INTAKE FORMS

If you are a CURRENT patient please click HERE to schedule.

Cornwall Counseling DOES NOT provide telehealth services.  ALL services are provided onsite, face-to-face.  (If you are not able to travel, please contact Dr. Cornwall directly at 859.321.4956 to arrange for accommodation.)

If you are a NEW PATIENT please continue to the information requested below.

PLEASE NOTE: Our Online Intake Form allows our patients to complete the necessary forms, prior to arriving for their first appointment. Please notify our office if you would like to complete these forms in person. If we do not receive your intake information within 24 hours of your initial appointment time YOUR APPOINTMENT WILL BE CANCELLED.

If you do not have your insurance information, prior to your first appointment, please contact your insurer. You may check on your insurance deductible and copayment prior to arriving. If you will be using commercial insurance, please plan to leave your credit card information, until your first claim clears.

Keep in mind, if you are using an Employee Assistance Plan (EAP), the plan name is NOT the name of your employer. Please ask your EAP representative to name the EAP you are using. Write down this information, along with the authorization number and the number of authorized visits.

If you must cancel your appointment, please provide 24-hour notice to our office using voicemail, text, email, or by calling. Missed appointments with less than 24-hour notice will incur a $45.00 late cancellation fee. (All no-shows are kept on file and you will not be permitted to schedule another appointment until this fee is paid.)

Thank you!

As a patient, all the information you share about yourself and others will be kept confidential. Only with your written permission will information be released to anyone outside of Cornwall Counseling, except as required by law. Legal exceptions include the following: clear and imminent danger to you or someone else, if there is a reasonable expectation that you will engage in dangerous conduct as defined by Nevada state statute, and reasonable suspicion that a child or elder is currently being abused a court order. Cornwall Counseling records do not become part of student educational or medical records without your written consent. While Cornwall Counseling staff members may consult with a supervisor, with one another, with outside council or with professionally licensed clinicians, all staff members are ethically and legally bound to treat that information confidentially.
Minors (under the age of 16) generally cannot consent to treatment; a parent or guardian consents on the minor's behalf. There are exceptions. Certain states allow minors whom the law deems especially mature, such as those who are married or in the armed services, to consent to treatment, and sometimes minors may consent to treatment for substance abuse or sexually transmitted diseases. The exceptions are few, however, and prove the rule that the law deems individuals under a certain age (often 16) not sufficiently mature to make treatment decisions. A parent who consents on the minor's behalf generally has the right to know the content of the child's treatment. This state of affairs changes when the minor reaches the age of majority (16). Until that time, the law will normally give the parent access to the child's treatment. From a clinical perspective, the situation is more complex. An important aspect of treatment is to foster an individual's autonomy, and a great pleasure of treating adolescents is to watch as they come to enjoy their growing independence. One aspect of independence is privacy. As a child grows into adolescence and into adulthood, the surrounding zone of privacy should increase, thus making room for a more defined sense of self and a greater sense of autonomy.
The HIPAA Privacy Rule gives individuals a fundamental new right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information. Health plans and covered health care providers are required to develop and distribute a notice that provides a clear explanation of these rights and practices. The notice is intended to focus individuals on privacy issues and concerns, and to prompt them to have discussions with their health plans and health care providers and exercise their rights. Cornwall Counseling is in compliance with 45 CFR 164 520 Notice of Privacy Practices for Protected Health Information. If you would like a copy of our HIPPA compliance statement, there is a copy in the office where you sign-in or you may request a copy when visiting our office. You may also download a copy of our HIPPA policy here: https://www.hhs.gov/sites/default/files/ocr/privacy/hipaa/understanding/coveredentities/notice.pdf
If you will be requesting Leave of Absence (LOA), Family Medical Leave Act (FMLA), Disability, Emotional Support Animal (ESA), Court Reports or any written documents, please visit our website and Click the Family Leave link.
I request to release confidential information to the following individuals or entities - Release of information (ROI) in healthcare is critical to the quality of the continuity of care provided to the patient. It also plays an important role in billing, reporting, research, and other functions. Many laws and regulations govern how, when, what, and to whom protected health information (PHI) is released. Please provide the EXACT type of information you wish to be released, e.g., notes, treatment plans, dates of service, etc. If you are seeking service through Cornwall Counseling in order to satisfy a court-related issue, or if you are seeking to use the information you are requesting as evidence in a current or future court proceeding or determination made under the law, i.e., Leave of Absence (LOA), divorce, child custody, adult welfare, Workers Compensation, Disability Claim, or for any future or impending court proceeding or case for which Cornwall Counseling will be, could be, may be or might be summoned to or required to appear as a witness, please declare that information in the space above. In addition, please provide the name(s), address(es), nature of the relationship to the patient(s), telephone number(s) and email address(es) of the individual(s) or entities with whom you wish to freely share confidential information.
Cornwall Counseling proudly accepts the following insurances (Choose One) If you are using and EAP plan, please ensure that you know your EAP provider name, authorization number, and number of authorized visits, before arriving for your initial visit. If you don’t know this information, please call back your provider and ask these questions. If you don't have this information, please prepare to pay by credit card.
Please understand that appointment times are limited. If you must cancel your appointment, we require 24-hour notice. There are NO EXCEPTIONS. Missed appointments, or appointments cancelled without 24-hour notice will incur a $45.00 late cancellation fee. You can cancel online through the scheduling portal by visiting https://www.therapyportal.com/p/cornwall211/ or by texting (859) 321-4956, emailing cornwallcounseling@gmail.com, or calling (859) 321-4956. You may leave a message, if there is no answer. If you have ANY questions about billing, please email 6030458@gmail.com
At times Cornwall Counseling may want to contact you by text or email to generally check on you. This contact may take place only one (1) time after approximately six (6) months of your last appointment. Do you agree to recieving a communication from your therapist inquiring about your well-being?

If you would prefer to schedule by telephone, please let us know when you call or text. Our telephone number is 859.321.4956. You will be asked to provide some information over the telephone, to help us evaluate if our clinic is your best treatment option. You may then be scheduled for an evaluation session, which provides an opportunity for you to build rapport with your therapist. You may be asked to provide some background about yourself and the reasons you are seeking counseling. In addition, the therapist will be able to answer your questions regarding services, fees, confidentiality, and what to expect in therapy.  If you cannot complete the intake form now, we can help you with it when you arrive for your appointment.  Please ensure that you have all of the necessary approvals and insurance information when you arrive.

You will be receiving an email requesting that you create an account in the Scheduling Portal. Please complete the instructions, so that you can schedule, cancel or make alternative choices for your future appointments.