JWFC Court Ordered New Client Packet

JORDAN WEST FAMILY COUNSELING SERVICE AGREEMENT
PATIENT INFORMATION
Name *

First Name Initial Last Name
Address *

Street Address

Street Address Line 2

City State

Zip Code
Home Phone *
Please enter a valid phone number.
Work / Cell Phone
Please enter a valid phone number.
Social Security Number *
Birth date *

Month Day Year
Date
Age *
Sex *

Male Female
Marital Status *

Single Married Widowed Divorced
Who is your Employer?
Job / Occupation
Whom may we thank for referring you?
In case of emergency, who should be notified? *
Emergency Phone Number
Please enter a valid phone number.

RESPONSIBLE PARTY
Relationship to Patient
Other Relationship to Patient
Name *

First Name Initial Last Name
Birth date *

Month Day Year
Date
Social Security Number *
Address (if different from patient’s)

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Please enter a valid phone number.
Person Responsible Employed by
Occupation
Business Address
Business Phone
Please enter a valid phone number.

PRIMARY INSURANCE
Relationship to Patient *
Other Relationship to Patient
Insurance Subscriber Name *
Birth date *

Month Day Year
Date
Address (if different from patient’s)

Street Address

Street Address Line 2

City State

Zip Code
Phone Number
Please enter a valid phone number.
Subscriber Employed by
Business Phone
Please enter a valid phone number.
Insurance Company Name *
Insurance ID Number
Names of other dependents covered under this plan
Is patient covered by additional insurance? *

Yes No
If yes, is the policy listed above primary?

Employee Assistance Program (EAP)
Is patient covered by an EAP? *

Yes No
If yes, what is the EAP Company?

Company Phone Number
Address (if different from patient’s)

Street Address

Street Address Line 2

City State

Zip Code
Authorization Number

Other Payment Source
Clergy *

Yes No
If yes, Clergy name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City State

Zip Code
Other than listed above? *

Yes no
If yes, source name
Phone Number
Please enter a valid phone number.

ASSIGNMENT AND RELEASE
I, the undersigned, certify that I (or my dependent) have insurance coverage with Insurance Company * and assign directly to my provider all insurance benefits otherwise payable to me for services rendered. I understand that I am ultimately responsible for all charges accumulated. I hereby authorize Jordan West Family Counseling to release all information necessary to secure the payment of benefits, and authorize the use of this signature on all insurance submissions. I give permission for treatment of myself/my dependent to my assigned provider.
Signature *

Clear
Relationship to Patient *
Other Relationship to Patient
Date

Month Day Year
Date

Patient Financial and Fee Agreement
Your insurance will be billed standard rates based upon the CPT (current procedural terminology) code. You will be responsible for co-pays, co-insurance, late cancelation, missed appointment fees or deductibles as directed by your insurance company at the time of service.

An appointment is a reservation for time with a counselor. Out of courtesy and respect for your counselor please contact Jordan West Family Counseling if you need to cancel an appointment. If an appointment is missed, without notifying Jordan West Family Counseling, a fee of $50.00 will be assessed. If an appointment is cancelled less than 24 hour prior to the appointment a fee of $50.00 will be assessed.

Due to insurance carriers’ tardiness in regards to service claims submitted by providers, please read the following information:
- If your insurance company does not respond in a timely fashion a “Statement” will be released to you. Upon receipt of the “Statem ent” we suggest that you contact your insurance carrier and request that they process your claim.
- Should you receive any correspondence from your insurance company in regards to your services in this office, you must respond to that correspondence immediat ely, in order to have the claim processed and paid.
- Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay a fixed allowance for certain procedure s, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co - insurance, or any other balance not paid by your insurance at the time of service.
- Jordan West Family Counseling will only bill the Primary Insurance. You will need to bill your Secondary Insurance. Documentation can be provided if it is required. You will be required to pay any co - payment or co - insurance at the time of service. Secondary insurance is not a substitute for co - payments /co - insurance.
Patient’s or authorized person’s signature: I authorize the release of any medical, behavioral health or other information necessary to process my insurance claim.

Insured’s or authorized person’s signature: I authorize payment of medical, behavioral health benefits to the provider for services. I fully understand that, regardless of insurance coverage, I am legally responsible for all fees due. I further understand Jordan West Family Counseling’s missed appointment and late cancellation policy

Patient’s authorized person’s signature: I acknowledge if an appointment is cancelled less than 24 hours prior to the appointment or the appointment is missed a fee $50.00 will be assessed.
Relationship to Patient *
Other Relationship to Patient
Date

Month Day Year
Date
Patient Name *
Authorized Person
Signature *

Clear
Returned checks will be assessed a $30.00 fee. Please note that unless your appointment is cancelled with a 24hour notice, latecancellation fees will apply. Delinquent accounts are subject to referral to collection agencies.If your account is referred to a collection agency the balance will be charged 35%collection fee. Interest will be assessed at a rate of 1% per annumwill apply for balances over 60 days old Any questions regarding financial issues may be directed to the Office Manager.

Release of Confidential Mental Health Information
Client Name *

First Name Initial Last Name
Social Security Number *
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State

Zip Code
Disclosure of Mental Health Information: Your mental health information and communication of that information is essential to your treatment. We prefer to speak directly with each patient but we understand that other individuals of family members may have knowledge of and be assisting in your treatment and progress. Please, list the individual(s) who we are authorized to discuss your treatment/progress with. (NOTE: We cannot discuss your treatment/progress with others, including parents, spouse, other family members, caseworkers, attorney general, Guardian Ad Litem, Judge, or court clerks unless they are listed below.)
Authorized person 1

Name of the person Relationship to Patient
Authorized person 2

Name of the person Relationship to Patient
Confidential Communication: Communication between Jordan West Family Counseling and you, the client is critical to your well-being. Please list the phone number(s) where we can reach you, your parent(s) or guardian.
Contact Information 1

Name of Person Phone Number Relationship to Patient
Contact Information 2

Name of Person Phone Number Relationship to Patient
Contact Information 3

Name of Person Phone Number Relationship to Patient
Permissions: Children over the age of 12 will be given consent for a counselor / Jordan West Family Counseling to communicate with parent(s) regarding their progress. In cases of an "in custody" client, permission will be given to communicate with foster parent(s), caseworker(s), Guardian Ad Litem, Attorney General or Judge. In addition, clients who are court referred into treatment will give consent to communicate with probation officers, Judge(s) and court clerks in order to send updates, treatment progress, treatment summaries, and treatment termination.
Relationship to Patient *
Other Relationship to Patient
Date

Month Day Year
Date
Signature: I hereby authorize the use or disclosure of my personal mental health information as described above . If patient is under the age of 18 a parent or guardian may sign that consent to disclose information. *

First Name Initial Last Name
*

Clear
Note: This restriction applies only to mental health treatment provided by Jordan West Family Counseling. Other providers involved in your treatment may require you to complete a separate request for restriction. Either you, or Jordan West Family Counseling to may terminate this restriction by completing the following.
This agreement is terminated as of
Patient Name
Signature

Clear
Relationship to Patient *
Other Relationship to Patient
Date

Month Day Year
Date

Appointment Reminders
Jordan West Family Counseling utilizes an auto reminder tool to improve the service we offer to you, the customer. This service allows Jordan West Family Counseling to communicate electronically with mobile devices (cellular phones), landline phones and e-mail accounts.

Despite this being a service offered to you we still put you in ‘the driver’s seat’, by enabling you to start and stop any further messages anytime you want. This service requires no purchase or fee to participate in the service, standard messaging and data fees may apply. Check your mobile plan for more details.

I agree to participate in this messaging service to have voice calls, text message or e-mail reminders sent, which relieves Jordan West Family Counseling of confidentially liability due to HIPPA compliance issues as you, the patient, are choosing the source of contact.

It is our belief that only you will be the person reading your email address. I understand that other members of my family may access messages left on my e-mail address. By signing this form, I agree to relieve Jordan West Family Counseling of any liability for this contact.

Your reminder call will come around 6:00 pm and no later than 8:00 pm the day prior to your appointment. If you need to cancel your appointment, please, contact Jordan West Family Counseling office 24 hours in advance to avoid a late cancellation or no show fee of $50.00.

The message that may be delivered is as follows: “John/Mary this important reminder is to let you know it is time for your appointment with (name of therapist)”.
Please indicate only one method of call reminders that you would prefer. *

Voice Phone Call Text Message (SMS) Email message No Reminder Calls / Messages. Please ask your counselor for a reminder card for your next appointment.
Phone Number (no text message)
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email Address:
example@example.com
Please initial that you understand you will NOT receive a reminder for your future appointments:

Clear
Patient Name *

First Name Initial Last Name
Patient or Guardian Signature *

Clear
Date

Month Day Year
Date

Notice of Privacy Practices For Protected Health Information
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.

This office is required to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices. This office will not use or disclose your health information except as described in this Notice. If you consent, the office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, medical history, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes are:
- A provider or assistant obtains treatment information about you and records it in a health record.
- During the course of your treatment, the provider determines he/she will need to consult with another specialist in the area. He/she will obt ain your signed authorization before sharing information with such specialists to obtain his/her input.
- Referral information may be forwarded to Diagnostic Testing Labs for further treatment or testing where the provider will want results of such treatment or testing reported bock to him/her.
- If the provider is a specialist, your health information and progress may be reported back to your primary care provider or referring provider, upon receipt of your written authorization.
Example of use of your health information for payment purposes:
- We submit requests health information from us regarding medical care given. We will provide informa tion to them about you and the care given. For example, a bill sent to your health insurance company may include information that identifies your diagnosis, and the procedures and supplies used.
Example of use of your health information for health care operations:
- We obtain services from our insurers or other business associates (an individual or entity under contract with us to perform or assist us in a function or activity that necessitates the use or disclosure of health info rmation) such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical transcription, medical review, legal services, and insurance. We will share he alth information about you with our insurers or other business associates as necessary to obtain these services. We require our insurers and other business associates to protect the confidentiality of your health information.
YOUR HEALTH INFORMATION RIGHTS

The health and billing records we maintain are the physical property of the treating provider. The information in it, however, belongs to you. You have the right to:
- Request a restriction on certain uses and disclousres of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted as required by law:
- Obtain a paper copy of the Notice of Privacy Practices for Protec ted Health information ("Notice") by making a request at our office.
- Request that you be allowed to inspect and copy your billing record - you may exercise this right by delivering the request in writing to our office;
- Obtain an accounting of disclosures of your health information as required to be maintained by law, upon request. An accounting will not include internal uses of information for treatment, payment, operations, or disclosures made to you; and
- Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.
You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and health care operations purposes.

Notice of Privacy Practices For Protected Health Information, Continued
OUR RESPONSIBILITIES

This office is required to:
- Maintain the privacy of your health information required by law;
- Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain a bout you;
- Abide by the terms of this Notice;
- Notify you if we cannot accommodate a requested restriction or r equest; and
- Accommodate your reasonable requests regarding methods to communicate health information with you. We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions re garding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy or our "Notice" or by visiting our office and pic king up a copy.
TO REQUEST INFORMATION OR FILE A COMPLAINT

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Betty Owen at 801-566-0749. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Betty Owen. You may also file a complaint by mailing it to the Department of Health and Human Services. We cannot, and will not, require you to waive the right to file a complaint with the Department of Health and Human Services (HHS) as a condition of receiving treatment from the office. Likewise, we cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.
OTHER DISCLOSURES AND USES

Notification of Family/Friends: Our office does NOT disclose protected health information or any other information to family members.

Appointment Reminders and Treatment Information: We may contact you and/or leave a message on your telephone answering machine to provide you with appointment reminders, lab results, prescription information, or billing information.

Workers Compensation: If you are seeking compensation through Workers Compensation, we may disclose your health information to the extent necessary to comply with laws relating to Workers Compensation.

Abuse, Neglect & Domestic Violence: We may disclose your health information to public authorities as allowed by law to report abuse, neglect, or domestic violence.

Law Enforcement: We may disclose your health information for law enforcement purposes as required by law, such as when required by a court order; for identification of a victim of a crime if certain protective requirements are met; to report a crime in emergencies; and other appropriate situations as permitted by law.

Judicial/Administrative Proceedings: We may disclose your health information in the course of any judicial or administrative proceeding as allowed or required by law or as directed by a proper court order or in response to a subpoena, discovery request or other lawful process if certain specific requirements are met. To avert a serious threat to health or safely, we may disclose your health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

Other Uses: Any other uses and disclosures of your health information besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.

HIPAA requires that we make the Notice of Privacy Practices available to you. We ask that you sign and date this form. When you sign and date this form you are agreeing that you were given a copy of the Notice of Privacy Practices. You are not agreeing to what the notice says.
Relationship to Patient *
Other Relationship to Patient
Date

Month Day Year
Date
The undersigned has received the Privacy Policy of Jordan West Family Counseling *

First Name Initial Last
Signature *

Clear

	Number of:
Days:
Weeks:
Months:
Years:

I have completed this questionnaire and verify that my answers are accurate.
Signature *

Clear
Date

Month Day Year
Date
Should be Empty:

	YES 1	NO 0
Have you ever used drugs other than those required for medical reasons?
Have you abused prescription drugs?
Do you abuse more than one drug at a time?
Can you get through the week without using drugs (other than those required for medical reasons)?
Are you always able to stop using drugs when you want to?
Do you abuse drugs on a continuous basis?
Do you limit your use to certain situations?
Have you had “blackouts” or “flashbacks” as a result of drug use?
Do you ever feel bad about your drug abuse?
Does your spouse (or parents) ever complain about your involvement with drugs?
Do your friends or relatives know or suspect you abuse drugs?
Has drug abuse ever created problems between you and your spouse?
Has any family member ever sought help for problems related to drug use?
Have you ever lost friends because of your use of drugs?
Have you ever neglected your family or missed work because of your use of drugs?
Have you ever been in trouble at work because of drug abuse?
Have you ever lost a job because of drug abuse?
Have you gotten into fights under the influence of drugs?
Have you ever been arrested because of unusual behavior while under the influence of drugs?
Have you ever been arrested for driving while under the influence of drugs?
Have you engaged in illegal activities in order to obtain drugs?
Have you been arrested for possession of dangerous drugs?
Have you experienced withdrawal symptoms as a result of heavy drug intake?
Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc)?
Have you ever gone to anyone for help for a drug problem
Have you ever been in a hospital for medical problems related to drug use?
Have you ever been involved in a treatment program specifically related to drug care?
Have you been treated as an out-patient for problems related to drug use?

	YES 1	NO 0
Do you feel that you are a normal drinker? (“normal” drink as much or less than most people)?
Have you ever awakened the morning after some drinking the night before and found that you could not remember a part of the evening?
Does any near relative or close friend worry or complain about your drinking?
Can you stop drinking without difficulty after one or two drinks?
Do you ever feel guilty about your drinking?
Have you ever attended a meeting of Alcoholics Anonymous (AA)?
Have you ever gotten into physical fights when drinking?
Has drinking ever created problems between you and a near relative or close friend?
Has any family member or close friend gone to anyone for help about your drinking?
Have you ever lost friends because of your drinking?
Have you ever gotten into trouble at work because of drinking?
Have you ever lost a job because of drinking?
Have you ever neglected your obligations, your family, or your work for two or more days in a row because you were drinking?
Do you drink before noon fairly often?
Have you ever been told you have liver trouble such as cirrhosis?
After heavy drinking have you ever had delirium tremens (D.T.’s), severe shaking, visual or auditory (hearing) hallucinations?
Have you ever been hospitalized because of drinking?
Has your drinking ever resulted in your being hospitalized in a psychiatric ward?
Have you ever gone to any doctor, social worker, clergyman, or mental health clinic for help with any emotional
problem in which drinking was a part of the problem?
Have you been arrested more than once for driving under the influence of alcohol?
Have you ever been arrested, ever for a few hours, because of other behavior while drinking?

	0	1	2	3
1. Anxiety, nervousness, worry or fear.
2. Feeling that things around you are strange or unreal.
3. Feeling detached from all or part of your body.
4. Sudden unexpected panic spells.
5. Apprehension or a sense of impending doom.
6. Feeling tense, stressed, “uptight,” or on edge.

	0	1	2	3
7. Difficulty concentrating.
8. Racing thoughts.
9. Frightening fantasies or daydreams.
10. Feeling that you’re on the verge of losing control.
11. Fears of cracking up or going crazy.
12. Fears of fainting or passing out.
13. Fears of physical illness or heart attacks or dying.
14. Concerns about looking foolish or inadequate.
15. Fears of being alone, isolated, or abandoned.
16. Fears of criticism or disapproval.
17. Fears that something terrible is about to happen.

	0	1	2	3
18. Skipping, racing, or pounding of the heart (palpitations).
19. Pain, pressure, or tightness in the chest.
20. Tingling or numbness in the toes or fingers.
21. Butterflies or discomfort in the stomach.

JORDAN WEST FAMILY COUNSELING SERVICE AGREEMENT

PATIENT INFORMATION

RESPONSIBLE PARTY

PRIMARY INSURANCE

Employee Assistance Program (EAP)

Other Payment Source

ASSIGNMENT AND RELEASE

Patient Financial and Fee Agreement

Mental Health Family History

Please answer these questions to the best of your ability

Problem Inventory

Release of Confidential Mental Health Information

Appointment Reminders

Notice of Privacy Practices For Protected Health Information

Notice of Privacy Practices For Protected Health Information, Continued

The Drug Abuse Screening Test (DAST)

Welcome to the Michigan Alcohol Screening Test (MAST), Revised

THE BURNS ANXIETY INVENTORY

THE BURNS DEPRESSION INVENTORY

Heading

	0	1	2	3
22. Constipation or diarrhea.
23. Restlessness or jumpiness.
24. Tight, tense muscles.
25. Sweating not brought on by heat.
26. A lump in the throat.
27. Trembling or shaking.
28. Rubbery or “jelly” legs.
29. Feeling dizzy, lightheaded, or off balance.
30. Choking or smothering sensations or difficulty breathing.
31. Headaches or pains in the neck or back.
32. Hot flashes or cold chills.
33. Feeling tired, weak, or easily exhausted.

	0	1	2	3	4
1. Feeling sad or down in the dumps.
2. Feeling unhappy or blue.
3. Crying spells or tearfulness.
4. Feeling discouraged.
5. Feeling hopeless.
6. Low self-esteem.
7. Feeling worthless or inadequate.
8. Guilt or shame.
9. Criticizing yourself or blaming yourself.
10. Difficult making decisions.

	0	1	2	3	4
11. Loss of interest in family, friends or colleagues.
12. Loneliness.
13. Spending less time with family or friends.
14. Loss of motivation.
15. Loss of interest in work or other activities.
16. Avoiding work or other activities.
17. Loss of pleasure or satisfaction in life.

	0	1	2	3	4
18. Feeling tired.
19. Difficulty sleeping or sleeping too much.
20. Decreased or increased appetite.
21. Loss of interest in sex.
22. Worrying about your health.

	0	1	2	3	4
23. Do you have any suicidal thoughts?
24. Would you like to end your life?
25. Do you have a plan for harming yourself?

	1	2	3	4	5	6	7
Alcohol
Marijuana
LSD
Mushrooms
Nicotine
Methamphetamine
Cocaine
Caffeine:
Opiates:
Club Drugs:
Steroids
Other:

	YES	NO
Have you ever spent most of a day using drugs?
Does it now take more alcohol or drugs to get the same effect as it once did?
Have you ever wanted to stop drinking or using drugs but could not?
Have you ever used drugs or alcohol to reduce or avoid withdrawal?
Have you ever had seizures after drug or alcohol use?
Have you ever had tremors after drug or alcohol use?
Have you ever experienced anxiety after drug or alcohol use?
Have you ever experienced night or day sweats after drug or alcohol use?
Have you ever experienced sleep disturbance after drug or alcohol use?
Have you ever experienced nausea or vomiting after drug or alcohol use?
Have you ever experienced hallucinations after drug or alcohol use?
Have you ever experienced vivid, unpleasant dreams after drug or alcohol use?
Have you ever experienced restlessness or nervousness after drug or alcohol use?
Have you ever been angry, irritable or frustrated after drug or alcohol use?
Have you ever become hostile or violent while using drugs or alcohol?
Have you ever skipped eating because of drug or alcohol use?
Have you ever continued to use drugs or alcohol longer than you planned?
Has the desire to use drugs or alcohol ever been so strong that you could not resist using?
Have you ever felt that your life revolved around your drug or alcohol use?
Have you ever spent most of a day recovering from alcohol or drug effects?
Have you ever had difficult performing your job or school duties because of drug or alcohol use?
Have you ever found yourself preoccupied with wanting to use drugs or alcohol?
Have you ever used alcohol or drugs when you felt sad, anger, or bored?
Have you every changed recreational activities to be with people who use?
Have you ever had medical problems that someone else believed were due to drug or alcohol use?
Have you ever used drugs or alcohol despite knowing that the use may negatively affect your health?

	0	1	2	3
Sleep Disturbance
Appetite Disturbance
Episodic Crying
Low Energy
Depressed Mood
Poor Concentration
Stress/anxiety/worry
Panic Attacks
Memory Loss
Obsessions/Compulsions
Phobias
Mood swings
Irritability
Aggressive Behavior
Homicidal thoughts
Suicidal Ideation
Cut or hurt self
Sexual problems
Physical Pain
Grieving
Substance Abuse
eating Disorder
Co-worker conflict
Relationship conflict
Work/Career Indecision
Academic Problems
Other

	YES	NO
Have you ever been required to have a substance abuse assessment?
Have you been terminated due to substance use/abuse?
Have you ever been placed on a “Last Chance Agreement?”
Have you avoided a job because you would have to complete a drug screen?
Have you had a work-related driving offense in the last 10 years?
Have you ever had a positive drug screen for any employer?
Have had a work-related accident in the last 10 years?
Have you been involved in co-worker conflicts?
Have you ever failed to complete a job probationary period?
Have you ever had driving offenses due to substance use?
Have you been arrested due to use or selling of illegal substances?
Do you have any problematic spending habits?
Have you ever filed bankruptcy?
Have you ever had your wages garnished?

	YES	NO
Do you keep alcohol or drugs in your home?
Are there many drugs or alcohol in your work environment?
Do many of your friends use drugs or alcohol?
Does your current or past partners use drugs or alcohol?
Do you believe that it is OK to use drugs or alcohol?

	Treatment Program Name	Mandated?	Date Completed	Amount of Time Abstinent
1
2
3

	YES	NO
Do you have a high school diploma or GED?
Do you have any other specialized training?
Do you have any learning disabilities?
Do you have spiritual belief systems?
Do you have a specific culture that you identify with?