY RECEIVING MENTAL HEALTH INFORMATION: The mental health information disclosed herein has been disclosed, and may only be redisclosed, pursuant to the written authorization of the client or the client’s legal representation or as otherwise provided in Chapter 228, Code of Iowa. Any unauthorized redisclosure of mental health information is unlawful and is subject to civil and criminal penalties.