Sinnergy Wellness Group
R · E · S · T · O · R · E  ·  M · N · T
Business Intake
Business & Billing Information
A short administrative intake — how you found us, billing address, insurance for superbill purposes, and how you prefer to be contacted. Separate from your clinical intake.
Please complete every field
Every answer helps build a complete clinical picture. If a question doesn’t apply to you, choose N/A or type “N/A” — don’t skip it. The form will gently guide you back to any missed fields before submitting.
1
Section 1
Who Is Completing This Form?
2
Section 2
How did you hear about us?
Referring Provider
Website
Client Referral
Insurance Company
Online Directory
Social Media / Ad
Book / Podcast
Other
3
Section 3
Name & Mailing Address
Your Name
Mailing Address
4
Section 4
Preferred Contact Method
Phone call
Text
Email
Healthie portal
N/A
Yes
No — please text only
Yes, but discreetly (don't mention the practice)
N/A
5
Section 5
Superbill & Insurance (Optional)
Private-pay practice. Sinnergy Wellness Group does not bill insurance. Payment is due at time of service by credit card on file. Some clients choose to submit a Superbill to their insurance company for possible out-of-network reimbursement. Reimbursement is not guaranteed and is entirely between you and your carrier.
Yes — please provide a Superbill monthly
No — not needed
Not sure yet
N/A
Insurance Information (for Superbill only)
Self
Spouse / Partner
Parent
Other
N/A
6
Section 6
Additional Notes (Optional)
R.E.S.T.O.R.E. MNT · Kristine Sinner, MS, RDN/LDN, CEDS-C
8700 E. Vista Bonita Suite 236, Scottsdale, AZ 85255
(480) 382-6109 · info@sinnergywellness.com