| Counseling Intake Forms ~ Client Information ~ Financial and Informed Consent |
Client Name ________________________________________________ HM Tel____________________________ Cell/wrk________________________ Address_________________________________________________________________________________________________ zip _________________ DOB ________________________________ Age _________ M ______ F______ Client's SS# _______________________________________________ Is it OK to leave messages at: Home ______ Cell _____ work __________ Email address: _________________________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 2.COMPLETE FOR MINOR CLIENTS ONLY OTHER WISE GO TO # 3 (include Birth parents/ adopted parents of client) Mother ____________________________________________ DOB_______________________ Tel _________________________________________ Father ____________________________________________ DOB_______________________ Tel _________________________________________ Who has Legal custody? _____________________________________________________________________________________________________ Who has Physical custody ? __________________________________________________________________________________________________ 2A. IMPORTANT - If there is a Legal custody agreement for a minor client a copy is required before counseling can begin. THE SIGNATURE OF ALL LEGAL CUSTODIANS OF A MINOR CHILD WILL BE REQUIRED BEFORE COUNSELING MAY BEGIN. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 3. Emergency Contact _____________________________________Relationship __________________________ Tel: ________________________ 4.Primary Care Physician ____________________________________ Address_________________________________________________________ Tel ________________________________________ Do you want Counselor to Coordinate services with Doctor? Yes___ No___ If yes Doctor to contact NAME________________________________________________________________ Tel: _________________________________ Fax____________________________________ Address __________________________________________________________________________ 5. Does Client have Medicaid? No _______ Yes ______ Medicaid #________________________________________________ 5A. Who Referred You? NAME __________________________________________________________________ Tel# __________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 6. INSURANCE INFO: Does Client have more than one insurance? No ___________ yes __________ IF YES COMPLETE BOTH #7 AND 8 BELOW Contact your insurance companies & obtain the information in 7A & 7B (some require appointment dates prior to authorization) 7. PRIMARY Insurance Co _________________________________________________Tel_________________________ GRP# _________________ ID# ________________________________________________________ 7A. Co-pay $___________________ Deductible $ _______________ How much of your deductible has been met for the year ? ____________________ 7B Prior Cert # _________________________________ # sessions apprv'd _____________ Beg Date ______________ End Date _______________ 7C. If Policy Holder someone other than client complete following: 7E. Insured Name ____________________________________________________ DOB: ______________________ SS# _________________________________ Relationship to client _____________________________________ If different than client: HM address ___________________________________________________________ HM Tel ____________________________ Cell # _____________________________________ Insured Employer _____________________________________ # years with employer _______ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Contact your insurance companies & obtain the information in 8A & 8B (some require appointment dates) 8. 2nd Insurance Co ______________________________________________________ Tel______________________GRP# _________________ ID# _______________________________________________________ 8A Co-pay $__________________ Deductible $ _______________________ How much of your deductible has been met for the year ? ____________________ 8B Prior Cert # ___________________________ # sessions apprv'd ___________________ Beg Date ______________ End Date _______________ 8C. If Policy Holder someone other than client complete following: 8E. Insured Name ____________________________________________________ DOB: _____________________ SS# _______________________________________ Relationship to client _______________________________ If Diff than client: HM address _______________________________________________________________ HM Tel __________________________ Cell # ______________________________________ Employer _____________________________________# years with employer _____________ Release of Information With my signature I as the client or guardian authorize any holder of medical and other information about me or my child as it pertains to my health care; to release all needed information to determine benefits payable, process my claims, or to collect the fees for counseling. Assignment of Counseling Benefits With my signature I hereby assign and request that all third party payments be made directly to Barbara Becherer. Future Authorizations for Sessions With my signature I authorize Barbara Becherer, LPC to complete the necessary paper work to request additional sessions from my health insurance or third party payer, when additional sessions are needed. Acknowledgement of Receipt of Notice of Privacy Practices You are hereby notified that you may review the NOTICE OF PRIVACY PRACTICES, which explain when, where and why my confidential health information might be used or shared. I understand that Barbara Becherer, LPC may share my confidential health information with others in order to treat me, in order to arrange for payment of my bill and for issues that concern Barbara Becherer’s operations and responsibilities. _______ I choose NOT to receive a copy of the Notice of privacy practices _______ I choose TO receive a copy of the Notice of privacy practices Client Rights • Knowledge of counselor’s education and training • To be fully informed of the conditions under which services will be provided • Discuss your counseling with the persons that you choose • Request information regarding a form of counseling used in your treatment • Review your file and or have summaries of your file released to other professionals with your written request • End counseling at any time, hopefully after you have discussed your reasons with this counselor, unless of course you are mandated to attend counseling. By ending counseling without discussing it keeps someone else from receiving needed counseling services • The right to ask questions about your counseling Client’s Responsibilities and Agreements PLEASE READ CAREFULLY agree to the following: • Arrive on time for my appointments • That I am responsible to pay for sessions that are not covered by a third party • Notify Barbara of any changes in Name, address, tel #, insurance company and or benefits • I will work with Barbara to develop a counseling plan and I will follow that plan • All Information provided is true and accurate • Give Barbara a 24 hour notice for appointment that I need to cancel, with the only exception being a true emergency • I will pay a $30 fee for missed sessions that I have not given a 24 hour cancellation notice • I understand that 2 missed session without 24 hours notice will be grounds for Barbara to discontinue my counseling • I will keep my calls to Barbara Becherer, LPC between 9 am – 6 pm unless there is a true emergency. FEES FOR SERVICES • All co pays and deductibles are due at the beginning of each session • Fees for services: Session fees are : Intake $150, Office $90, outside office $150 - Letters and reports $35 per page; copies of files will be provided with a written request and at the going rate to be paid for in advance • All telephone calls for more than 15 minutes in length will be charged to you at the rate of $90 per hours and billed in 15 minute increments. • Unpaid fees associated with counseling may be turned over for collection and client will be responsible for fees associated with that collection. There will be a fee of $25 for each returned check. CONFIDENTIALITY POLICY Personal information shared with Barbara Becherer, LPC is confidential and all reasonable precautions will be taken to maintain confidentiality while you are in my care. There will be no recording of the session by either party unless requested in writing. There are, however, some limitations to confidentiality that may require the disclosure of information as follows: 1. Abuse or neglect – Missouri state law requires all therapists to report suspected physical or sexual abuse, or neglect of children or elderly adults. 2. Threats – We report serious threats of physical harm to self or others. 3. Education, Research and Peer consultations – For the purpose of professional supervision, research, and peer consultation cases are reviewed and discussed. There may be times that sessions may be filmed or pictures or may be taken . 4. Third Party Payment – When you use a 3rd party payments, like insurance Barbara Becherer, LPC, will be required to disclose specific clinical information (i.e. Diagnosis) to the insurance company in order for you to receive payment. 5. Court order – A judge in a court of law may require the disclosure of specific information pertinent to a case before the court. 6. Written Permission - If you give me written permission to release information to another party. 7. Criminal Activities - If you have revealed criminal activity or information CHILD / PARENT CONFIDENTIALITY Barbara Becherer, LPC strongly encourages parent participation in all phases of child treatment. At the same time, specific details of the information provided by children is not shared with parents in an effort to encourage children to be as honest and forthcoming as possible, and to maintain an emotionally safe environment for them. Note that we do not discourage children from sharing information with their parents but we ask that instead of asking your child for information that you allow your child to volunteer the amount and kinds of information that they are ready to share. I usually encourage them to do so when they are ready as part of the therapeutic process. During my counseling I understand that Barbara Becherer, LPC makes no guarantees as to the results of treatment or evaluations. The counseling process is one in which you seek to understand yourself, your feelings more clearly and perhaps, to make some changes in your life as a result of what you have learned. My role in counseling is a facilitator for your self understanding and or changes. You will aid yourself in this process by being honest and open with this counselor. Occasionally Barbara may say things that are hard for you to hear. Because the counseling process includes exploration of aspects of yourself that have been previously hidden you may be surprised by the intensity of new emotions. Be assured this is part of the healing process which may occur during counseling. PLEASE READ CAREFULLY BEFORE SIGNING Please be aware that my policy is to not testify or get involved in custody or other court issues due to the concerns of damaging the therapeutic relationship. I do not participate in custody evaluations and if a custody situation arises you will be referred to your insurance company to obtain a professional that specializes in custody evaluations. Any subpoena to court is automatic grounds for termination of services Agreement 1. I hereby agree not to subpoena Barbara Becherer, LPC for testimony or ask for copies of my records or my child’s records or evaluations from Barbara Becherer, LPC. 2. I will not request access to any of Barbara Becherer’s documents or records pertaining to my child, but I will instead meet with Barbara to discuss my child’s progress. 3. I am the Financially responsible party and I have legal custody The undersigned certifies that I have read the statements on page 1 through 3 of this document and that I agree and accept the terms herein. I agree that I am financially responsible for all fees that are not covered by a third party. I agree that I am financially responsible for the fees required to collect unpaid counseling fees. There are certain restrictions and requirements that are important for you to read before signing this form. Please print a copy of this form for your files. Signature client/guardian __________________________________________________ Date _______________________ Signature witness _______________________________________________________ Date _______________________ |
| Print and complete this form and Client History form and take with you to your first Appointment. If the client is ages 3 - 17 years old also complete the youth Assessment Form If you do not want to print in color set your printer's color to black or gray scale |
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