Ollie's Branch Intake Form

Overview

Help us match you to the right therapist

Having a therapist with whom you can establish a personal connection and who matches your needs and preferences is important. Before you complete Ollie’s Branch intake form, here are important details to review.

If you, or someone you love, are experiencing a mental health emergency or you are concerned about immediate harm, please call 911 or go directly to the nearest Emergency Department. Here are additional helpful resources. 

Ollie’s Branch provides accessible and trustworthy mental health support to heart warriors, heart parents/caregivers, grandparents, siblings, bereaved parents/guardians, prenatal families, and pediatric cardiac healthcare workers.

Heart warriors and their family members receive specific therapy sessions depending on their needs. Services can be accessed while the heart warrior is inpatient or outpatient, during pregnancy, or after death. Services are available virtually or with limited in-person availability where we have a hospital/social partner. 

Ollie Hinkle Heart Foundation (OHHF) will match you to a therapist based on the information you share and provide the therapist’s information to you. Therapy sessions are scheduled between you and the therapist. OHHF pays all or a portion for the first 8 sessions per individual, 16 sessions for prenatal clients, or 16 sessions per couple used together or separately. The therapist will bill OHHF for our portion, and you will be asked to pay none or some of the costs through a sliding fee or your health insurance. OHHF requires you to give 24-hour notice for cancellations or rescheduling unless the therapist requires you to give more notice than this. 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. Unless it is an emergency, if you miss or late cancel two scheduled sessions with your therapist without giving 24-hour notice, you will be removed from the Ollie’s Branch program.

The therapists we work with are independent providers, not our employees, agents, or representatives. The therapists themselves are responsible for the performance of the therapy services. You can switch to a different Ollie’s Branch therapist if you feel the therapy services provided did not fit your needs or expectations. While we have a large community of therapists, because of license requirements, not all therapists are available in every location. If your matched therapist stops participating in Ollie’s Branch for any reason, we will notify you by email and offer to match you to a new therapist. By completing this intake form you agree that these services may not meet every need depending on your situation. Additionally, these services are not a substitute for certain mental health services that require specific expertise.

We require every therapist providing therapy services through Ollie’s Branch to be an 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 in their field and be qualified and certified, or actively seeking this certification, by their respective professional boards after successfully completing the necessary education, exams, training, and practice requirements.

The therapist provides professional services, and OHHF serves as the connector. 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 any Telehealth or state licensing requirements regarding where you are located when the professional services are provided. 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 start the process of matching to a therapist in Ollie’s Branch.
Please complete the following to help us make the best possible match to a therapist who can serve your needs. If you have questions, email olliesbranch@theohhf.org.






















Availability

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






Initials





If not, put "none."

If not, put "none."

Fill out once for each person seeking mental health services























Availability

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






Initials





If not, put "none."

If not, put "none."
If you are seeking mental health services for additional people, please click "add another response" below.
Please repeat Heart Warrior information if previously entered.
















Green Bottle

We are looking to spread access to mental health support to as many people with childhood-onset heart conditions and their families as possible. Please review the Green Bottles below and choose which bottle represents your financial resources and experience. 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.

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






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.




















Signature

By typing your name and initials, you are acknowledging the following for yourself and any additional people added to 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 fully participate as a client in Ollie's Branch, which includes completing a satisfaction survey at the end of care and answering the Patient Depression Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) for adults and for minors completing the Strengths and Difficulties Questionnaire (SDQ) at beginning and end of care.

    • The PHQ-9, GAD-7, and SDQ survey information allows you and the therapist to discuss and guide your therapy. OHHF receives de-identified results to understand the impact of the services provided.

  • 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 my health insurance and other relevant information will be shared with potential therapist(s) to check my benefits. This service may be through a third-party entity, for example, Headway, Mentaya, or others.

  • 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 licenses for the therapist(s) provided to me, OHHF can provide me, if requested, with information about the therapist's background or qualifications that OHHF collects. 

  • I understand that my choice of therapists 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.



Contact Information