Comprehensive Counseling & Consulting, LLC

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1 Welcome to Comprehensive Counseling & Consulting, LLC! We look forward to working with you! Below you will find the intake packet which may be printed out and completed before your first appointment. We will review the paperwork during your first session and will answer any questions you may have at that time. Please allow 1-1 ½ hours for your first appointment. Subsequent appointments will last approximately 45 minutes. We are conveniently located in Bessemer, Michigan. INSURANCE: We accept many major insurances. It is the responsibility of each patient to know and understand their coverage. Please call the 800 number on the back of your insurance card to verify that we are on the panel of providers for your plan and that your plan allows MSW s (Master Social Workers) to bill. DIRECTIONS: From Wakefield: Follow U.S. 2 towards Bessemer. After you pass the C & M Mobil Gas Station, you will turn right on Beecher Street (two streets after the Mobil Station and before you get to the Citgo Station). Comprehensive Counseling & Consulting, LLC is the first building on the right hand side. It is a two story building with gray siding and green shutters. There is a company sign right above the mail box. From Ironwood: Follow U.S. 2 towards Bessemer. After you pass the Citgo Gas Station, you will turn left on Beecher Street (two streets after the Citgo Station and before you get to the Mobil Station). Comprehensive Counseling & Consulting, LLC is the first building on the right hand side. It is a two story building with gray siding and green shutters. There is a company sign right above the mail box. If you have any questions prior to your appointment, please do not hesitate to contact us at (906) ! Wishing you well~ Wendy Young, LMSW, BCD Clinical Director

2 Client Registration Date Referred by Patient Name Phone Number Cell Phone Address City State Zip Birthdate Age Social Security Number Occupation Physician Employer Work Phone Church Affiliation My initials indicate that I approve a confirmation letter to my referral source may be sent Date (I understand that o other information may be sent without a fully signed release of information.) INFORMATION ABOUT SPOUSE OR PARENT Name SS # Address City State Zip Code Phone Birthdate Employer Work Phone INSURANCE INFORMATION Primary Insurance I.D., Group and Plan Numbers Mailing Address

3 NO SHOW POLICY A missed appointment is a loss to everyone. We ask for a minimum of a 24-hour notice if you are unable to keep your appointment. No shows will be charged $25.00, which is payable prior to scheduling the next appointment. Two consecutive no shows shall be grounds for termination of therapy. Your therapist will discuss this with you, should it become a problem. Client Signature Date Therapist Signature Date

4 101 North Beecher Street Bessemer, MI (906) Treatment Contract and Informed Consent I am entering into this treatment contract with the understanding that I may discuss any questions I have regarding my treatment and treatment goals with my therapist. I agree to obtain treatment at Comprehensive Counseling & Consulting, LLC. I understand the risks, benefits, relevant costs, time frame of services and alternatives of exploring psychotherapy elsewhere. I have considered the possible consequences to myself of deciding not to engage in treatment. I fully realize the limits of the services being offered to me, my child, or my family. Successful treatment depends upon my willingness to engage myself in the therapeutic process as facilitated by my therapist, to find the solutions to my problems that are in keeping with my own values and beliefs. I am committed to this process. I understand that I can withdraw from treatment at any time, but that it would be in my best interests to let my therapist know when I believe I am ready to terminate treatment. Signed Date Witness Date

5 Notice of Privacy Practices - Brief Version THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCOLSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Our commitment to your privacy: Our practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. We also are required by law to keep your information private. These laws are complicated, but we must give you this important information. This is a shorter version of the full, legally required NPP and you may have a copy of this to read and refer to it for more information. However, we cannot cover all possible situations, so please talk to our Privacy Officer (see the end of this handout) about any questions or problems. We will use the information about your health, which we get from you or from others mainly to provide you with the treatment, to arrange payment for our services, and for some other business activities, which are called, in the law, health care operations. After you have read this NPP, we will ask you to sign a consent form to let us use and share your information. If you do not consent and sign this form, we cannot treat you. If we or you want to use or disclose (send, share, release) your information for any other purposes, we will discuss this with you and ask you to sign a release to allow for this. Of course we will keep your health information private, but there are some times when the laws require us to use or share it. For example: 1. When there is a serious threat to you health and safety the health and safety of another individual or the public We will only share information with a person or organization that is able to help prevent or reduce the threat. 2. Some lawsuits and legal or court proceedings. 3. If a law enforcement official requires us to do so. 4. For Worker s Compensation and similar benefit programs. There are some other situations like these, which don t happen very often. They are described in the longer version of the NPP.

6 Your rights regarding your health information: 1. You can ask us to communicate with you about your health and related issues in a particular way or at a certain place, which is more private for you. For example, you can ask us to call you at home, and not at work to schedule or cancel an appointment. We will try our best to do as you ask. 2. You have the right to ask us to limit what we tell people involved in your care or the payment for your care, such as family members or friends. below. 3. You have the right to look at the health information we have about you such as your medial and billing records. You can even get a copy of these records for a fee. Contact our privacy officer to arrange how to see your records. See 4. If you believe the information in your records in incorrect or missing important information, you can ask us to make some kinds of changes (called amending) to your health information. You have to make this request in writing and send it to our privacy officer. You must tell us the reason you want to make the changes. 5. You have a right to a copy of this notice. If we change this NPP, we will post the new version in our waiting area and you can always get a copy of the NPP from the privacy officer. 6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with our privacy officer and wit the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way. If you have questions regarding this notice or our health information privacy policies, please contact our privacy officer, Wendy Young. She can be reached at (906) The effective date of this notice is June 1, Also, you have other rights, which are granted to you by the laws of our state. These maybe the same or different from the rights described above. I will be happy to discuss these situations with you now or as they arise.

7 Our office is a medical setting, we offer the following list of patient rights that must be read by each patient before they begin treatment. If you have any questions about any of these items, please present them to your therapist. PATIENT RIGHTS 1. Every patient has a right to be treated with dignity and respect, regardless of race, national origin, sex, age, religion, disability or sexual orientation. 2. Every patient has the right to expect that the provider of services in this office has met the minimum requirements required by the State of Michigan to practice psychotherapy. If you wish, you may examine public records maintained by your therapist s governing board that include the credentials of your therapist. 3. You have the right to participate in planning for your treatment and to hear what your treatment will consist of. 4. You have the right to be informed of alternatives to treatment and any possible side effects. 5. You have the right to be informed of any fees for which you are responsible and to hear of them before services are rendered. 6. You have a right to see your treatment record at any time. Your therapist will review the contents of your file with you. 7. If you are dissatisfied or have a concern about treatment, please feel free to let your therapist know. If you continue to feel dissatisfied, you can be referred to another provider of therapy services. If you feel it is necessary, you can obtain information on how to file a grievance. 8. If possible, please pay your co-payment at the time of each session. We will bill your insurance for each visit, unless you opt to private pay. 9. CONFIDENTIALITY: The information you disclose to me during therapy sessions is kept in your file in a locked area. Information is released only in the following situations: a. When your claims are filed with your insurance/eap company, you authorize us to release information that they request to process your claims.

8 b. The law requires disclosure of information you provide about child abuse or neglect. c. The law requires disclosing information on imminent danger of harm to yourself or others. d. Courts can subpoena your file in legal action. The legal system can access your file if there are matters involved in national security. e. When information is requested by another clinic or agency, you must sign a release of information form if you wish to have this information released. I have read this list of patient rights and understand them fully. Patient Signature Date I have received a copy of the Notice of Privacy Practices. Patient Signature Date I understand that I am responsible for payment in full, should my insurance company/eap fail to pay for services rendered. Patient Signature Date RELEASE and INSURANCE ASSIGNMENT: I authorize Comprehensive Counseling & Consulting, LLC, to release medical information to my insurance company at their request. No information will be released to my attorney or other third party without separate authorizations. I hereby authorize Comprehensive Counseling I Consulting, LLC, to receive payments directly from my insurance/eap company. Patient Signature Date

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