Adult Intake Packet

Privacy and Rights Acknowledgement
Client Name: *
Date:

Month Day Year
Date
Please read the following policies and check boxes below:

Check box- I have read and understand my Patient Rights, stating as a patient of Hope for a Better Tomorrow, I have specific rights that are enumerated in Wisconsin Statutes 51.61 and Wisconsin Administrative Code HHS 94. Check box- I have read and understand the Cancellation Policy stating that I can be charged a $50.00 cancellation fee if I cancel my appointment with less than a 24 hour notice. (Unless due to illness or emergency) Check box - I have read and understand my Limits of Liability Policy stating therapy services carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any "cures" cannot be guaranteed for any condition due to many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of my life are considered risks of therapy sessions. Check box - I have read and understand my Limits of Confidentiality stating what I discuss during my therapy sessions are kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of my legal guardian. The following is a list of exceptions: Duty to Warn and Protect, Abuse of Children or Vulnerable Adults, Prenatal Exposure to Controlled Substances, Minors/Guardianship and Insurance Providers and Hope for a Better Tomorrow Clinician Collaboration. Check Box- I have read and understand the HIPAA stating how therapeutic and medical information about you may be used and disclosed, your rights as a patient and ways for you to get additional information on our policies. Our clinic has always been very protective of your personal information. Under new federal regulations (HIPAA Privacy Act), we have adopted additional guidelines to ensure proper use, confidentiality, and disclosure of your health information.
By signing below, I am acknowledging that I have read and understand the above policies. Paper or electronic copies can be obtained by request.
Client Signature *

Clear
Signature (Parent or Guardian) (If over 18yrs, write n/a) *

Clear
Date

Month Day Year
Date

Payment Acknowledgement Agreement
Client Name: *
Date:

Month Day Year
Date
Please read the following statements and check boxes in acknowledgement below:

Check box- I understand and agree that my co payment co insurance and deductibles are due and payable at the time of service. I understand that charges not covered by my insurance company as well as applicable co payments and deductibles are my responsibility and will be subject to the therapists self pay amount. I understand that co-payment and deductible amounts may change depending on my mental health benefits within my insurance policy. Check box- I understand that any unpaid services will be considered delinquent and will be sent to a collection agency. Check box - I understand and agree that I will be charged a $50.00 cancellation fee if I cancel my appointment with less than a 24 hour notice. (Unless due to illness or emergency) Check box - I understand and agree to the $3 fee when using a credit or debit card other than medical cards to pay for any and all services. Cash and check are no charge. There will be a $20+ fee for any bounced checks.
By signing below, I understand and agree to the above statments. I authorize my insurance benefits to be paid directly to Hope for a Better Tomorrow.
Client Signature *

Clear
Signature (Parent or Guardian) (If over 18yrs, write n/a) *

Clear

Client Printed Name: *
Client Signature: *

Clear
Signature (Parent or Guardian) (If over 18yrs, write n/a) *

Clear

Client Printed Name *
Signature *

Clear
Signature (Parent or Guardian) (If over 18yrs, write n/a) *

Clear

Physician or Psychiatrist Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Check the box below-

Yes, I want this information released to my Primary Care Physician or Psychiatrist No, I do not want this information released to my Primary Care Physician or Psychiatrist I do not have a Primary Care Physician or Psychiatrist at this time
Print Patient Name *

First Name Last Name
Signature (Client 12 years of age and older) *

Clear
Signature (Parent or Guardian, 12 years and younger) (If over 12yrs, write n/a) *

Clear
Date

Month Day Year
Date

Should be Empty:

ADULT INITIAL PSYCHOTHERAPY INTAKE

Privacy and Rights Acknowledgement

Payment Acknowledgement Agreement

Health Risk Assessment