Thank you for choosing A Healing Place for your mental health wellness. Please complete the required forms below before your first appointment, forms that are required have a asterik* next to them. If we do not receive the completed forms before your appointment we may have to reschedule the appointment. HIPAA information can be found HERE, you may request a printed copy of the HIPAA policy. If you have any questions please call 920-725-1230 or send an email to info@healingplaceccc.org

Client Demographic Form *
Telehealth Informed Consent
Consent for Treatment*
Release of Information (ROI)
ELECTRONIC COMMUNICATION AND TECHNOLOGY CONSENT*
good faith estimate
FINANCIAL RESPONSIBILITY POLICY*
Your rights and protections against surprise medical bills