Forms & Practice Information

On this page you will find the forms necessary for the service you are requesting from Hawthorn Counseling Group. The standard HCG fee schedule is included in each set of forms shown below.

Submission of a completed set of forms is requested before starting to receive services. Please print the appropriate set of forms, review, sign, scan and return via email to:

jdjochem@gmail.com

If the service you are receiving is covered by your health insurance plan and you wish Hawthorn Counseling Group to submit health insurance claims for services please also provide a copy of your health insurance card and include this with the materials. Of course, if you have any questions about any of these materials feel free to contact Dr. Jochem.

Fee Schedule

Fee Schedule

Forms

Psychotherapy Services Patient Registration Forms

Evaluation Services Patient Registration Forms

Co-Parenting Consultation Client Registration Forms

Parent Coordination Client Registration Forms

Mediation Client Registration Forms

Collaborative Divorce Client Registration Forms

Release of Information Form

Statement on Telehealth & Use of Email

Telehealth Statement

Telehealth Consent Form

Email & Text Consent

Statement on Good Faith Estimate

Good Faith Estimate Statement

Good Faith Estimate Worksheet