Friendswood Counseling Center, LLC Phone: (479) 200-6034 3526 E. FM 528 Rd, Suite 200 Fax: (281) 819-7845 Friendswood, TX 77546 Email: kristi@friendswoodcc.com Website: www.friendswoodcc.com Client Registration CONTACT INFORMATION: Today s Date: Reason for seeking counseling services: Name: DOB: / / Age: SSN: DL#: Gender: Address: City: State: Zip Code: Home #: Cell #: Work #: Please check which numbers I have permission to contact: Home Cell Work Permission to send appointment reminders via text message to cell phone: Yes No Email Address: What s the best way to contact you? Employer/School: Permission to email: Yes No Can I leave a message? Yes No Occupation: Referred by: Marital status (check one): Single Married Separated Divorced Widowed Domestic Partnership RESPONSIBLE PARTY: (Who is responsible for the account if different from the above name and address) Name: SSN: Employed by: Relationship to the Client: DL#: DOB: Occupation: Address City: State: Zip Code: Home #: Cell #: Work #: 3.16
MEDICAL HISTORY Primary Physician: Psychiatrist: Current Medications: Emergency Contact: Name: Relationship: Home #: Cell #: Work #: INSURANCE INFORMATION Name of Primary Health Insurance Company: Phone Number: Address: City: State: Zip Code: Subscriber Information Name: SSN: DOB: / / Address: Employer: Employer Phone #: Member ID #: Group #: Name of Secondary Health Insurance Company: Phone Number: Address: City: State: Zip Code: Subscriber Information Name: SSN: DOB: / / Address: Employer: Employer Phone #: Member ID #: Group #: FINANCIAL ARRANGEMENTS The following methods of payment are accepted: Cash, Check, Debit, Visa, MasterCard and Discover. Payment is due in full at each appointment. Please check the appropriate option which you prefer: Cash Check Debit Visa, MasterCard or Discover Payment policy decided on by both parties is as follows: $ per session. I understand that I will be responsible for a missed appointment fee of $60.00 if I am unable to keep my scheduled appointment and do not notify the office 24 hours in advance. I agree to provide my credit/debit card information during my first appointment for this purpose and understand it will be securely kept on file. Signature: Date: 3.16
Friendswood Counseling Center, LLC Phone: (479) 200-6034 3526 E. FM 528 Rd, Suite 200 Fax: (281) 819-7845 Friendswood, TX 77546 Email: kristi@friendswoodcc.com Website: www.friendswoodcc.com Client Agreement and Informed Consent Form Welcome to Friendswood Counseling Services, LLC! We are so glad that you have decided to take that important first step in reaching out for support. We appreciate you giving us the opportunity to work with you. This document is intended to provide you with information about our treatment approach, methods and services offered as well as to hopefully answer any other questions you have about what to expect and the nature of the counseling process. Therapy: Therapy is a place to identify and build on current strengths, learn problem-solving strategies, develop or enhance coping skills, learn more effective ways to communicate with others and receive support and feedback. The counseling relationship is designed to be one that will facilitate change and growth. The therapist and the client both have active roles. Our goal is to provide a comfortable and supportive environment conducive to insight, healing and personal growth. Your role will be to identify goals that you would like to achieve during the course of therapy and be willing to examine any potential obstacles and strengths that will either hinder or help you move toward obtaining your desired goals. During our first session (intake session), we will gather information about your history, current strengths, struggles/areas of concern and your goals for treatment. This will be a time for you to ask any questions that you may have and to determine if you wish to proceed with ongoing therapy. We strongly believe that individuals should feel comfortable with the therapist that they choose and, hopeful about therapy. In the next several sessions you will have the opportunity to share your thoughts, feelings and perceptions and request assistance with certain situations/issues that arise between sessions as we also collaboratively work toward achieving the agreed upon treatment goals established during the intake session. An important part of therapy will be to practice new skills and monitor certain behaviors/thoughts. There may be times you are asked to do some homework in between sessions that may consist of reading and completing handouts, keeping records or practicing a specific skill. The length and frequency of our therapy together will be determined by your specific needs and goals. We will periodically evaluate your satisfaction and progress. If at any time you have questions or concerns regarding fees, services, or the direction of our sessions, please do not hesitate to address them with us. We welcome any questions and feedback. In the later stage of therapy, we will meet less frequently in preparation for termination. Although you may terminate your therapy whenever you wish, it is very helpful to have at least one session together to summarize your progress, define the work that remains and to say good-bye. Counseling can have benefits and risks and it is important to consider both when making any treatment decisions. Since therapy involves discussing unpleasant aspects of your life, there is a risk that you may experience temporary uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. Counseling has also been shown to have many benefits including improved relationships, a significant reduction in feelings of distress and resolutions of specific problems. We are unable to make any guarantees about how the therapy process will be for you, specifically. Minor clients: If you are the parent or guardian and are requesting services for your child/adolescent under the age of 18, we will need your permission to provide counseling services to him/her. Keep in mind while you have the right to question and understand the nature of your child/adolescent s sessions, treatment is usually more effective if your child/adolescent has some privacy. It is therapeutically important that your child/adolescent develops a level of trust with us so if you agree, we will only provide you with a general overview of each session along with your child s level of participation and progress. However, there are limits to confidentiality (listed under Confidentiality ). Page 1 of 4
Fees/Payment: Office Policies, Procedures and Fees The fee for each therapy appointment is $120 and due at the time of service. Sessions will be 45 minutes long. We will file with your insurance company as a courtesy to you. If we are working in network the fee is reduced based on our contract with your insurance company. In such cases, your insurance company will pay a portion of the cost of your therapy per session and the remainder (co-pay) will be due and collected at the time of service. Agreed upon payment is due at the time of service. Your insurance company will be billed for the services; however, you are ultimately responsible for the full payment of our fees. Accepted forms of payment include cash, check, Visa, MC, and Discover as well as FSA (Flexible Spending Account) and HSA (Health Savings Account) debit cards. There will be a $25 charge for any returned checks. In addition to weekly appointments, we charge $120 hourly for other professional services you may need, although we will break down the hourly cost if we work for periods of less than one hour. Other professional services include: report or letter writing to teachers, physicians, psychiatrists, etc. site visits travel time longer sessions telephone calls lasting longer than 15 minutes attendance at meetings or phone consultations with other professionals (that you have authorized) preparation of records or treatment summaries None of these services are covered by your insurance plan. If you become involved in legal proceedings that require our participation, you will be expected to pay for all of our professional time, including preparation and transportation costs. Due to the complexity and difficulty of legal involvement, the fee is $170 per hour. Cancellation Policy: If you need to reschedule or cancel an appointment, please contact us as soon as possible. Not doing so takes away the opportunity to give that appointment to another client. Your insurance company will not pay for missed appointments. We understand that emergencies happen and will be happy to work with you in those situations. Appointments cancelled/rescheduled at least 24 hours prior to the session time will not be charged. Appointments cancelled/rescheduled with less than 24 hours notice will be charged $60. No shows will be charged $60. Reminder texts/calls are only made when our times allows us to do so. Do NOT rely on this courtesy to keep from missing appointments One no show may be allowed; after the second occurrence, we may choose to refuse the scheduling of future appointments. Frequent cancelling/rescheduling will incur a charge and may also result in a refusal of future appointments. Page 2 of 4
Professional Records We keep a record of the counseling services we provide to each client. You may ask to see and/or copy your record by making an appointment specifically for that purpose or we can prepare a summary for you instead. You may also ask us to correct your record. Contact Information The primary way to get in touch with us is by contacting us is on our cell phone. We do not answer phone calls during session so please leave a detailed message including reason for the call and the best number to reach you (daytime number and evening number). Voicemail messages are confidential and we will return calls as soon as possible or within 24 hours. If you are in crisis and need immediate assistance, please call 911 or go to your nearest emergency room. Confidentiality Protecting your privacy is very important to us. The information in your record is confidential and will not be disclosed to anyone without your written consent, unless required by law. The exceptions to confidentiality include: If you tell us that you are going to harm or kill yourself or someone else, we are required by law to do whatever we can do to prevent that from happening and to ensure your safety and the safety of others. This may require notifying family members, parents, legal guardians, legal authorities and/or the potential victim. If you tell us about incidents of child abuse, or the abuse of a disabled person or the elderly, we are required to report this to the proper authorities. We are required to release your records if they are subpoenaed by a court of law. In addition to the above, there are several other situations where confidentiality cannot be insured, including: If you provide us with a request to release your records. If you are in family counseling, I cannot guarantee confidentiality will be maintained by other family members. If you are a child (under 18 years of age) or unable to voluntarily consent, a guardian must give written consent and can access your records. If you choose to file insurance or work with a managed care company, information regarding your treatment, diagnosis, prognosis, and the specific issue for which you have come to treatment are available to the insurance or managed care company. We make every effort to release only the minimum information necessary for the purpose requested. Once this information is given to the insurance or managed care company, however, we have no control over how the information is used. You will be asked to sign a release of information if records are requested from us. You have the right to deny the release of information If there is payment owed to Friendswood Counseling Center, LLC you will receive a letter. If payment is not made within two weeks of the letter, your name, address and amount owed will be released to a third party for collections. Therapists in this office are either Licensed Professional Counselors (LPC) or Licensed Marriage and Family Therapists (LMFT) with the State of Texas. Services provided will be in accordance with the Code of Conduct for LPC s and LMFT s as set forth by the LPC and LMFT Licensing Board. If you have concerns about our counseling relationship, we encourage you to address them with us directly. For LPC licensure and compliance information, you may call: (512) 837-6658, or write to Texas State Board of Examiners of Professional Counselors, 1100 W. 49 th Street, Austin, TX 78756-3183. For LMFT licensure and compliance information, you may call (512) 834-6657. Page 3 of 4
Client Agreement and Informed Consent Form I have read and fully understand this document. All questions that I had have been answered to my satisfaction and I recognize that I have the opportunity now and in the future to discuss any question I may have with my counselor. I agree to the policies, procedures and fees explained herein. I agree to accept counseling from you and am voluntarily signing this form. Client Signature Date -------------------------------------------------------------------------------------------------------------------------------------------- If the client is a minor list the name of the minor child Name of child I declare that I am the legal guardian and/or managing conservator of the above-named child and grant permission for his/her psychological treatment. Print Name: Signature: Page 4 of 4
Friendswood Counseling Center, LLC Phone: (479) 200-6034 3526 E. FM 528 Rd, Suite 200 Fax: (281) 819-7845 Friendswood, TX 77546 Email: kristi@friendswoodcc.com Website: www.friendswoodcc.com HIPPA/Notice of Privacy Practices (Brief Version) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED 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. I am also 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 notice of privacy practices. The full version is available upon your request and contains more information regarding your protected health information. Please talk to our Privacy Officer (see end of this form) about any questions or problems. How we use and disclose your protected health information with your consent We will use the information we collect about you mainly to provide you with treatment, to arrange payment for our services, and for some other business activities that are called, in the law, health care operations. After you have read this notice we will ask you to sign a consent form to let us use and share your information in these ways. If you do not consent and sign this form, we cannot treat you. If we want to use or send, share, or release your information for other purposes, we will discuss this with you and ask you to sign an authorization form to allow this. Disclosing your health information without your consent There are some times when the laws require us to use or share your information. For example: When there is a serious threat to your or another s health and safety or to the public. We will only share information with persons who are able to help prevent or reduce the threat. When we are required to do so by lawsuits and other legal or court proceedings. If a law enforcement official requires us to do so. For workers compensation and similar benefit programs. There are some other rare situations. They are described in the longer version of our notice of privacy practices. Your rights regarding your health information You can ask us to communicate with you in a particular way or at a certain place that 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. You can ask us to limit what we tell people involved in your care or the payment for your care, such as family members and friends. You have the right to look at the health information we have about you, such as your medical and billing records. You can get a copy of these records, but we may charge you for it. Contact our privacy officer to arrange how to see your records. See below. If you believe that the information in your records is incorrect or missing something important, you can ask us to make additions to your records to correct the situation or to amend them. You have to make this request in writing and send it to our privacy officer. You must also tell us the reasons you want to make the changes. You have the right to a copy of this notice. If we change this notice, we will post the new version in our waiting area, and you can always get a copy of it from the privacy officer. 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 with the Secretary of the U.S. 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. Also, you may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. We will be happy to discuss these situations with you now or as they arise. If you have any questions regarding this notice or our health information privacy policies, please contact our privacy officer, who is Kristi Ottis, MS, NCC, LPC and can be reached by phone at (479) 200-6034. The effective date of this notice is March 8, 2016 Page 1 of 2
Acknowledgement of HIPPA/Notice of Privacy Practices Client name (please print): I hereby acknowledge that I have received the HIPPA/Notice of Privacy Practices for Friendswood Counseling Center, LLC Signature: Date: Printed name of Legal Guardian (if client is under age 18) Legal Guardian s Signature (if client is under age 18) Date: Page 2 of 2