Please fill out the secure form below to register a person age 18 or older for services. Step 1 of 7 14% Client InformationName(Required) First Last Social Security Number(Required) Gender(Required) Male Female Other Date of Birth(Required) MM slash DD slash YYYY Primary Phone(Required)Secondary PhoneRace(Required) African American Asian Hispanic Native American Non-Hispanic Prefer not to answer White Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Does Client Speak English?(Required) Yes No If No, What is the Primary Language? Preferred Office Location(Required) Cumberland Gloucester Johnston Warwick No Preference Select AllYou can select more than onePreferred Method of Teletherapy(Required) Phone Video No Preference Clinician Preference(Required) Female Male No Preference Request a Specific Clinician Name of Specific Clinician Best Available Days(Required) Monday Tuesday Wednesday Thursday Friday Saturday Sunday Select AllYou can select more than one.Best Available Times(Required) Morning Afternoon Evening Select AllYou can select more than one.Brief Reason for Treatment(Required)(Examples: anxiety, behavioral issues, school issues, substance abuse, grief, etc.)Referred By(Required) DCYF Pretrial Probation Public Defender Family Court PCP Online Tri-County Gateway EAP Program Other Referral Source Name First Last Referral Source Phone Is Client Receiving Mental health Services From Another Agency/Provider(Required) Yes No Where Are They Receiving Services? Are there any Substance Abuse issues, Client of Family?(Required) Yes No Who is having Substance Abuse Issues Insurance InformationPrimary Insurance Company(Required) Policy #/Member ID(Required) Secondary Insurance Company Policy #/Member ID Consent FormsPatient Consent to Treatment(Required) I agree to the followingI give permission for my child, or the child for whom I am responsible, (whose name is listed below) to receive outpatient therapy at The Inner You.Office Policies Consent(Required) I agree to the office policies listed belowZERO TOLERANCE POLICY: The Inner You, LLC promotes a policy of Zero Tolerance for all forms of violence and inappropriate behavior. This policy covers employees, employers, clients, and all other visitors to the practice. This policy is enforced at all times and includes all areas of the property, including the entire building and parking lot as well as over telephone communication. Forms of violence including physical assault, threatening behavior, obscene language, or verbal abuse in person or over telephone calls toward staff and providers will NOT be tolerated. Any violation of this policy will result in immediate termination of services from the practice. CANCELLATION AND NO-SHOW POLICY: We understand that situations arise in which you must cancel your appointment. It is requested that if you must cancel your appointment you provide at least 24 hours’ notice before your scheduled appointment. Appointments cancelled less than 24 hours’ notice or failure to show for your appointment will be considered a missed appointment. Missed appointments are charged a minimum $45.00 fee (some providers do charge a higher amount). After missing three appointments without notification we may reserve the right to dismiss you from care from our practice. The Cancellation and No-Show fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment. An administrative fee of $10.00 will be added to the patients account should we need to bill for these fees. NON-PAYMENT: Any balances must be paid in full within 30 days of service, including missed appointment fees. If the balance is not paid after 30 days, there will be a 1% increase in the balance each month it is late. Payment arrangements can be made by calling our office at 401-773-7116. You will not be able to schedule future appointments until the first payment of any payment arrangement is received. If payment is over 90 days late, the balance will be sent to collections. The balance will need to be paid in full with our collection agency before you will be scheduled for future appointments. RETURNED CHECKS: Any returned checks are subject to a $35 service fee. Any returned check must be resolved before any future appointments can be arranged. IN CASE OF EMERGENCY: The Inner You, LLC has 24 hour/7 days a week emergency coverage. In the event of an emergency, please call our office at 401-773-7116 during regular business hours. If you are calling about an emergency after business hours, please contact the clinician on call at 401-527-3102. If you are experiencing a life-threatening emergency or require urgent care, call 911 or proceed to your nearest emergency care center. PATIENT APPOINTMENT REMINDERS: As a courtesy to our patients, we try to provide appointment reminder calls or texts when possible. However, we are not able to guarantee this service. Patients are responsible for recording and keeping scheduled appointments. All copayments and balances on your account will be collected at your visit. Please come prepared or your appointment may be rescheduled.Insurance and Treatment Plan(Required) I agree to the treatment plan and insurance authorizationTREATMENT PLAN: I give The Inner You, LLC permission to develop a treatment plan and provide treatment with my participation. I hereby authorize The Inner You, LLC to furnish all information to insurance carriers concerning my illness, and/or treatments, and I hereby assign to the clinician(s) all payments for medical services rendered. I understand that I am responsible for any amount not covered by insurance; this includes any course of treatment that is not a covered benefit. I understand that I am responsible for notifying The Inner You, LLC of any changes in my insurance coverage. If I am delinquent in updating this information and the charges are denied, I understand that I will be held responsible for these charges. I agree to be financially responsible for all visits not covered. I authorize The Inner You, LLC to bill and receive payment from third party payors, if any, for coordination of benefits. I understand that I am fully responsible for obtaining the proper authorization prior to my first appointment. If I am covered by a third-party payor and have no other health care, I agree to pay all copayments as required by the health plan. I further authorize any third party to pay The Inner You, LLC for services provided to me. If these services are not paid by the third-party payor within 60 days, I agree to make payment myself. The Inner You, LLC does not participate with Medicaid. I understand that I will be fully responsible for any fees not covered. A Provider may, at any time, dismiss a patient from our practice should a patient fail to adhere to their agreed treatment plan. BHDDH Data Authorization Form(Required) I agree to the BHDDH Data Authorization Form The Inner You Counseling Center is honored to be a licensed mental health facility through The State of Rhode Island. We work to maintain the standards of care set forth by the State of Rhode Island Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH). The Inner You has established excellent standards of care and safety. We abide by, maintain, and uphold all state regulated standards. Due to this additional licensure, The Inner You is mandated to provide client demographic information to the State of Rhode Island. This information is utilized for expanding services throughout the State and to ensure non- discriminatory standards are being maintained. By agreeing to the BHDDH form you understand The Inner You is a licensed agency through The State of Rhode Island and BHDDH and you hereby allow The Inner You to report necessary demographic information to The State of Rhode Island and/or BHDDH. This information will be maintained by both The Inner You and The State of Rhode Island to ensure The Inner You is abiding by best practices and ensuring non-discriminatory actions are being upheld.Acknowledgement of Receipt of Notice of Privacy Practice and Rights of Client(Required) I have reviewed a copy and understand I can request a copy or access an electronic copy on The Inner You, LLC website at any time I refuse to sign this acknowledgement Patient Agreeing to Consent Form Selections(Required) First Last Client General InformationDate of Birth(Required) MM slash DD slash YYYY Gender at Birth(Required)MaleFemaleGender Identity(Required)Same as BirthNot Same as BirthRefuse to AnswerUnknownSexual Orientation(Required)HETEROSEXUALGAYLESBIANBISEXUALOTHERREFUSEDUNKNOWNVeteran Status(Required)ActiveVeteranNo ServiceUnknownMartial Status(Required)NEVER MARRIEDMARRIEDCOHABITATINGSEPERATEDDIVORCEDWIDOWEDUNKNOWNEducation Level(Required)NEVER ATTENDEDSOME ELEMENTARYCOMPLETED 8TH GRADESOME HIGH SCHOOLCOMPLETED HIGH SCHOOLBEYOND HIGH SCHOOLCOLLEGEGRADUATEUNKNOWNRace and Ethnicity(Required)American Native/Alaskan NativeAsianBlack/African AmericanHawaiian/Pacific IslanderCaucasianHispanicUnknownAdmissions Specific InformationReferral Source(Required)SELFMENTAL HEALTH PROVIDERSUBSTANCE USE PROVIDERHEALTH CARE PROVIDERHOSPITALSOCIAL SERVICE AGENCYSHELTERSCHOOLEMPLOYERCOMMUNITYCOURTUNKNOWNCourt Referral(Required)NOT APPLICABLECIVILCOURTADULT DRUG COURTFAMILY COURTJUVENILE COURTADULT DIVERSIONPRISONPROBATIONDUI/ DWIOTHERFrequency of Attending Self-help Groups (AA/NA)(Required)NOT APPLICABLENONE1-3 IN PAST MONTH1-2 IN PAST WEEK3-6 IN PAST WEEKDAILY*In the last 30 daysClient Zip Code(Required) Additional Client InformationType of Residence(Required)PRIVATEPUBLICRESIDENTIAL FACILITYASSISTED LIVINGNURSING HOMEFOSTER HOMECORRECTION FACILITYSOBER HOUSEHOMELESSUNKNOWNFamily Size(Required) Number of Dependent Children(Required) Monthly Household Income(Required) Employment Status(Required)FULL TIMEHALF TIMEPART TIMEARMED FORCESVOLUNTEERUNEMPLOYEDSTUDENTHOMEMAKERINMATERETIREDDISABLEDUNKNOWNEmployment Type(Required)NOT APPLICABLECOMPETITIVESUPPORTEDTRANSITIONOTHERUNKNOWNPrimary Payment Type(Required)SELF-PAYCOMMERICALMEDICAIDRITECARECo-Occurring Condition InformationSubstance Abuse(Required)YesNoUnknownDevelopmental Disability(Required)YesNoUnknownPregnant(Required)YesNoUnknownSmoking(Required)YesNoUnknownHypertension(Required)YesNoUnknownHepatitis(Required)YesNoUnknownLife Threatening Viral Illness(Required)YesNoUnknownHigh Cholesterol(Required)YesNoUnknownObesity(Required)YesNoUnknownDiabetes(Required)YesNoUnknownAsthma(Required)YesNoUnknownPulmonary Disease(Required)YesNoUnknown Admission of Substance Use InformationIf seeking treatment for substance use please complete the following. If NO - please select NA.Primary Substance Used(Required)N/AALCOHOLMARIJUANABARBITURATESBENZODIAZEPINESCOCAINEECSTACYFENTANYLHEROININHALANTSMETHADONE- NON PERSCRIPTIONMETHAMPHETAMINEOTHER AMPHETAMINESHALLYCINOGENSOPIATESSEDATIVESSTIMULANTSTRANQUILIZERSNONPRESCRIPTION MEDICATIONSOXYCOTINSTERIODSYNTHETIC CANNABISRoute of AdmissionORALSMOKEINJECTINHALEOTHERFrequency of UseNONE1-3 TIMES IN PAST MONTH1-2 TIMES PER WEEK3-6 TIMES PER WEEKDAILYAge of First Use Secondary Substance UsedN/AALCOHOLMARIJUANABARBITURATESBENZODIAZEPINESCOCAINEECSTACYFENTANYLHEROININHALANTSMETHADONE- NON PERSCRIPTIONMETHAMPHETAMINEOTHER AMPHETAMINESHALLYCINOGENSOPIATESSEDATIVESSTIMULANTSTRANQUILIZERSNONPRESCRIPTION MEDICATIONSOXYCOTINSTERIODSYNTHETIC CANNABISRoute of Admission - SecondaryORALSMOKEINJECTINHALEOTHERFrequency of Use - SecondaryNONE1-3 TIMES IN PAST MONTH1-2 TIMES PER WEEK3-6 TIMES PER WEEKDAILYAge of First Use - Secondary Tertiary Substance UsedN/AALCOHOLMARIJUANABARBITURATESBENZODIAZEPINESCOCAINEECSTACYFENTANYLHEROININHALANTSMETHADONE- NON PERSCRIPTIONMETHAMPHETAMINEOTHER AMPHETAMINESHALLYCINOGENSOPIATESSEDATIVESSTIMULANTSTRANQUILIZERSNONPRESCRIPTION MEDICATIONSOXYCOTINSTERIODSYNTHETIC CANNABISRoute of Admission - TertiaryORALSMOKEINJECTINHALEOTHERFrequency of Use - TertiaryNONE1-3 TIMES IN PAST MONTH1-2 TIMES PER WEEK3-6 TIMES PER WEEKDAILYAge of First Use - Tertiary EmailThis field is for validation purposes and should be left unchanged.