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 Please review the New Client Forms below; complete the Information/Acknowledgement/Consent provided below prior to your first therapy session so time will not be spent filling out forms during your appointment.

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**Accepting Insurance:

Aetna | BCBS | Cigna/Evernorth | OptumHealth/ United Healthcare |Medcost |CBHA

 

-We do not accept EAP nor do we complete any Medical Excuses,  Leave or Workers' Comp Claims

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*Attention Clients: Once you've set up an appointment, please check your email for a

Therapy Notes Client Portal access message  where you will be able to create a login.​*

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New Credit Card on File Policy Effective as of January 24, 2022

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Client Information/Acknowledgement/ Consent

Please fill out the following form.

Can we leave a message on the number provided concerning scheduling and other matters?
Can we leave a message on the number provided concerning scheduling and other matters?
Will you be using insurance?
Upload Insurance Card (back/front)
By signing below, you are indicating that you have read and understand the information contained in this contract that you have obtained a copy from the website, and keep for your records. All questions you have about this statement have been answered to your satisfaction.
I acknowledge that I received and have been given an opportunity to read a copy of Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I may contact John W. Goodwin III., MA, LCMHC, at atalkwithjohn@gmail.com or at (704) 412-1407.
I acknowledge that I received and have been given an opportunity to read a copy of the Teletherapy informed Consent from. I understand that if I have any questions regarding the form, I may contact John W. Goodwin III., MA, LCMHC, at atalkwithjohn@gmail.com or at (704) 412- 1407.

Thank you for submitting!

*Patient Waiting List:
(If an appointment is unavailable and you would like to be added to the waiting list)
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