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Client Setup and Intake Information

Please make sure you have contacted our office
before sending the following information.

Main Office#: (952) 222-7936

 

Below you will find the necessary information you'll need as part of your client intake process. You will be adding most of your information through your client portal.

If you have any questions on the below process, please call (952) 222-7936 

NOTE: All images you send need to be at least 150dpi resolution or higher (original or actual size).

Initial Profile Setup - (We just need this first part to get started.)

Regardless of you being set up as a private pay or insurance billing client, you will need to provide the following information to set up your initial SimplePractice Client Profile and your secure Client Portal.

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Please specify if you will be a private pay (cash rate) client or not. Private pay clients oftentimes choose this method if they have a high deductible insurance or no insurance. Account statements can be retrieved from your client portal account if needed.


Please submit all of your Initial Client Information
using our secure email service provider by Clicking Here.

 

You can also fax this information to (866) 318-3073.
Both of these methods are secure, HIPPA compliant methods
for sharing information with Know Thyself.

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DO NOT SEND ANY PERSONAL INFORMATION TO ANY CONTACT AT KNOW THYSELF VIA REGULAR EMAIL.
EMAIL IS NOT A HIPPA COMPLIANT METHOD FOR CLIENT COMMUNICATIONS.

 

Client
Contact Info

Please provide the following contact details for client receiving therapy:

  1. Full Name

  2. Personal Mobile Phone Number (if applicable)

  3. Personal Home Phone Number (if applicable)

  4. Personal Email Address

  5. Is the client is under the age of 18 (a minor)?  (Yes or No)

  6. If the client is a minor we will need the information of the client's parent(s) and/or guardian.

Parent / Guardian or Other Contact(s)

Please provide the following contact details for all of the people we should have on file as your emergency or support contacts. If you are a minor, you must provide the contact information for your parent(s) and/or guardian.

  1. Full Name

  2. Personal Mobile Phone Number (if applicable)

  3. Personal Home Phone Number (if applicable)

  4. Personal Email Address 

Referral Source

Please tell us who referred you to Know Thyself Healing & Therapy. This could be from a web site, internet search, friend, family member, or other organization. We track this information for marketing purposes only.

Billing Information - (You will add this later once your profile is set up.)

Below is the necessary information needed for both private pay (cash rate) and insurance billing clients.

 

If you have any questions on the below process, please send an email to Office@Raatz.com or call (952) 222-7936

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Once we have the above "Initial Profile" information, we will be creating your client portal. Our SimplePractice software will be sending you and email. The message will be coming from the address "yourprovider@simplepractice.com". Please add this to your contacts or mark as a valid address in your system. This will help prevent emails from the software to be routed to your SPAM or Junk email boxes. If you don't get an email from our system, please take a look at these areas for the message.


This information will be entered by you using your Client Portal account. You do not need to secure message this information to us. NOTE that if you don't see your Client Portal access email, please review your SPAM or Junk email boxes. Some providers will put these emails into this area. Be sure to include the email address received in your safe/allow list for future emails.

State ID

You will need to provide a picture or scanned image of the front of your State issued identification card (e.g. Driver's License). If this card does not have your current mailing address, you will also need to provide that.

If the client is a minor without ID or does not have a Sate issued identification card, please be sure to include all of the below contact information requirements when submitting your information. This can be uploaded to your Client Portal. You will find the upload area under the Documents section, then scroll to the bottom and find “My Uploads”. 

Billing 
Contact Info

Please provide the following contact details for the person who will be responsible for payment of your services. If you are using insurance, this name will be the person who is the primary insurance on the policy. If you are private pay, this will be the name of the person who will be paying the session billing amounts. If you are a minor, you must provide the contact information for your parent(s) and/or guardian:

  1. Full Name

  2. Personal Mobile Phone Number

  3. Personal Home Phone Number (if applicable)

  4. Personal Email Address

  5. Current Mailing Address (no PO Boxes)

Credit Card

Please enter the following into the Client Portal for both Insurance or Private Pay Clients:

  1. Valid Credit Card or HSA Debit Card Number

  2. Name of person on the Card

  3. Expiry Date of Card

  4. Other required card information needed

  5. Billing Mailing Address for the Card

Insurance Verification Form

Please download the following form to understand your current policy plan with regard to your payment obligations.         Click Here To Download

Insurance Information for Primary Insured

Please provide the following insurance information for the Primary Insured person on the account. You will enter this via the Client Portal.

  1. Primary Insured's: 

    1. Full Name

    2. Personal Mobile Phone Number

    3. Personal Home Phone Number (if applicable)

    4. Personal Email Address

    5. Current Physical Home Address (no PO Boxes)

    6. Birth Date (of parent)

  2. Insurance Card Images (see above image requirements at top of page)​

    1. Front of Card​

    2. Back of Card

  3. Driver's License Image​ (see above instructions under State ID to do this)

    1. Front of Card​

Insurance Information for Dependant

Please provide the following insurance information if you are the dependent on another person's medical insurance plan. This is most common for children on their parent or guardian's health insurance plan. You will enter this via the Client Portal.

  1. Client's:

    1. Full Name

    2. Personal Phone Number (if applicable)

    3. Personal Home Phone Number (if applicable)

    4. Personal Email Address (if applicable)

    5. Current Physical Home Address (no PO Boxes)

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