Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

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1 Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name of Spouse: Years Married: Spouse's Age: Occupation: Employer: Emergency contact name: Relationship to client: Highest level of Education: Phone number: Present Church affiliation: Present Primary Care Physician: Address of Physician: Date of last medical exam: How would you rate your health?

2 Are you presently taking any medication? If yes, what kind? Any health-related concerns at present: Who referred you to us? Have you ever had counseling or spiritual direction before? If yes, list names and dates seen: 1 2 What crisis or need led you to seek counseling or spiritual direction at this time? In your own words, describe what you hope to accomplish/receive through this process Check the services you are requesting: Spiritual Direction ( ) Counseling ( ) Prayer ( ) Yoga ( ) Massage Therapy ( ) Are you interested in receiving information on our services for any of the following? Cancer Support ( ) Grief Support ( ) Adult Depression ( ) Marriage Support ( ) Parenting, Teens, School Age, Toddlers & infants ( ) Stress Management ( ) Tutoring Services ( )

3 Is there anything else that you would like us to know about you in order to make the best provider placement? Do you prefer a Male Provider? ( ) or Female Provider? ( ) No Preference ( ) Best days and times for you to meet:

4 COUNSELING: $70 per 50 minute appointment. FAMILY / MARITAL THERAPY: $100 for up to a 90 minute appointment SPIRITUAL DIRECTION: $50 per hour ENNEAGRAM: $10 for test, $70 for up to 2 hour analysis MASSAGE: $65 per hour THERAPEUTIC MENTORING: $45 per hour WORKSHOPS: vary depending on topic PAYMENT At The Well, our goal is to provide you with high quality, efficient and compassionate care. Our staff members go to great lengths to verify insurance information before your appointment if applicable or to inform you of your payment responsibility if you are paying a fee for service. FEE FOR SERVICE Payment is required on the date of service. If a Receptionist is not available on this date, payment should be made to the Provider you are seeing upon arrival. You will not be permitted to schedule any more appointments if your balance is not paid in full. Please feel free to pay with cash, check or credit card. INSURANCE PLANS-There are many details involved in the process of payment for the services you receive. In order for this process to flow smoothly, it is essential that you understand what information must be shared between you, us and your health insurance carrier and what each party s responsibilities are in the process. We ask that patients be actively involved in understanding ANY medical coverage plan that you carry.

5 Prior to scheduling your first appointment, you must call your health insurance company and ask two things: 1. What are my mental health benefits? Most insurances will authorize 6-12 visits at a time with the same co-pay you pay when you see your medical doctor. Be sure to take note of any deductible. Please be advised and aware of your plan benefits before coming in. 2. Do I need a referral and authorization number? Any patient that has an insurance that we accept is required to call the insurance company prior to scheduling your first appointment to obtain an authorization number. This is necessary for visits to be covered. The authorization number will be given to you over the phone and you will need to write it down and bring it with you to the first appointment. The number to call is on the back of your insurance card and is usually identified as Behavioral Health with a separate 800 number than your medical member services number. Any information given to you by your insurance carrier should be presented to the office as soon as possible to avoid any claim/payment issues. Additionally, copays are due at the time of visit and should be presented upon arrival to either the Receptionist or Provider that you are seeing. OUTSTANDING BALANCE: You are responsible for paying any outstanding balances that insurance companies have not covered. Once we receive an Explanation of Benefits from your insurance company, we may need to adjust your balance based on the contracted rate. If you discontinue treatment, you are still responsible for outstanding balances on your account. Please be advised that if your clinician does not receive payment for services, he/she may discontinue your treatment. CANCELLATIONS / NO SHOWS: You will be charged in full for a missed appointment or cancellation with less than 1 business day notice, i.e. Monday appointments need to be cancelled by the preceding Friday. This will be applied to your balance. RETURNED CHECK: In the event that a check is returned, you will be charged a $25 fee, in addition to any bank fees. In the event that a second check is returned, you will be charged the same fees and have to arrange another method of payment.

6 PHONE CALLS: Typically there is no charge for phone calls. However, phone calls that are extended or constitute therapy may be billed at our standard hourly rate, depending on the circumstances. Client Signature Date

7 Your therapist or spiritual director is legally bound to maintain confidentiality regarding material you discuss with him or her. Such information cannot be released to any other party without your written consent. In such cases, you will be asked to complete an Authorization Form. There are some instances, however, when information may need to be released without your verbal or written permission. These situations include: If your therapist or spiritual director determines that you are at serious risk to harm yourself or others, family members, or if necessary, the police will be notified to insure the safety of yourself and others. If your therapist or spiritual director believes that a child, a handicapped person, or an elderly person in your care is suffering injury due to abuse or neglect. In that case, appropriate agencies such as the Department of Child and Family Services will be notified. If an insurance company requires the therapist to provide information regarding diagnosis or the course of treatment, in order to provide payment for ongoing services. The Well s Notice of Privacy Practices document explains this issue in detail, including your rights as a client to know what private health information is communicated to the insurance company. If a judge orders your therapist s or spiritual director s records of his or her sessions with you. This may occur in cases involving such issues as sexual assault, child custody, or disability determination (Worker s Compensation). If compelled to release such data, your therapist or spiritual director will attempt to reveal only such information as is pertinent to the court order, and will otherwise protect the confidentiality of your sessions as much as possible. If you have any questions or reservations about the policy in regard to confidentiality, then the policy should be discussed before signing below. By signing below you are accepting the confidentiality policy, its limits and exceptions. Client Signature Date

8 We are required by federal law known as the Health Insurance Portability and Accountability ACT (HIPPA) and by Massachusetts law to maintain the privacy of your medical and health information, also referred to as Protective Health Information (PHI). Our Notice of Privacy Rights and Practices describes how information about you may be used and disclosed and how you can obtain access to this information. Please review it carefully. When we use or disclose your PHI, we are required to abide by the terms of the notice (or any other notice in effect at the time of the use or disclosure). You have the right to request in writing that we restrict how PHI about you is used or disclosed. We are not required to agree with this restriction, but if we do, you will receive written confirmation of our agreement to which we will be bound. Your signature below constitutes your acknowledgment that you received a copy of our Notice of Privacy Rights and Practices and your consent under Massachusetts law to the kinds of uses and disclosures of PHI mentioned in this notice. I am a client of, A Center for Hope and Healing Inc. ( ). I hereby acknowledge receipt of 's Notice of Privacy Practices. Name [please print]: Signature: Date: OR I am a parent or legal guardian of [client name]. I hereby acknowledge receipt of client. Notice of Privacy Practices with respect to the Name (please print): Relationship to client: Parent Legal Guardian Signature: Date:

9 Our Notice of Privacy Practices provides information about how we may use and disclose Protected Health Information about you. The Notice contains a client Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how Protected Health Information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of Protected Health Information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Well provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The client understands that: Protected Health Information may be disclosed or used for treatment, payment or health care operations. The Practice has a Notice of Privacy Practices and that the client has the opportunity to review this Notice. The Practice reserves the right to change the Notice of Privacy Policies. The client has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The client may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition treatment upon the execution of this Consent. This Consent was signed by: Printed Name Client or Representative Relationship to client (if other than client): Date: In front of: (witness name)

10 ** Client Copy to keep ** This summary of our privacy practices is contains a condensed version of our Notice of Privacy Practices. Our full-length Notice follows this summary. This information is made available on request by a client Date of Last Revision:February 2011 Effective Date: Immediately THIS NOTICE DESCRIBES HOW PERSONAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We understand that your Personal Health Information is private to you, and we are committed to protecting the information about you. As our client, we create medical records about your health, our care for you, and the services and/or items we provide to you as our client. By law, we are required to make sure that your Protected Health Information is kept private. How will we use or disclose your information? Here are a few examples (for more detail please refer to the Notice of Privacy Practices that follows this summary): When there is a serious threat to your health and safety or the health and safety of another individual or the public. We only share information with a person or organization that is able to help prevent or reduce a threat. Some lawsuits and legal or court proceedings If a law enforcement official requires us to do so. For Workman's Compensation and similar benefit programs. To ensure payment for services rendered. If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint. You have certain rights regarding the information we maintain about you. These rights include: The right to inspect and copy The right to request restrictions The right to amend The right to a paper copy of this notice The right to an accounting of disclosures The right to request confidential communications