FORMS


Financial Policies

The following forms are included in the intake paperwork to clarify our billing and collection policies:

Nutrition Only Forms

Other Forms

Notice of Privacy Practices – Confidentiality is very important to us. We hope that you will read over our Privacy Practices to familiarize yourself with our policies that protect your private health information. Upon completing your intake paperwork for Chrysalis, you will be required to sign an Acknowledgement of Receipt that indicates that you have read our Privacy Policies.

You will also need to review our Rights and Consent to Treatment for information about our treatment practices and policies, including our social media policy.

Information Update – Clients are expected to complete our Information Update form to notify us of any demographic or insurance changes. If you are aware of a recent change and need to update us, feel free to complete this form and bring it with you to your next appointment.

Release of Information/Request for Information – To ensure our client’s confidentiality, protected health information is not shared without written consent from our client or their guardian (unless a client is deemed an immediate risk to self or others). The Release of Information is so that providers can communicate with one another via phone, fax, or e-mail. The Request for Information is only to be used if Chrysalis Center is asking for documentation from other providers. Most of the time, the Release of Information is sufficient, but check with our staff to clarify which form you might need.

Note: For those under the age of 18, a legal guardian’s signature is required on both the Release and Request for Information.

Informed Consent for Teletherapy – if your clinician indicates that you need this additional consent for teletherapy sessions, they will inform you.

If there are any questions about these policies, please contact our Compliance Officer or Office Manager as appropriate.

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About Us

At Chrysalis, we believe that a supportive, healing environment is essential in order for change and growth to occur. We seek to offer such an environment to clients and help them create that in their lives and relationships. Read More

Hours

Mon: 8AM - 6PM
Tue: 8AM - 6PM
Wed: 8AM - 6PM
Thu: 8AM - 6PM
Fri: 8AM - 4PM
Sat: CLOSED
Sun: CLOSED

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