Our Story Youth & Family Therapy LLC

Client Information

Legal First Name / Middle Initial

Last Name

Preferred First Name ( optional )

Date of Birth
( MM-DD-YYYY )

Street Address

Street Address 2

City

State

ZIP Code

Cell Phone ( for Text Message Reminders )
Preferred Contact #

Home Phone
Preferred Contact #

Bill To Contact

Same as above Different

First Name or Organization Name / Middle Initial

Last Name

Street Address

Street Address 2

City

State

ZIP Code

Phone

Log in Details

( If client is a minor, the legal guardian must enter their email address below. )

Confirm Email

Username
Between 8 and 40 letters and numbers

Local Time / Timezone

Challenge Questions

( These will be used to retrieve your password. Answers must be between 4 and 30 characters, cannot contain any spaces. )

Question #1

Answer

Question #2

Answer

( If you feel you must write down your questions in order to remember them, make sure to keep it in a safe place. )

Terms and Policy

Credit/Debit Card Policy

Clients are required to have a debit/credit card on file in their secure account in my electronic health record system for as long as they are receiving services. By accepting this policy, you are consenting to allow Our Story Youth & Family Therapy LLC to charge your debit/credit card for sessions and late cancellation fees (for individual and family therapy clients only). Your card will be charged following each session and you will receive an email notification. I will let you know if your card is denied for some reason and you can update your card information via the client portal.

Electronic Signature of Client or Legal Guardian ( Type Full Name )
( Full Name )
I have read and I agree to the Credit/Debit Card Policy

Late Cancellation Policy

If you need to cancel a session, I ask that you notify me as soon as possible. For "no-shows" or cancellations made less than 24 hours in advance, a fee of $50 may be charged to your credit/debit card on file (for individual and family therapy clients only). I may choose to waive the fee for unforeseen or emergency circumstances such as sudden illness and dangerous road conditions. We may also be able to reschedule your session if I have an opening that week. If so, no fee will be charged. Consistency increases the effectiveness of individual and family therapy.

Electronic Signature of Client or Legal Guardian ( Type Full Name )
( Full Name )
I have read and I agree to the Late Cancellation Policy

Electronic Communication Policy

Secure messaging is provided through the client portal on my website. If you wish to communicate electronically about more personal matters, the client portal is the most secure method. If you choose to use email instead, it is important that you understand confidentiality is not guaranteed. I may use unencrypted email to communicate about scheduling and to send handouts. Our Story Youth & Family Therapy LLC uses Google Meet for telehealth sessions, which is a HIPAA secure video platform.