Ollie's Branch Intake Form

Overview

Before you begin filling out the Ollie’s Branch intake form, please take a moment to review these important details. We understand that this process can feel overwhelming and want to ensure you have all the information you need to feel confident and supported.

Disclaimer

If you or someone you care about is experiencing a mental health emergency or is in immediate danger, do not hesitate to call 911 or go directly to the nearest emergency department. You are not alone—valuable resources are available to help you.

Eligibility

  • Individuals with childhood-onset heart conditions and their parents, caregivers, grandparents, siblings, bereaved families, and individuals expecting a baby with a heart condition.

  • Pediatric cardiac healthcare workers who have been in their position for at least 6 months.


Availability

  • Virtual care available in all 50 states, D.C., and Puerto Rico, with limited in-person availability. 

  • Based on what you share, we will match you with a therapist and send you the therapist’s information. 

  • Sessions are scheduled between you and the therapist. 


Individualized Approach

  • A dedicated OHHF Care Manager works with you to understand your needs and determines an initial number of therapy sessions. 

  • You may be responsible for none or a portion of the costs through a sliding scale or your health insurance. 

  • Therapists bill OHHF for our share of the costs. Depending on your personal situation, you will pay your therapist directly for any costs for which you are responsible. 


Your Responsibilities

  • OHHF requires you to give your therapist 24-hours notice for cancellations or rescheduling unless the therapist requires more notice. 

  • You will be responsible for paying for any no-show session(s) and will be expected to have a credit card or payment source on file with the therapist. 

  • You are no longer eligible for services through Ollie’s Branch if you miss or late cancel two scheduled sessions with your therapist without giving 24-hour notice unless excused due to an emergency.


Therapist Community

  • Therapists are independent providers, not our employees, agents, or representatives. 

  • Therapists are responsible for the performance of the therapy services. 

  • You can switch to a different therapist if the services do not fit your needs or expectations.

  • Our therapist community provides a range of services, including exposure therapy, trauma-informed care, psychotherapy, relationship therapy, cognitive therapy, LGBTQ+ informed therapy, and various creative therapies (play, music, and art). We also offer family and group therapy, along with behavioral and addiction therapies. 

    • Language access is available through English- and Spanish-speaking therapists, as well as translation services for other languages.

  • While we have a large community of therapists, not all therapists are available in every location because of license requirements. 

  • If your matched therapist stops participating in Ollie’s Branch for any reason, we will notify you by email and offer to match you with a new therapist. 

  • By completing this intake form, you agree that, depending on your situation, these services may only meet some of your needs. 

  • These services are not a substitute for certain mental health services that require specific expertise.

  • Every therapist providing services through Ollie’s Branch is expected to be accredited, trained, and experienced provisionally or fully clinically licensed U.S. psychologist (PhD / PsyD), licensed marriage and family therapist (LMFT), licensed clinical social worker (LCSW), licensed professional counselor (LPC), or similar applicable recognized professional certification based on their state or jurisdiction. 

    • Therapists must have a relevant academic degree and be qualified and certified by their respective professional boards or actively seek this certification after completing the necessary education, exams, training, and practice requirements.

    • OHHF also provides therapists with additional education on the unique needs of the heart community and resources to understand terminology related to various childhood-onset heart conditions.


OHHF & Therapist Responsibilities

OHHF serves as the connector, and the therapist provides professional services.

  • OHHF is not part of your relationship with the therapist, and OHHF does not obtain personally identifiable clinical information from the therapist. 

  • Compliance with any professional laws or requirements is the therapist's responsibility alone. 

  • Therapists must also comply with telehealth or state licensing requirements regarding their location and when they provide professional services. 

  • OHHF defers to the therapist regarding their obligations to ensure their privacy and security responsibilities are met, including the use of Telehealth technology.

  • All your information is kept confidential per our privacy policy. 

  • OHHF does not share or sell your information with third parties without your written consent. OHHF uses the information you provide to improve our services and better understand the needs of the heart community.


Please take a few minutes to answer the following questions to allow us to start matching to a therapist in Ollie’s Branch.

Let's get started



This form must be completed by someone who is 18 and above to serve as the primary contact for the household. If you are under 18, please close this form until  your parent, caregiver, or guardian can fill this out providing their information as the primary contact and giving their consent for you as a minor.








Name & Contact Information

Please complete the following as the primary contact for your household whether you are or are not seeking services for yourself. If you have questions, email olliesbranch@theohhf.org.


















Tell us about your Heart Condition

















If yes, please submit here

When we connect with you about therapy, we'll also share information about this additional support.

Tell us about your Heart Warrior






























If yes, please submit here

Tell us about your household





Tell us about your financial health

We are looking to spread access to mental health support to as many people with childhood-onset heart conditions and their families as possible. This will help us determine the amount of financial assistance OHHF can provide toward your therapy sessions. You may be asked to pay none or some of the costs through a sliding scale or by using your insurance.

Please answer the following questions honestly by selecting the statement that best represents your needs. 

Our team will reach out after we review your intake form to talk about options before we match you with a therapist.

Definitions:
* Basic needs include food, housing, and transportation.
** Expendable income might mean you can regularly buy coffee at a shop, buy new clothes, go to the movies, etc.











Tell us about your healthcare coverage








Insurance companies require the collection of "sex assigned at birth" for billing purposes. OHHF recognizes the diversity of gender identity and expression.

The address that was provided on page 3 of this form.









If your card doesn't have a back, please upload a second copy of the front.





If your card doesn't have a back, please upload a second copy of the front.




Tell us about any barriers to care









Share your therapy preferences

We will do our best to match you with a therapist based on the information below but cannot guarantee being able to meet all requests. We will reach out with any questions and to discuss options.
























Share your availability


The more availability and flexibility you can provide allows us to better match you with a therapist in our community.






Initials




Additional Adult seeking services

You indicated the need for services for another adult in your household, please provide their email so we can send them a form to provide their contact information, therapy preferences, availability, and consent. Anyone over 18, unless legally unable to, must provide consent for services for themselves.



Therapy Preferences for Heart Warrior

Please complete the following to help us make the best possible match to a therapist who can serve the needs of your Heart Warrior. We will do our best to match them with a therapist based on the information below but cannot guarantee being able to meet all requests. We will reach out with any questions and to discuss options.

























The more availability and flexibility you can provide allows us to better match them with a therapist in our community.






Initials




Name & Therapy Preferences for Dependent/s in Household

Please complete the following to help us make the best possible match to a therapist who can serve the needs of your family member/s. Please provide their name, demographic information, therapy preferences, and availability. If you are completing this for more than one dependent, please click "add another dependent seeking services" at the bottom to provide this information for each additional person. If you have questions, email olliesbranch@theohhf.org.














We will do our best to match them with a therapist based on the information below but cannot guarantee being able to meet all requests. We will reach out with any questions and to discuss options.

























The more availability and flexibility you can provide allows us to better match them with a therapist in our community.






Initials




Consent & Information authorization

By typing your name and initials, you are acknowledging and agreeing to the following for yourself and any minors in your care listed on this Intake Form:


  • I have reviewed OHHF’s website privacy policy and agree with all terms.

  • I have reviewed OHHF’s client rights and responsibility policy and agree with all terms.

  • I agree to abide by Ollie’s Branch's no-show/late cancellation policy as outlined on the first page of this Intake Form.

  • I will complete a satisfaction survey at the midpoint and end of care for myself and any applicable minors. This survey will be emailed to the email address on my intake form.

  • I will complete clinical surveys at the beginning and end of care for myself and any applicable minors. These surveys include the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) for adults and the Strengths and Difficulty Questionnaire (SDQ) for minors, as applicable.

    • Your therapist will administer the survey(s) to you, and your therapist will receive a copy of the results. The information allows you and the therapist to discuss and guide your therapy.

    • The results of the surveys are also reported to OHHF. OHHF may use the results to understand the impact of the services provided. OHHF may share the results for purposes including but not limited to research and grant funding. Any results shared outside of OHHF will be aggregated (looked at in total) and de-identified (not tied to your name) before being shared. Your data is not a determining factor in the care you receive via Ollie’s Branch.

  • I understand I will be treated with dignity and respect, and I will treat OHHF employees and Ollie’s Branch partnered therapists with dignity and respect.

  • I consent to this form being provided electronically to the therapist who will provide services for me and the other individuals (if applicable) listed under this program's intake form.

  • I understand OHHF is providing a referral for the therapy that is part of this program. 

  • I understand OHHF is not responsible for anything that transpires within the relationship between myself and the therapist.

  • I understand that while OHHF reviews or confirms licenses for the therapist(s) provided to me, I can also request OHHF to provide me information about the therapist's background or qualifications that OHHF collects.

  • I understand that my choice of therapist(s) within this program is mine, and I am not relying on promises or assurances about therapists other than what is provided in writing by OHHF.

  • I understand that OHHF has not and will not provide me with medical, legal, or tax advice.





I hereby authorize the names of those listed below to discuss and participate in the coordination of my services through Ollie's Branch Mental Health Program in accordance with Health Insurance Portability and Accountability Act (HIPAA) regulations. I understand that if names are not listed below, Ollie Hinkle Heart Foundation, cannot release any information.





You identified a language need other than English on your form. Consent is required if a translator/interpreter needs to be present during therapy sessions. By typing your name and initials, you acknowledge and agree to:

  • A translator/interpreter can be present during my sessions with my counselor/therapist so I can communicate effectively.

  • I understand that when I choose to have a translator/interpreter present, the translator/interpreter will have access to personal information that I share with my counselor/therapist.

  • I understand that I may revoke my consent to the presence of the translator/interpreter at any time. However, I acknowledge that such revocation may compromise counseling/therapy quality.



Ollie's Branch FAQ