Face Sheet

Choices Mental Health Counseling PLLC

Narrowsburg, NY 12764 | tom@choicesmhc.com
Full Legal Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

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Date
Email*
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Address*

Street Address

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Postal / Zip Code
Cell Phone*

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Land Line or Alternate Phone

Area CodePhone Number
Do you smoke cigarettes?*
Insurance Carrier and Member ID Number, or "None"*
Occupation and Employer*
Current Medications and reason taken*
Primary Care Provider or other prescriber
Relationship Status*
Name of Partner or Spouse (or "None")*
Children's Names and Ages (or "None")*
Gender*
Ethnicity*
Religious affiliation or spiritual belief*
Date last drank alcohol

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Date
Date last used recreational or unprescribed drugs

MonthDayYear
Date
Prior mental health or substance abuse counseling, both inpatient and outpatient, where and when.*
In a sentence or two, please describe the issue(s) for which you are seeking counseling.*
Who referred you or recommended you contact this office?*
Relevant legal issues (pending charges or CPS involvement - court and attorney's name if any; if on probation or parole PO's name)*
Please attach a clear digital picture of your insurance card.

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Additional Remarks (best time to reach you, or anything else you want to share)
Tele Mental Health

Via Secure Online Video Conferencing
Do you have access to the Internet and a private space where you can talk?

YesNoNo, but I will soonFace-to-face, only in Narrowsburg
For virtual visits, what sort of device will you use to connect for sessions (iPhone, Android, tablet, computer, etc.)?
RELEASE OF INFORMATION, LIFETIME SIGNATURE ON FILE,

CANCELLATION POLICY, PAYMENT AUTHORIZATION,

ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES,

PERMISSION TO SEE CHILD(REN) AND OTHERS PRESENT IN COUNSELING

I understand that being on time for appointments is my responsibility. I agree to pay 50% of my usual fee for any block of time reserved for me unless I have provided 24 hours advance notification. I will be responsible for this and for any co-payments, deductibles, and for services provided that are not covered by my insurance plan. I authorize payment of all insurance benefits for services rendered by this office to be made payable to Choices Mental Health Counseling PLLC or the provider and authorize the aforesaid to release to the Centers for Medicare and Medicaid, its agents, or any other insurer or third-party payer all information necessary to determine benefits payable for related services. If I do not provide Choices with my complete and accurate insurance information, I will be a “cash pay” client (out of pocket or out-of-network) and I will be opting to not use any insurance with which I might be in-network. Further, if I provide insurance information at a later date, it will not be retroactively applied but will alter the agreement going forward only. If using Medicaid Transportation, I authorize my provider to confirm my attendance at healthcare appointments with Medical Answering Service LLC and any transportation vendors: and to be seen in the presence of family members or unrelated persons I allow to attend appointments with me. I permit a copy of this authorization to be used in place of the original. This form will serve as a lifetime signature form. I acknowledge receipt of and reading the Notice of Privacy Practices, and that any future revisions will be posted on the web at choicesmhc.com. The undersigned agrees that all unpaid fees owing after the date of service may be assessed a service charge at the rate of one and one-half percent (1-1/2%) per month or eighteen percent (18%) per annum from that date. In the event of default where it becomes necessary to turn this account over to a third party for collection, the undersigned agrees to pay all costs of collection, including reasonable attorney’s fees and court costs. To the best of my knowledge, the above information is true. I understand that falsification of any information above could result in termination of services. If seeking services for a child under age 18: I consent to all the above on behalf of my minor child and myself.
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Choices Mental Health Counseling PLLC

Tele Mental Health