Ollie's Branch Healthcare Team Member 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.

Name & Contact Information

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.


















Share More About your Profession










Tell Us About Any Barriers to Accessing 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




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. 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

Tell Us About Your Healthcare Coverage





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





Tell Us About Your Household





Consent to Participate in Ollie's Branch

By typing your name and initials, you are acknowledging and agreeing to the following for yourself 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 fully participate as a client in Ollie's Branch which includes completing a satisfaction survey at the midpoint and end of care and answering clinical surveys at the beginning and end of care. These surveys include the Patient Depression Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7).

    • The survey information allows you and the therapist to discuss and guide your therapy. The results are reported to OHHF de-identified for the purpose of understanding 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 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.





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.