Download Forms

Before our Intake Assessment session, please follow these instructions:

1. Read the Clinician Disclosure form and print or save it for your records if you desire.
2. If you want online sessions, read the Telemental Health Informed Consent form and print or save it for your records if you desire.
3. Read the Notice of Privacy Practices form and print or save it for your records if you desire.
4. Print the Intake form.  Complete it and sign it.
5. Print the Signature form.  Complete it, initial it in five places (or six, if you desire online sessions)., and sign it on the last page.  Please note:  If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).
6. Print the Billing form and sign it.
7. Photograph both front and back of your insurance card.
8. Return the Intake form, the Signature form, the Billing form, and the images of your insurance card to me by one of the following methods.
   • Fax the forms to 360-504-3984.
   • Mail the forms to my office: Kim Ykema Counseling PLLC, 908 Georgiana Street, Port Angeles, WA.
   • Scan or photograph the forms and attach them to an email using KimYkemaCounseling@gmail.com.  My email is NOT HIPAA compliant so this is the least confidential way to send me your information.  If you choose this method, you are choosing to take the risk of losing confidentiality.  

After I receive the signed forms, I will contact you to confirm our Intake Assessment appointment.

I know that paperwork can be confusing.  If you have any questions, please contact me. Contact

Clinician Disclosure

Telemental Health Informed Consent

Notice of Privacy Practices

Intake

Signature

Billing