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New Client Appointment Request Form

Thank you for your interest in working with Rust Wellness Group! We are committed to providing person-centered and accessible mental health care. To ensure we connect you with a clinician who best meets your needs, please complete this form to the best of your ability.


Our team will review your information and reach out to within 24 business hours. We will initiate scheduling a free consultation if there is availability.

Demographic Information

Rust Wellness Group is committed to inclusivity and respects individuals' preferences regarding names and pronouns. We encourage individuals to share their preferred name and pronouns, and we will only ask for legal names and sex (assigned at birth) when required for insurance purposes.

Birthday

Therapy Preferences

We cannot guarantee that every Therapist will have immediate availability, however we try our best to ensure each person seeking care is matched with the best Therapist for them.

I am seeking:
Is there a specific Therapist you would like to work with?
Select any of the following topics related to what brings you to therapy:

Payment Information

Rust Wellness Group is In Network with various Commercial Insurances. Since everyone's plan is unique in terms of coverage - this information will help up verify coverage information in advanced.

Payment Method/Insurance Type

Please read before submitting

CONSENT FOR TELEHEALTH CONSULTATION


  1. I understand that my health care provider wishes me to engage in a Telehealth consultation.

  2. I understand that a Telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

  3. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the Telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

  4. I understand that a Telehealth consultation does not guarantee eligibly for services, and the therapist has an ethical responsibility to recommend a higher level of care- or refer me to another provider if presenting challenges/diagnoses are outside of their scope of practice.


CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE


Telehealth by SimplePractice is the technology service we will use to conduct Telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:


  1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

  2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

  3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

  4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.

  5. To maintain confidentiality, I will not share my Telehealth appointment link with anyone unauthorized to attend the appointment.

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