INTAKE FORM
General Information
Client:
Name: ________________________________ Date:________________
Social Security Number: _________________ Date of Birth: _____________
Parent/Guardian’s Name (if applicable):______________________________________________________
Home Address:
Street: ______________________________________________ Apt. #: _____
City: ____________________________ State: ___________ Zip Code: _______
Phone Number_________________________________ (cell / work / home)
Alternate Phone Number: _________________________ (cell / work / home)
Emergency Contact:
*Please enter an emergency contact who is not living with you.
Name: _________________________________________________________
Phone Number: ________________________________ (cell / work / home)
Relationship to Client: ___________________________________________
Address: _______________________________________________________
Miscellaneous Information
Referred by: _____________________________________________________
Phone Number: ___________________
May Capital Counseling Services, LLC send a thank you note to the person or agency who referred you? Please circle: YES or NO
Referral’s Address:
Street: _____________________________________ Apt./Suite #: _______
City: __________________________ State: ___________ Zip Code: _______
Reason for seeking therapy at this time: ________________________________
Insurance Information
Policy Holder:
Name: ______________________________ Date of Birth: ____________
Social Security Number: ______________________
Employer: ______________________________________________________
Client’s Work Address: ______________________________________________
Group Number: _____________________
Authorization Number (if applicable): ___________________________________
Insurance Phone Number: ___________________________________________
Insurance Claim Billing Address: _______________________________________
Medical Information
Please list any medications you are currently taking and the physician(s) who prescribes and monitors the medication(s).
Medication Name: _________________________________________________
Medical Condition:________________________________________________
Dose: ____________________ Frequency: __________________
Start Date: _________________
Physician’s Name: _________________________________________________
Phone Number: _____________________
Please list any previous or current mental health or substance abuse treatment you’ve received. _______________________________________________________
Please list any previous or other current medical conditions. ___________________
POLICIES & PROCEDURES
Please place your initials to the left of each paragraph below to indicate that you understand and agree with each policy/procedure.
____ Payment: You, herein known as Client, are responsible for all costs of services and for understanding your insurance benefits prior to receiving treatment from Capital Counseling Services, LLC and its associates, herein known as CCS.
____ Individual psychotherapy is charged at a rate of $___ per session (standard rate); Family and couple’s psychotherapy is charged at a rate of $___ per session. All appointments are forty-five (45) minutes in duration, unless other arrangements are made in advance. Client agrees to provide initial payment with a personal check or provide a voided/cancelled check to be held on file. Clients who are experiencing financial strain may qualify for a reduced fee. This is in the provider’s discretion. All outstanding balances must be paid prior to scheduling Client’s next appointment unless other arrangements are made in advance. Payment, including but not limited to, co-payments, deductibles, co-insurance, etc. is required at the beginning of each appointment. By initially this section or signing below, Client acknowledges that it is his/her responsibility to understand fully all aspects of his/her insurance coverage prior to receiving services from CCS. An additional $___ fee will be charged for each returned check.
____ Written assessments and treatment related letters, etc. that are not related to in-network insurance payment are also billed at the standard fee. Fifty percent (50%) of the total estimated payment for written assessments or completion of forms, etc. is required at the time of the request. The remaining payment is due at the next appointment when the final product is provided to Client.
____ Any appearances in court shall be billed to Client at a rate of $___ per day or any portion thereof. Preparation for court proceedings, providing depositions, attending meetings, and/or having discussions with attorneys, even if CCS is called to testify by another party, whether or not associated with collections, will be charged to Client on a pro-rata basis at the applicable session rate, as provided above, in addition to any outstanding claims. The per mile fee for transportation to and from any such proceeding or meetings shall be billed at $0.50. Any additional charge, such as parking and/or tolls, shall be billed to client at actual cost.
____ Client related phone calls under fifteen (15) minutes are not charged. Unscheduled telephonic counseling sessions that are fifteen (15) minutes or more in duration are prorated according to the standard fee noted above. Scheduled telephonic counseling sessions are available; however, payment of the standard fee is required when the appointment is scheduled, as these appointments are not covered by insurance plans.
____ Insurance: CCS participates in some insurance plans and employee assistance programs (EAP) and will bill these companies directly. It is Client’s responsibility to contact his/her insurance company to clarify what services his/her policy covers and request a pre-authorization, if one is needed, prior to his/her first appointment. If CCS bills your insurance company directly, you are responsible to pay all deductibles, co-payments and/or co-insurance at the beginning of each session. All outstanding balances must be paid prior to scheduling your next appointment unless other arrangements have been made in advance. Billing information is transmitted via fax and postal service to/from your insurance company.
____ Electronic Technology: There are two (2) occasions when CCS will utilize electronic technology. CCS needs the client’s permission to use these technologies. By initialing the following two subsections Client is giving CCS permission to utilize these technologies. If Client does not initial the following two subsections he/she is not granting CCS permission.
____ Client gives CCS permission to fax information to a person or insurance company for the purpose of billing insurance for services rendered. (If Client chooses not to initial this section CCS will not be able to bill Client’s insurance.)
____ Client gives CCS permission to contact him/her via cell phone or personal data assistant (PDA). (If Client does not initial this section there may be a delay in returning Client’s calls.)
____ Managed Care: Some insurance companies use managed care systems. In order to access treatment, managed care companies may require written treatment plans to authorize additional sessions. Only information pertinent to the request for additional sessions is provided. (See the “Confidentiality” and “Payment” sections listed below and above, respectively.) Client agrees and allows CCS to provide these treatment plans.
____ Cancellations/No-Shows/Lateness: When it is necessary to cancel an appointment, Client shall provide not less than full forty-eight (48) hours notice. Canceled/sessions without full notice will be billed at the applicable service rate, regardless of insurance reimbursement rates. For example, if Client cancels a couple’s therapy session he/she will be billed according to the couple’s therapy rate specified above. Similarly, if Client does not appear for an individual therapy session (“no show”) then he/she will be billed according to the charge for that service. (See the “Payment” section above.) Client agrees that verbal agreements with CCS do not modify this section or any part of this contract/policy and procedures. Canceled appointments cannot be billed to Client’s insurance company. Exceptions for cancellations are rarely accepted, however the following emergencies are considered:
- Severe illness of yourself or your child requiring immediate or emergency medical/behavioral health care;
- Sudden death of a family member; or
- Inclement weather (ex: severe snow storm leading to closure of public agencies in the immediate office area)
If Client will be late fifteen (15) minutes or more for a scheduled appointment, Client shall contact the provider. If no call is received then the appointment will not be guaranteed; Client will be charged regardless of insurance copayment or reimbursement rates. (See “Payment” in the section above.) In the event Client misses his/her standing appointment without notification (no-show) then future scheduled appointments will also be canceled. In this case please contact CCS within the following twenty-four (24) hours to reschedule.
____ Emergencies: CCS shall only be reached via cell phone/PDA (571-344-5926); however, in the event of any emergency Client agrees to call ‘911’ or shall go directly to the nearest emergency room or hospital.
____ Confidentiality: Information revealed by Client during treatment is confidential and cannot be shared with anyone else without Client’s prior written consent. However, Client should be aware there are some exceptions:
- According to State and Federal laws, if a disclosure is made regarding child or vulnerable adult abuse or neglect, CCS must report the abuse/neglect to the appropriate authorities. Also, if Client demonstrates or expresses imminent danger to or severe inability to care for her/himself or another dependent person, CCS must act to avert that danger;
- In rare situations, clinical records and/or a therapist’s testimony may be subpoenaed by a court.
- As part of the counseling profession, CCS engages in clinical supervision. In accordance with ethical standards, CCS will make every reasonable effort to maintain confidentiality by withholding identifying information;
- Managed care companies may require that written treatment plans be filed for review by their employees for authorization of services; and/or
- In case of national security.
In all cases, reasonable steps are taken, whenever possible, to protect Client’s privacy. That is, only information relevant to the situation is disclosed. Every effort will be made to inform Client if an exception occurs.
____ Consent for Treatment: By initialing this section and participating in scheduled appointments Client is consenting for treatment. This may consist of various modalities including individual or couples counseling, group therapy and/or family therapy with the goal of stabilizing current stressors and associated symptoms. As treatment progresses and difficult issues are discussed levels of stress and tension may also rise. Likewise, the benefits of treatment may include improved levels of functioning, self-confidence and self-esteem, etc. It is important for Client and CCS to work together in managing these ups and downs. In addition, continued treatment is Client’s decision. However, CCS may make recommendations for ongoing treatment based upon Client’s progress. It is suggested that one final session be allotted to discuss any pending issues. If Client cancels or misses a scheduled appointment; does not contact CCS for thirty (30) or more consecutive calendar days; and/or does not respond within five (5) calendar days to CCS’ attempts to make contact it is understood that Client terminated treatment against medical advice.
____ Unpaid Claims: By initialing this section Client acknowledges that CCS shall take legal action on any and all outstanding claims unless some payment agreement is negotiated and met. This includes, but is not limited to, forwarding claims/billing information to collection agencies, attorneys, and/or the appropriate courts (Small Claims Court), etc. as well as credit bureaus, banking institutions, Client’s employer(s), etc. to obtain payment. Unpaid/outstanding claims are billing statements that are overdue for thirty (30) or more consecutive calendar days after the statement is issued. Every attempt will be made to first process these statements by your insurance company, if applicable, for initial payment.
____ Client further agrees to permit CCS to add a monthly interest rate of five percent (5%) to all outstanding claims starting on the thirty-first (31) day from the billing statement in which the date of service(s) initially appear. Client agrees to pay this monthly interest rate and understands that these charges will be added to the principle balance due until payment is received in full.
____ Additionally, by signing this section Client agrees to pay for all fees associated with the collection of overdue sums. This includes, but is not limited to, reasonable legal/attorney fees, court attendance as aforesaid, court fees for filing, process server, mileage, parking, postage, all out-of-pocket expenses, as well as time expended by CCS charged at the applicable session rate. These fees will be added to the principal balance.
NOTICE OF PRIVACY PRACTICES
This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
HIPAA
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by Capital Counseling Services, LLC or their affiliates, collectively known herein as CCS, I or Agency, in any form are kept properly confidential. This act gives you certain rights and control regarding how your health information is used.
Honoring your privacy
Your health record contains personal information about you and your health. Except in the specific instances mentioned below, CCS does not release identifying health information (called protected health information or PHI) about you without your specific written authorization. (Also refer to the “Policy and Procedure” form for additional information.)
Use and disclosure of health information
- Treatment: If CCS needs to communicate with others about your treatment, your prior written permission will be obtained. In most instances, the purpose of this communication is to enable me to provide or coordinate your treatment. This can include consultation with physicians, other clinicians or consultants. There are some very circumscribed situations as explained in the “Required or Permitted by Law” section of this document in which your written permission for CCS to communicate with other parties is not required. (Also refer to “Required or permitted by law …”section for additional information.)
- Payment: CCS may use and disclose PHI so that I can receive payment for the treatment provided to you. This will only be done with your authorization. Examples of payment related activities include determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, or reviewing services provided to you to determine medical necessity. The type of information usually requested by insurance companies pertains to your diagnosis, symptoms, current functioning, treatment plan, response to treatment, etc. I will, at your request, discuss what information I am sharing with your insurer and allow you to review this information prior to it being submitted. If you request that this information not be shared with your insurer, treatment may be arranged on a self-pay basis.
- Health Care Operations: At times, I will have to contact you regarding your treatment, scheduling of appointments, billing and other matters. It is your responsibility to inform me which methods you prefer to maintain your privacy. For example, if you do not want to be contacted at work please inform me of this fact. Or, if you do not want me to leave my name on a family voice mail message system. I attempt to conduct these communications with a respect for your privacy, but you will need to inform me of special concerns you have regarding such matters.
Also, I share information about my clients with professional colleagues for the purpose of facilitating your treatment, fostering my own professional development or helping to train other colleagues. In doing so, I am careful to conceal the identity of the client. Such non-identifying disclosures are not formally considered “protected” information.
Revocation of Authorization
You may revoke an authorization you have given for release of your personal health information at any time provided it is done in writing. You may not revoke authorizations to the extent that (1) I have already taken actions relying on your original authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
Required or permitted by law: Uses & disclosures of PHI from mental health records not requiring consent
- Right to Access, Inspect and Copy: You may request access to your protected health information and billing records. Requests for access must be made in writing. I may charge a reasonable, cost-based fee for copies.
- Right to Amend: If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information. Please note that I am not required to make such amendments.
- Right to Accounting Disclosures: You generally have the right to receive an accounting of the disclosures of your PHI made by me after April 14 of the current calendar year.
- Right to Request Restrictions: You have the right to reasonable requests to receive confidential communications of protected health information from me by alternative means or at alternative locations. For example, you may wish to receive phone calls from me at home rather than at work or you may prefer to have bills sent to a particular location.
- Right to a Copy of this Notice: A copy of this document will be provided upon request.
This document is effective as of February 1, 2005 and I am required to abide by the terms of the Notice of Privacy Practices currently in effect. I reserve the right to change the terms of this Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that I maintain. I will provide you with a written copy in the case of a revised document.
Revised/Updated August 13, 2010
