Email, text messaging, and other electronic communications are not secure mediums and therefore, confidentiality cannot be assured. Please use discretion when sending information that is sensitive in nature.

Prior Behavioral Health Experiences

1. Outpatient Counseling (from most recent to earliest experiences)

2. Intensive Treatment (including residential treament, treatment foster care, and hospitalizations)

(from most recent to earliest experiences)

Medical History (current and in the past)

Medications

Describe your daily caffeine consumption (tea, coffee, energy drinks, chocolate, soda):

Education and Employment (if applicable):

Are you currently employed?YES

Do you have any concerns about employment? YES

Have you been in any branch of the military? YES

(Feel free to include an addendum document if you need more space for any of these sections)

Drug and Alcohol History

Alcohol

Tobacco

Non-Prescribed Drugs

Education History

Education History

Military Experience

It is the policy of Liberated Counseling LLC that clients have the right to say whether they wish to receive Outpatient services.  Each client has impartial access to treatment, regardless of race, religion, gender identity, ethnicity, age, sexual preference or disability, within the range and diagnostic criteria for which Liberated Counseling LLC provides treatment. 

The undersigned acknowledges that Liberated Counseling LLC makes no guarantees to the undersigned or the client as to the results or likelihood of success of Liberated Counseling LLC services. 

The undersigned acknowledges that if a client becomes dangerous to him/herself or to others, the staff will exercise the necessary precautions to protect the client or others.

The undersigned acknowledges receiving a copy of information about Liberated Counseling including policies and procedures, Informed Consent, HIPPA compliance protocols, and Notice of Privacy Practices.

The undersigned releases Liberated Counseling LLC staff from any liability for the loss or damage of personal property and/or money while receiving services at Liberated Counseling LLC or at the client’s home.

My signature below attests to the fact that / have read this form, understand its content and request that the above information be released as specified.

Thank you for choosing Liberated Counseling as your therapy provider. Please review carefully the consent to disclosure to insurance companies (if applicable) and receipt of notice of privacy practices below. If you agree to each item, please initial next to each statement indicating your agreement and sign at the bottom.

RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have been provided a Notice of Privacy Practices that fully explains the uses and disclosures that Liberated Counseling will make with respect to my individually identifiable health information. I understand that I have the right to review said notice before signing this consent. Additional copies of this notice are posted on the website www.liberatedcounseling.com and also in the office. I also understand that Liberated Counseling reserves the right to change its notice and the practices detailed therein prospectively, and will notify me of any changes.

RECEIPT AND CONSENT TO INFORMED CONSENT AND ADDITIONAL POLICIES

I acknowledge that I have been provided and reviewed a copy of Informed Consent, additional privacy policies and cancellation and no show policy. I understand these policies and agree to abide by the boundaries and stipulations therein.

I understand the limits of confidentiality in communication by electronic means. I will use discretion when electronically communicating information to this therapist.

CONSENT TO DISCLOSURE TO INSURANCE COMPANY (IF APPLICABLE)

I understand that I do not have to consent to the uses or disclosure of my individually identifiable health information treatment, payment, and health care operation. I also understand that if I do not consent, Liberated Counseling may refuse to provide me health-care services unless applicable state or federal law requires Liberated Counseling to provide such services.

I understand that I may revoke this consent in writing, but that the revocation will not be effective to the extent that Liberated Counseling has already taken action in reliance on my earlier effective consent.

I understand that as part of my healthcare, Liberated Counseling originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my care and treatment.
• A means of communication among health professionals who contribute to my care.
• A source of information for applying my diagnosis information to my bill.
• A means by which a third-party payer can verify that services billed were actually provided.

I understand that if my medical insurance company is providing payment for services rendered at Liberated Counseling, the following disclosures of my identifiable health information may apply:

• Liberated Counseling will have to release information including dates of sessions, CPT codes billed, and diagnostic information about me to my insurance company, or their legal representative in order to obtain payment.
• If records are requested by my insurance company as a requirement to process payment for services rendered, Liberated Counseling will attempt to notify me of the documents being disclosed and permit me to review them prior to their disclosure. Documents may include any documents generated by Liberated Counseling about me.
• I will have to authorize my insurance company to make benefits payable to Liberated Counseling.

My signature below attests to the fact that / have read this form, understand its content, and agree to these conditions.

CONSENT TO PAYMENT POLICIES

Please review carefully the boundaries and expectations outlined below. Please initial next to each statement indicating your agreement and sign at the bottom. These are considered a necessary condition for treatment.

Payment Policies

I understand that all Copays, Deductible payments, Self-pay, or Sliding-scale fees are due at the time or service. If my insurance company denies paying for my services or indicates a deductible payment or different copay amount than indicates on my insurance card, then these payments are due five business days after I am invoiced.

 I understand that if I don't have insurance, I will be expected to pay the noted fee (or sliding scale fee) for these services at each appointment. Any payments may be made via cash, check, or credit card.

I understand that the full-scale fees for services are as follows: Intake Assessment $200, After Hours Therapy $200 per 55 minutes, Counseling / Therapy Appointments $175 per 55 minutes, Couples Therapy Appointments $175 per 55 minutes, and a one-time $30 fee for the Gottman Relationship Checkup Assessments for couples' clients.

I understand that any balances not paid within 30 calendar days may be turned over to collections with an additional 2% late fee added. I understand that if my bill must be turned over to collections due to not paying my balance after 30 calendar days, I am responsible for the collection's fees (typically 40% of the total bill).

I understand that if payment for the services I receive is not made, the therapist may stop my treatment.

I understand that if I pay by check or credit card and the payment is later recouped (e.g. the check bounces), a fee of $50 per incident will be incurred. I understand that this balance must be paid by alternative means in 5 days. 

ADDITIONAL SERVICES

I understand that any out of session communication (telephone call or other medium) lasting more than 5 minutes will result in a fee of $25 per 15 minutes. There will be no fee for contacts lasting less than 5 minutes. 

I understand that other services such as record preparation, report writing, and other documentation are charged at the rate of $25 per 15 minutes.

 I understand that if I choose to subpoena Stephen Ratcliff, all legal services including preparation time, testimony time, transportation time, and commute time will incur a fee of $500 per hour due prior to testimony date.

CONSENT TO CANCELLATION POLICY

I understand that if I am unable to attend my scheduled therapy appointment, I must first notify Liberated Counseling by email or at 505-504-5449 by text or voicemail 24 hours in advance of my appointment.

I understand that If I do not call to cancel or reschedule my appointment, this will be considered a no-show. Additionally, arriving later than 20 minutes for my scheduled therapy appointment time constitutes a no-show. No-shows to appointments are not covered by my health insurance and will result in a subsequent fee. The fee is $25 for all clients. Reoccurring no-shows / same day cancellations may result in the termination of my counseling.

 I understand that re-occuring no-shows / same day cancellations (2 instances in 12 months) may result in the termination of services. I understand that if I miss my scheduled appointment, it is my responsibility to call to set up another appointment. I understand that if I don't respond to contact attempts from Liberated Counseling, this will be interpreted as communication that I no longer wish to receive services.

I understand that if extenuating circumstances arise and I cancel in advance of my appointment but not with 24 hours' notice, Liberated Counseling may choose to waive this fee on a case-by-case basis.

 I understand that if I miss my scheduled appointment, it is my responsibility to call to set up subsequent appointments. Failure to cancel with 24-hour prior notice may result in me losing my preferred time slot. If I am failing to maintain contact, Liberated Counseling may take this as communication that I am terminating services.

 My signature below attests to the fact that / have read this form, understand its content, and agree to these conditions.

Client's Rights

1. The right to efficient and equal service, regardless of race, gender, religion, ethnic background, education, social class, physical or mental disability, sexual orientation, gender identity, or economic status.
2. The right of considerate, courteous and respectful care from all Liberated Counseling, LLC staff.
3. The right to informed consent and full discussion of risks and benefits prior to any invasive procedure, except in an emergency. Alternative to the proposed procedure must be discussed with the client.
4. The right to receive information in an understandable manner.
5. The right to obtain a referral for bi-lingual services or to have an interpreter present in session if needed.
6. The right to the names, titles, and professions of Liberated Counseling, LLC staff with whom the client speaks and from whom services or information are received.
7. The right to refuse examination, discussion, and/or procedures to the extent permitted by law and to be informed of the health and legal consequences of this refusal.
8. The right of access to the client's own personal health record.
9. The right to confidentiality and privacy of the client's personal mental health records as provided by the law. The details of the clients life and treatment are shared only with the client's parent's or guardian's permission and the client's explicit consent.
10. The right to expect reasonable continuity of care within the scope of services of Liberated Counseling, LLC.
11. The right to examine and receive a full explanation of any charges made by Liberated Counseling, LLC regardless of the source of payment. 
12. The right of respect for the client's civil rights and religious opinions.
13. The right to be represented by a family member of guardian if the client is unable to fully participate in treatment decisions.

Client's Responsibilities

1. Provide accurate and complete information relevant to your treatment at Liberated Counseling, LLC.
2. Ask questions if you do not understand any aspect of your treatment.
3. Report safety concerns immediately to your therapist.
4. Avoid drugs, alcoholic beverages or toxic substances while in attendance of your therapy session.
5. Accept the consequences if you do not follow the care, service, or treatment plan provided to you.
6. Respect the property of other people and of Liberated Counseling, LLC. Be considerate of other clients. 
7. Be considerate of other clients.
8. Sign a written acknowledgement that you have received the applicable Notice of Privacy Practices.
9. Provide accurate information needed for processing your insurance coverage.
10. Be responsible for payment of all services, either through your third party payers (insurance company) or by personally making payment for any service that are not covered by your insurance policy(s) including second opinions or consultations.

By signing below, / acknowledge my client's rights and responsibilities listed herein.

PRIMARY CARE PHYSICIAN COORDINATION OF CARE RELEASE FORM

THIS WILL AUTHORIZE: Liberated Counseling, LLC (Tel. 505-504-5449)

TO RELEASE TO:

Cancellation / Expiration: I understand that I may cancel this authorization at any time by sending my health providers my cancellation notice in writing. I understand that my health care providers may have already released records according to this authorization prior to receiving my notice of cancellation.

This authorization shall remain valid for one year from the date of signature unless revoked in writing by the client's guardian or conservator. This authorization releases Liberated Counseling, LLC from any and all legal liability that may arise as a result of compliance with this release of information request.

I specifically authorize the release of my medical records to include the following records (initial all you consent to be released):

My signature below attests to the fact that / have read this form, understand its content and request that the above information be released as specified.