Client Forms

Fill Out Your Forms Before Your Appointment

Check here for forms relating to client release of information, billing and payment information, and new client intake forms. Dr. Ingram would like to know as much about you so he can better plan for his sessions. Whether you are looking for individual counseling sessions, group counseling, or couples counseling services, you can find all the forms you’ll need on this page.

Dr. Ingram offers psychotherapy and interpersonal counseling for various groups of all ages. Using the skills of a licensed counselor that he has accumulated from years of study and personal experience, Dr. Ingram will provide all the help you need. Fill out the forms below to get started!

Fill Out Your Forms Before Your Appointment

Here are all the forms relating to client release of information, billing and payment information, and new client intake forms. Dr. Ingram would like to know as much about you so he can better plan for your sessions. Whether you are looking for individual counseling sessions, group counseling sessions or couples counseling sessions, you can find all the forms you’ll need on this page.

Client Intake Form

Steven A. Ingram, D.Min., LPCC-S, LSW

The information you provide in this form will be kept confidential. Please fill out this form. If the information changes, like your contact information and mailing address, please update the data for our records.

Today's Date *

Full Name *

Date of birth *

Home Address *

City *

State *

Postal code *

Home/Mobile Phone *

Email *

Marital Status *

Number of Children *

Their Names and Ages

Who Lives With You?

Name of Employer *

Job Title *

Who Referred You to Dr. Ingram?

Brief Mental Health History:

Have You Previously Been in Therapy? *

If Yes, Name of the Therapist(s) and Approximate Dates of Service:

Have You Ever Been Hospitalized for Mental Health Reasons? *

If Yes, Please Give the Name of the Hospital, Approximate Dates, and Why You Were Hospitalized:

Are You Taking Any Other Medication? *

If Yes, Please List Them and Give the Name of the Prescribing Physician:

How is Your Current Health, in General? *

List Any Physical or Health Problems You are Currently Experiencing:

Do You Use Alcohol or Recreational Drugs?

If Yes, Please Give Frequency and Amounts:

What are You Hoping for Therapy to Help You Do and What Else Would You Like for Dr. Ingram to Know?

Captcha

Authorization for Use or Disclosure of Protected Health Information

1. Full Name

2. Date of birth

3. Date Authorization Initiated

4. Information to be released:

5. Purpose of Disclosure: The reason I am authorizing release is:

7. Person Authorized to Make the Disclosure: Steven A. Ingram, 8354 Princeton-Glendale Road, Suite 118, West Chester, OH 45069

8. Person(s) Authorized to Receive the Disclosure:

9. This authorization will expire on

Or upon the following conditions:

Authorization and Signature: I I authorize the release of my confidential protected health information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions.

Client Signature

Clear

Date of Signature:

Captcha

Billing, Payments, & Insurance

I understand and agree to the following:

1. Fees: Individual is $160 for 45 minutes and Couples are $195 for 55 minutes ; Group is $100 for 75 minutes.

2. Sessions are 45 minutes unless otherwise specified.

3. The payment for each session is due at the beginning of each session.

4. You can pay by check, Venmo or by using a credit card via PayPal. (If you use PayPal you will be charged an additional 3% to cover the cost of that service.)

5. Dr. Ingram’s billing service will send out a statement at the beginning of each month if you have a balance due.

6. Late Cancellations and Missed Appointments:

You will be charged the full fee for missed sessions which are cancelled less than 24 hours before the appointment time. Of course, illness and emergencies are exceptions, and will be treated on a per-case basis.

(Please initial here that you have read and agree to the missed appointment policy_____.)

7. Agreement

I have read the terms and conditions set out in this document, and I agree to be bound by them.

Signature

Clear

Today's Date

Printed Name

Licensed Professional Counselor

Dr. Ingram aids his clients with psychotherapy and interpersonal therapy to identify how they contribute to their own difficulties and how to overcome their loud, internal critics. Dr. Ingram offers honest thoughts and considerations to his clients, in hopes of them creating and living the most fulfilled life.

As a spiritual counselor, individual counselor, couples counselor and group counselor, Dr. Ingram provides multiple types of sessions and various ways to address any issues present. With over 30 years of counseling experience, Dr. Ingram is a licensed professional counselor, skilled and trained to guide his clients through hard times and help them overcome difficult experiences. Dr. Ingram believes in helping his clients to build a connection to self, a connection to others, and a connection to spirit.

Comfortable Environment

Currently offering teletherapy sessions, Dr. Ingram wants to create an environment that his clients feel comfortable in asking questions and discussing anything with him. He encourages his clients to express their real and honest thoughts, emotions, and feelings. He believes that authenticity, empathy, trust, commitment to the work, affirmation, and validation are all elements of good counseling.

See if Dr. Ingram is the right therapist for you. For more information or to schedule a teletherapy appointment with Dr. Ingram, fill out your information in the forms above.

See if Dr. Ingram is the right therapist for you. For more information or to schedule a teletherapy appointment with Dr. Ingram, fill out your information in the contact form above.

Client Forms

Client Forms

Fill Out Your Forms Before Your Appointment

Fill Out Your Forms Before Your Appointment

Licensed Professional Counselor

Comfortable Environment

See if Dr. Ingram is the right therapist for you. For more information or to schedule a teletherapy appointment with Dr. Ingram, fill out your information in the forms above.

See if Dr. Ingram is the right therapist for you. For more information or to schedule a teletherapy appointment with Dr. Ingram, fill out your information in the contact form above.

(513) 613-4050