Thank you for choosing Honor Wellness. The next few pages will guide you through the intake paperwork that you’ll need to fill out prior to your appointment. Please read and acknowledge the below Financial Responsibility information prior to completing all of the required intake forms. All intake forms must be completed prior to your first appointment. By continuing through this process you consent to submit the intake paperwork through this platform.
Before continuing - are you in law enforcement, corrections, probation, fire service, pre-hospital emergency medical services, emergency dispatching, active or veteran military, or a household member of someone who is? If not, please do not proceed. We are happy to give you a referral to a clinician locally in your area.
Financial Responsibility Acknowledgement
Please acknowledge the following information prior to completing the intake survey and ancillary forms.
By participating and/or submitting to treatment, counseling, or other services provided by Honor Wellness Center (HWC), you authorize HWC to file a claim with your insurance carrier for services rendered. Full in-network insurance coverage is not a requirement for treatment or services rendered by HWC, however, you understand that you are responsible for any part of the charges or fees that are not covered/paid by your insurance provider, including but not limited to any co-pays, out of network fees, or patient responsibility amounts identified by your insurance carrier/provider. If you lack complete insurance coverage or do not have any insurance coverage, you understand that you must identify this fact to HWC prior to any services or treatment being rendered. HWC will then arrange an appropriate payment agreement, in writing, including but not limited to amounts due, payment schedule, and payment methods, which you must agree to abide by during any treatment or services and after the cessation of any treatment or services. You understand that you will be billed directly for services not covered by insurance or services for which you have agreed to pay and that you are financially responsible for treatment or services rendered by HWC.
Please acknowledge that you have read and understood the above by entering your name and date of birth below. You may then click the “continue” button to be directed to the intake form page.
Thank you