Transitions Counseling Growing Towards Change th Street, Suite W-6 Frisco, Texas Phone: Fax:

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1 Transitions Counseling Growing Towards Change th Street, Suite W-6 Frisco, Texas Phone: Fax: Insurance Information Sheet It is important that you thoroughly complete this form and provide a copy of both sides of your insurance card(s). Thank you. CLIENT INFORMATION Name: Birth Date: Address: SS#: City: State: Zip: Home Phone: Mobile Phone: Employer: Is client a dependent child? Yes or No Martial Status: (Circle one) M S Other PRIMARY INSURANCE INFORMATION (Person Responsible for Payment) Who is the Insured: SS#: Birth Date: Employer of Insured: Work Phone: Insurance Co.: Policy #: Group #: Customer Service Phone: Mental Health Phone: Co-Pay Amount: DO YOU HAVE SECONDARY INSURANCE? Yes or No Who is the Insured: SS#: Birth Date: Employer of Insured: Work Phone: Insurance Co.: Policy #: Group #: Customer Service Phone: Mental Health Phone: Authorization # DO YOU HAVE EAP? Yes or No Name of EAP: Phone # of EAP: Authorization #: Sessions Authorized: From To I authorize the release of any medical or other information necessary to process an insurance claim. I understand that Transitions Counseling will diligently attempt to get accurate information regarding my mental health insurance benefits. I will not hold Transitions Counseling liable for insurance nonpayment due to misquoted benefits. I acknowledge I am responsible to know and understand my benefits plan. Transitions Counseling will file my insurance claims for me as a courtesy. I am ultimately responsible for all charges my insurance company does not pay, except for contracted network provider discounts that may apply. I also request assigned benefits be paid to Transitions Counseling and/or the provider indicated above. Signature of Client and/or Insured: Date:

2 2 CLIENT S PERSONAL DATA Client s Name: Birth Date: Social Security #: Is the client a minor (under age 17) child? YES NO Street Address: Home Phone: City, State, Zip: Work Phone: Driver License #: Cell Phone: Other Phone: Marital Status: Married (No. of years): Single: Separated (since): Divorced (since): Client s Occupation: Employed by: Today s Date: If client is a minor complete this section. Fill in all that apply. Birth Mother s Name: Step Father s Name: Birth Father s Name: Step Mother s Name: Name of responsible party: Street address of responsible party: City, State, Zip: Who brought minor child for counseling? Who is the legal guardian for the minor client? What is your relationship to minor client if none of the above? If divorce or a temporary order has precipitated arrangements, please provide a copy ASAP, particularly if one parent is sole conservator. If applicable, who is the sole conservator? Please list all members of your household: Name/Relationship Birth Date/Age Sex EMERGENCY CONTACT INFORMATION Who would we contact in case of an emergency? Name / Phone #: Name / Phone #:

3 3 SPIRTITUAL INFORMATION Do you consider yourself a Christian? YES NO Do you desire Christian counseling? YES NO Church Denomination: What church do you attend if any? MEDICAL INFORMATION Name of Primary Care Physician: Phone #: List any medical conditions: Are you currently on any medications? YES NO If so, please identify medication, dosages and times taken: Are you allergic to any medications? YES NO If yes, what are they? ALCOHOL / DRUG HISTORY YES NO OCCASIONAL 1. Do you drink alcoholic beverages? 2. Have you or a family member ever been concerned about your alcohol usage? 3. Have you ever been concerned about another family members alcohol usage? 4. Do you have a history of illegal drug use or prescription abuse? 5. Have you or a family member ever been concerned about your illegal drug use or prescription drug abuse? 6. Have you ever been concerned about another family members illegal drug use or prescription drug abuse? 7. Do you smoke cigarettes or other tobacco products? LEGAL DATA Are there any legal cases pending? YES NO Briefly describe the nature of those cases: WHAT FEES ARE INVOLVED IN THE COUNSELING PROCESS? My standard fee is $ for an initial session, $85.00 for a 50 minute session and $ for a 25 minute session. (The actual cost to you may vary due to insurance and copays or a sliding scale agreement. If the client is using an EAP, the client will not be charged as long as their sessions are covered by the EAP) If a licensed therapist is filing out of network insurance on behalf of the client, clients are responsible for the agreed upon rate for all sessions at the time the session occurs and they are also responsible to notify the therapist when the deductible has been met and their fee would be reduced. If the client overpays, a credit or refund would be issued at their request. If a client has a change in insurance, it is their responsibility to notify their therapist and provide a copy of their new insurance card. It is my practice to charge $50.00 on a prorated basis for other professional services you may require, such as report writing, telephone conversations which last longer than 5 minutes, preparation of records or treatment summaries, or the time required to perform any other service which you may request of me. A minimum fee of $50.00 is charged for copies or records or reports and minimum of two weeks notice is required.

4 4 COURT RELATED FEES I have no forensic experience and being a master s level counselor or intern would generally not be considered an expert witness. If you become involved in litigation that requires my participation including but not limited to divorce, custody disputes, or cases involved in CPS or criminal activity, and due to the complexity and difficulty of legal involvement, I charge $150 per hour for preparation for and attendance at any legal proceedings. Also, a $1500 retainer will be required up front if a subpoena is issued or court appearances are requested. COUNSELING DETAILS Briefly describe your current difficulty: What are your goals you hope to achieve through counseling? Have you ever been to counseling before? YES NO Support/ Recovery Groups: YES NO If yes, identify counselor and the dates: Briefly explain the nature and outcome of that counseling: THERAPIST NOTES: Diagnostic Impressions: Initial Treatment Plan:

5 5 Confidentiality Information In general, the confidentiality of all communications between a client and a therapist is protected, and I can only release information about our work to others with your written permission. However, there are a number of exceptions including some legal proceedings. If I believe that a client presents a danger to him/herself or to someone else, I am required to take protective actions. If I believe that a child, an elderly person, or a disabled person is being abused, I must file a report with the appropriate state agency. Should such a situation occur, I will make every effort to fully discuss it with you before taking any action. Understand that confidentiality is not the same as statutory privilege. If I receive a legal subpoena or if you ve given permission for exchange of information for insurance purposes, details regarding our sessions may be disclosed. I will try and make every effort to contact you first should this occur. Please refer to the disclaimers on our Release of Confidential Information form. I may occasionally find it helpful to consult about a case with other professionals. In these consultations, I make every effort to avoid revealing the identity of my client. The consultant is, of course, also legally bound to keep the information confidential. Unless you object, I will not tell you about these consultations unless I feel that it is important to our work together. Marriage Counseling: If you are involved in marital counseling, confidentiality does not include your spouse and is left up to my discretion. Parents of Adolescents: If the client is a child or adolescent and is engaging in reckless behavior or persistent substance use, we will discuss the situation and I will give him/her the opportunity to inform their parent/guardian in my presence since this constitutes harm to self. Please understand that we will not betray confidences of parental defiance or rebellion that are not life threatening. We will make every effort to encourage the minor to be forthright with their guardians as transparency is a recognized dynamic of a healthy relationship. If the parent feels betrayed by our keeping of confidentiality, we encourage the family to schedule a family session to discuss this matter. Parent Consultations: Also, in counseling involving a minor child as the identified patient, the rights of confidentiality extend to them only. If you share information during a parent consultation that would impact their treatment or if the child is present, realize that either parent has access to the child s records and anything said by the other parent would not be considered confidential during a family session or parent consultation since they are not a counseling patient. Legal Issues: If at any time you involve Transitions Counseling as a company in legal proceedings including but not limited to requesting files for an attorney, having a subpoena issued by an attorney or court, requesting a deposition, or verbally or in writing threatening to name a staff member or the organization in a lawsuit, we will disclose general case information to our attorney in order to follow best legal and ethical practices when addressing these issues. RIGHTS & RESPONSIBLITIES Rights You have a right to be provided with professional and respectful care. You have a right to know your therapist s assessment of the problem, the recommended treatment, and resources available to help deal with your situation. You also have the right to refuse our suggestions. Responsibilities 1. To be honest, open, and willing to share your concerns 2. To ask questions when you don t understand or need clarification

6 6 3. To discuss any reservations you have about your treatment plan 4. To follow the agreed upon treatment plan 5. To report changes or unexpected events related to your problem 6. To keep appointments whenever possible or to call and cancel within 24 hours prior to your appointment. (see payment information you will be charged the entire session fee for appointments not cancelled with 24-hour notification) Remember, you are responsible for your thoughts, feelings, actions, and growth. We are here to help facilitate that growth to the best of our ability. PAYMENT INFORMATION The following information is provided to avoid any misunderstanding or disagreement concerning your payment for professional services. The fee for the initial 50-minute therapy session is $ The fee for all follow-up sessions is $ It is the same for individual, couple, or family therapy. Payment is expected at the time of service. As a courtesy, Transitions Counseling will file your insurance claims with your signed consent. Transitions Counseling charges for missed appointments. Transitions Counseling charges full fee for appointments that are not cancelled with 24-hour notification. Each of these payment requirements are discussed below. Insurance 1. If you have managed care or employee assistance through your employer or through a private policy, Transitions Counseling will file your insurance with your consent. Sign the insurance information sheet if you wish us to file as a courtesy to you. 2. Co-payments must be made at the time of service. 3. If you are seeing a provider that is in your managed care network (In Network), your fee will be the negotiated rate as stated in the contract between the network and your therapist. Deductibles amounts are due at the time of service. 4. If you are seeing a provider that is not in your managed care network (out of network), you are responsible for amounts your insurance does not pay up to $ for in the initial session and $85.00 for follow up sessions. 5. For clients using Employee Assistance (EAP), there is no charge for a set number of authorized sessions. 6. If you authorize this office to file insurance by your signed consent, we will do so, but you must understand that you insurance coverage is an agreement between you and your insurer. It is your responsibility to remit payment for charges not covered by your claim and insure your carried remit payment. If a problem occurs with your claim, you will be required to make payment or establish a written financial payment plan with our office until your insurance problem is resolved. Financial Payment Arrangements There is a $35.00 service charge for insufficient checks. Insufficient checks are deposited twice. If the second deposit is also insufficient there will be an additional $35.00 service charge. After the second insufficient deposit we will only accept cash for payments for services rendered until the insufficient check and service charges are paid in full.

7 7 APPOINTMENT CANCELLATION POLICY Twenty-four hour (24) notification is an expected courtesy to the therapist who is reserving time for you and to other clients who are waiting to schedule appointments. You must give 24-hour advance notification for cancelled appointments. The advance notice is standard in our profession. If you miss an appointment without 24-hour notification, you will be charged the entire session fee after one warning (If using insurance- the amount is the contracted rate). If you do not notify us 24-hours in advance when canceling an appointment, you will be charged the entire session fee. Insurance plans rarely pay for such charges. 1. You will receive written notification of the missed appointment and a bill for the agreed upon amount within a few days of the previously scheduled appointment time. If you think there is an error, contact the office immediately. 2. You must pay for the missed appointment charge in full at your next scheduled visit OR make a partial payment and arrange a payment plan. 3. Payments must be made in addition to other co-pay amounts or deductibles that may be due on subsequent visits. 4. Payment must be timely or I cannot continue to schedule appointments. CAN I SEE MY RECORDS Both law and the standards of my profession require that I keep appropriate treatment records. You are entitled to receive a copy of the records. Because these are professional records, they can be misinterpreted and/or upsetting. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. Most often a summary is supplied because handwriting and notes are for my use in treatment and comply with an information request including a minimum fee of $50 and must give two weeks notice to allow for these records to be prepared. Files are shredded six years after the date of our final session or in compliance with State Board and HIPAA guidelines. GIFTS Please understand due to ethical standards set forth by the state of Texas and my professional associates, it is my policy not to receive gifts. PERMISSION TO CONTACT YOU BY From time to time we may contact you via about appointment times with your permission. We will always be discreet; the name of this office will not be used in our correspondence. For example, we would say, Reminding you of your appointment with (therapist name) on Tuesday, March 17th at 2:00pm. Please call or REPLY to confirm, cancel, or reschedule. To assure absolute confidentiality, we will correspond via ONLY about appointment dates and times. I give my permission to contact via . YES NO My address is: Optional second

8 8 SIGNATURE FOR PROFESSIONAL SERVICES AGREEMENT I do voluntarily agree to participate in the assessment and counseling as offered by Transitions Counseling Services. I am aware that treatment often involves family therapy or education which will be recommended if the therapist deems it important to the healing process. I acknowledge that no guarantees have been made to me regarding the outcome of my therapy. I understand my rights and responsibilities as stated in this document. I consent to the use of my personal health information for routine practices for treatment, payment, and health care operations according to the laws of the State of Texas and the Federal government as outlined in the Confidentiality Section of this document and discussed in detail in the Confidentiality Policy and Privacy Practices. I have read and agreed to the payment information as stated in this document. I understand I will be charged for appointments that are not cancelled within 24-hours or for appointments I miss altogether. By my signature below, I accept all the terms and conditions as herein stated. Client s Name: Client s Signature: Date: *Parent/Guardian s Signature Date: *(required if client is 17 or under-in some cases the therapist may require legal documentation of guardianship of children 17 or under)