A Connecticut Nonprofit Organization dedicated to helping our first responders and veterans.
A Connecticut Nonprofit Organization dedicated to helping our first responders and veterans.
Intake Survey
New Client Intake Form
Please complete the form below and the forms on the previous page Prior to your first session
Please note the following prior to completing and submitting this form:
Expenses:
You are responsible for all co-payments and/or out-of-pocket expenses incurred as a result of attending mental health counseling sessions and/or group sessions with Honor Wellness Center. It is recommended that you call your insurance company as soon as possible so that you are aware of your specific co-pay and/or out-of-pocket expense, and so that you know what your responsibility will be for each session. You may pay all expenses due to Honor Wellness at the time of your session or online at honorwellness.org. Cash, check, and credit card (including HSA’s) are all accepted.
Cancellation Policy:
There is a 24-hour cancellation policy unless otherwise agreed to by Honor Wellness. If you do not cancel your appointment prior to 24-hours prior to the date and time of your appointment, and you do not attend, the session will be billed to you at the normal insurance rate of payment.
Submission Acknowledgement:
By completing and submitting this form, you consent to mental health counseling and/or group treatment with Honor Wellness Center. You agree to release Honor Wellness Center from any legal liability during and/or after your mental health counseling treatment. You also affirm that the information that you provide herein is accurate to the best of your belief and knowledge.
