Schedule A Consultation

To schedule an appointment:

1st: Call Agape Psychological Services at 775-322-4003 and speak to Kris Reasons, Administrative Assistant, during business hours to schedule an appointment.

2nd: Fill out the form below and submit it. Your information will be confidentially sent to Agape Psychological Services. 

Agape Psychological Services Intake Packet

Date



Client Information







Marital Status

Please select one



Income



Employer Information





Parent/Legal Guardian, (if patient is a minor)




Mother's Information






Fathers's Information





Others in Home:

















Emergency Contact




Who is Financially responsible for your Bill?

(Please note that you are responsible for collecting court ordered payments from any ex-spouse(s), parents, etc., if they are not here to sign our financial agreement themselves. Payment is due at time of service unless other arrangements have been made in advance. Thank you.)


Agape Psychological Services Consent for Treatment

As a client, your rights are guaranteed by the rules of good professional practice and by law.
You have the right:

1. To Psychological care and treatment.

2. To be advised about treatment choices and possible treatment outcomes.

3. To refuse treatment.

4. To privacy. Information about treatment is confidential and must not be released to anyone without prior written consent by you. There are, however, limits to privacy.

Limits to privacy include:

A. If you report abuse and/or neglect of a child, or if we suspect abuse, we are required and will notify authorities.

B. If you report abuse or neglect of the elderly, or if we suspect abuse, we are required and will notify authorities.

C. If you threaten to harm someone else, we are to warn the person who is in danger and report possible danger to the police.

D. If you threaten to harm yourself, we may intervene with emergency measures and/or require that you be hospitalized until treatment can be continued in a less restrictive setting.

E. The court can obtain your clinical records with a court order.

F. Ex-spouses have the right to review their child’s records unless those rights have been terminated by the court

G. All clinical records will be shredded 5 years from the date of the last session, or, in the case of a minor, 5 years after he/she turns 18.

H. For security reasons, in common areas and therapy office may be video recorded. This does not include audio recording.

Please question us if you don’t understand or disagree with any condition(s) of our policy or our consent to treatment statements. Therapy is an important process and the relationship with your therapist is critical. We want to encourage and develop strong, open and caring relationships.

By signing, you give permission to the therapist to treat the client
Client or Guardian signature if client is a minor


Please select yes or no for the following questions, if applicable.


I give Agape Psychological Services permission to thank whomever referred me to this organization.

I give Agape Psychological Services permission to contact me by telephone: At my home

I give Agape Psychological Services permission to contact me by leaving messages on my answering machine/cell phone


Agape Psychological Services Payment Agreement

We require you to read, initial and sign this form prior to any treatment

Thank you for choosing us as your mental health provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy.

1. Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Our relationship is with you only. We will provide you with an itemized receipt that you may submit to your insurance company for reimbursement.

2. Fees for services are due at the time of treatment.

3.Before we can allow any release of information about you we need a signed release of information form to be in your file.

4. We require a signed payment agreement between Agape and the client or client’s legal guardian (If client is a minor).

5. We now accept: Cash, Check, Debit Cards, Money Orders, Discover Card, Visa & MasterCard. There will be a $25.00 charge for any (NSF) returned check.

Missed Appointments

Please note that unless your appointment is cancelled at least 24 hours in advance, you may be charged for a missed appointment at the normal rate for an office visit. Please call if you have to reschedule.






Business Hours

Business Hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

8:00 AM   –   8:00 PM

8:00 AM   –   8:00 PM

8:00 AM   –   5:00 PM

8:00 AM   –   5:00 PM

Closed

Closed

Closed

If you would prefer to download the intake form, you make click on the blue download button below.

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