Forms

Price Transparency and Fees

Description of fees and policies related to payment structure at this practice.

Informed Consent for Mental Health Treatment revised Oct 15 2025

This form details the policies in place that you should be aware of at Moore Hope Mental Health.

Bill of Rights

This form explains your rights while being treated by Moore Hope Mental Health.

Authorization to allow exchange of records or other communication with any other individual or group

Complete this form for any other parties with whom records/discussion of your care may need to occur

*MUST DO* Signature page for Informed Consent Document

Please sign and return attesting that you received and agree to these policies related to your care.

*MUST DO* Signature page for Bill of Rights form

Please sign and return indicating that you received and understand the Bill of Rights form.

*MUST DO* Refill Instructions & Medication List

Please complete if in need of refills prior to your first appointment at Moore Hope Mental Health

*MUST DO* Informed Consent for Telehealth (virtual) appointments

Please sign and return that you agree to special aspects of care related to Telehealth visits

*MUST DO* Client Contact Information and Consent for Third Party Billing

Please complete this form and return. Note that 2 signatures are required at the bottom.

*MOST PEOPLE MUST DO* Authorization to obtain records from Madelia Health

This form will allow release of records of care by Rebecca Moore while at Madelia Health

*IF YOU SAW ME IN MANKATO ONLY* Authorization to obtain records from Mankato Mental Health Associates

Please complete and return to release records of care from Rebecca Moore at Mankato Mental Health