Freedom, Health, and Wholeness
Forms
New Client Paperwork
New Client Paperwork – Print and fill out information about yourself and read consent to treatment and practice policies.
Health Insurance Portability and Accountability Act (HiPAA)
Health Insurance Portability and Accountability Act (HiPAA) – This form details the legal duties and privacy practices of the counseling center as well as how your medical and mental health information may be used and disclosed. HIPAA is referenced in the client paperwork and it available here for you to read. Please let me know if you have any questions regarding your protected health information.
No Surpises Good Faith Estimate
Effective January 1, 2022 the Federal No Surprises Act went into effect requiring a “Good Faith Estimate” for non-insurance or cash paying clients.
Release of information
Release of Information – This form authorizes me to discuss your treatment with your physician, or anyone other than yourself that you want me to be able to talk with, including your spouse. If you were referred by your physician or psychiatrist, please print this form and bring it to the session with your doctor’s name and contact information. If you do not have a medical doctor, former counselor or other individual you want me to communicate with, this form is not required.
Have a Different Question?
Call — 404-906-9831
Freedom, Health, and Wholeness
Kimberly Wallace LPC LLC
2852 Johnson Ferry Road, Suite 100
Marietta, GA. 30062
404-906-9831