Client Intake Form

Today's Date*

Date

Services Requested*

TherapyMedication ManagementBoth

Client Information

Client Name*

Social Security #

Address*

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code

Mobile Phone Number*

Alternate Number

Birth Date*

Date

Race / Ethnicity

Marital Status

Gender Identity

Assigned Gender at Birth

Preferred Pronouns

Email Address

example@example.com

School / Employer

Level of Education

Guardian Information

Guardian 1

Guardian Name

Relationship to Client

Address

Phone Number(s)

Email Address

example@example.com

Guardian 2

Guardian Name

Relationship to Client

Address

Phone Number(s)

Email Address

example@example.com

(If guardian, Synergy Clinical Services of Central Iowa L.L.C. requires proof of guardianship paperwork)

In Case of Emergency

Name of Emergency Contact*

Relationship to Client*

Phone Number*

Court Involvement*

NoYes

If Yes, Name of Worker

Last, First

Worker Phone Number

Insurance Information

Primary Insurance

Insurance Company Name*

Policy Number*

Group Number*

Subscriber's Name*

Subscriber's Date of Birth*

Date

Client's Relationship to Subscriber*

Secondary Insurance

Insurance Company Name

Policy Number

Group Number

Subscriber's Name

Subscriber's Date of Birth

Date

Client's Relationship to Subscriber

Financial Policy

Welcome to Synergy Clinical Services of Central Iowa L.L.C. Please carefully read through the following financial information.

Insurance:

Your health insurance is an agreement between you and your insurance company. We make every effort to help you understand your therapy benefits using the insurance information you provide. We will contact your insurance company and receive a breakdown of benefits for therapy services. The information we receive from your insurance company will allow us to provide you a rough estimate. We can only estimate your benefits as provided by your insurance company. It is still your responsibility to know your insurance benefits including eligibility, covered benefits, medically necessary procedures, and exclusions. Please contact the customer service at your insurance company to discuss benefits for therapy services prior to your appointment. You are responsible for any charges not covered by your plan.

All co-payments, coinsurances, and deductibles must be paid at the time service is rendered, unless other arrangements are made in advance. Your insurance company requires that we collect all deductibles and co-payments. It is your responsibility to pay your Synergy Clinical Services of Central Iowa L.L.C. account balance in full. If you are unable to pay the full balance, you must contact the billing department at (515)277-6399 to make acceptable payment arrangements. Medicaid clients are not required to make out of pocket payments.

Change in Insurance Coverage: Synergy Clinical Services of Central Iowa L.L.C. will bill your insurance for services rendered. However, if you or your child have any change in coverage or change in insurance policy, you must notify us of this change. If you are issued a new insurance card please allow us to take a copy of it for the client chart.

***You will be billed for any charges that cannot be paid because of changes to you or your child’s coverage and/or any denied claims***

Cancellations:

You also understand and agree to provide 24-hour notice of cancellation and if you fail to do this, you will be charged a cancellation fee. You acknowledge that a pattern of missed appointments constitutes grounds for termination of services.

Billing:

Payment is due at the time services are rendered. For all returned checks, there will be a charge of $40.00. If your account has not been paid for more than sixty (60) days and arrangements for payment have not been agreed upon, Synergy Clinical Services of Central Iowa L.L.C. has the option of using legal means to secure the payment. This might involve hiring a collection agency or going through small claims court which will require the agency to disclose otherwise confidential information. In most collection situations, the only information Synergy Clinical Services of Central Iowa L.L.C. releases regarding a client’s treatment is his/her name, the nature of the services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.

Patient Informed Consent/Consent for Treatment

I have chosen to receive treatment services through Synergy Clinical Services of Central Iowa L.L.C. The type and extent of services that I will receive will be determined following an initial assessment and thorough discussion with me. I understand there is no assurance that I will feel better because services are a cooperative effort between my counselor and me. I will work with my counselor in a cooperative manner to resolve my difficulties.

I understand that all information shared with the clinicians at Synergy Clinical Services of Central Iowa L.L.C. is confidential and no information will be released without my consent.

I understand that the state and local laws require that my counselor report the following:

1. When there is risk of imminent danger to myself or to another person the counselor is ethically bound to take necessary steps to prevent such danger.

2. When there is a suspicion that a child or elder is being sexually or physically abused or neglected or is at risk of such abuse or neglect, the counselor is legally required to take steps to protect the child or elder, and to inform the proper authorities.

3. When a valid court order is issued for medical records, the counselor and the agency are bound by law to comply with such requests.

I have read and have had explained to me the basic rights of individuals who undergo treatment through Synergy Clinical Services of Central Iowa L.L.C. The rights include:

1. The right to be informed of the various steps and activities involved in receiving services.

2. The right to confidentiality under federal and state laws relating to the receipt of services

3. The right to humane care and protection from harm, abuse, or neglect.

4. The right to make an informed decision as to whether to accept or refuse treatment.

5. The right to contract and consult with a counselor and select practitioners of my choice and at my expense.

If I have questions regarding this consent form or about the services offered by Synergy Clinical Services of Central Iowa L.L.C., I may discuss them with my counselor. I have read and understand the above. I consent to participate in the evaluation and treatment offered to me by Synergy Clinical Services of Central Iowa L.L.C. I understand that I may stop treatment at any time. I understand that I can revoke my consent at any time except to the extent that if I do not revoke this consent, it will expire automatically one year after all claims for treatment have been paid. I also understand that I have the right to inspect records pertaining to my treatment.

Privacy Notice

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. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE OF PRIVACY PRACTICES, PLEASE CONTACT OUR MAIN OFFICE AT (515) 277-6399.

We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. We make a record of the medical care we provide and may receive such records from others. We use these records to provide or enable other health care providers to provide quality medical care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this medical practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact us at phone number listed above.

You Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Receive notice of our policies and procedures used to protect your protected information;
Request that certain uses and disclosures of your protected information be restricted, provided, however, if we release the information without your consent or authorization, we have the right to refuse your request;
Access to your protected information be amended, although we are not required to grant your request;
Obtain an accounting of certain disclosures by us of your protected information for the past six (6) years;
Revoke any prior authorizations for use or disclosure of protected information, except to the extent that action has already been taken; and
Request that communications of your protected information are done by alternative means or at alternative locations.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information, talk to us. Tell us what you want us to do, and we will follow your instructions.

Uses and Disclosures

Synergy Clinical Services of Central Iowa L.L.C. collects health information about you and stores it in a chart (on a computer system This is your medical record. The medical record is the property of Synergy Clinical Services of Central Iowa L.L.C., but the information in the medical record belongs to you.

Generally, your protected information may be used and disclosed by us only with your expressed written authorization. This written authorization includes to whom the information may be disclosed, what information may be disclosed, and for what purpose. You may revoke this authorization at any time, although any information released prior to the revocation may be used as stated on the consent.

There are some exceptions to this general rule. The law permits us to use or disclose your health information for the following purposes:

Treatment Purposes: We may use or disclose your protected information for treatment purposes to doctors, nurses, hospitals, for instance, in order to facilitate your treatment.
Payment Purposes: Your protected information may be used or disclosed to your insurance company, for instance, for payment purposes as it may be necessary to disclose this information so that we may properly receive payment for treatment and services provided.
Health Care Operations: Your protected information may be used or disclosed for health care operations. For example, record review related to quality assurance and improvement activities.
Compliance and Quality Assurance: We may release your protected information to another individual or entity covered by the HIPPA privacy regulations that has a relationship with you for fraud and abuse detection or compliance purposes, quality assessment and improvement activities, or review, evaluation or training of professionals or students.
Oversight Activities: Your protected information may be used or disclosed to an oversight agency for activities authorized by law. Examples of oversight activities include audits, investigations, and inspections. In most cases, the oversight activity will be for the purpose of overseeing services and agency compliance with certain laws and regulations.
Judicial and Administrative Proceedings: If you are involved in a lawsuit or other administrative proceeding, we may release your protected information in response to a court or administrative order. We may also release protected information pursuant to a subpoena or discovery request, but only if efforts have been made by the requestor to provide you with notice of the request and you have failed to object or the objection was resolved in favor of disclosure, or in the alternative, the requestor has obtained a protective order protecting the requested information.
Law Enforcement: We may release your protected information to law enforcement officials when required or permitted by federal or state law to do so.
Public Safety: We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
Emergency Circumstances: Protected information may be disclosed to personnel who have a need for information about a client, such as for the purpose of treating a medical or mental condition which poses an immediate threat to the health and safety of any individual or the public and which requires immediate intervention.
Individuals Involved in Your Care: We may give out your protected information to a friend or family member who is helping with your care or with payment for your care. However, prior to sharing your protected information in this instance we will first attempt to obtain your verbal or written consent. An example of when obtaining such consent would not be feasible would be if you are involved in a serious accident and unavailable to give your consent and it is necessary for us to speak with your emergency contact or other responsible party.
Mandatory Reporting of Child Abuse/Dependent Adult Abuse and Neglect: Synergy Clinical Services of Central Iowa L.L.C. staff are mandatory reporters of child abuse and dependent adult abuse and neglect. In the event that there is reason to suspect that child abuse or dependent adult abuse or neglect has occurred, your protected information may be disclosed as required by law.
As Authorized by Law: We will disclose your protected information for reasons not described above when required by law to do so.
More Stringent Laws: Some of your protected information may be subject to other laws and regulations and are afforded greater protection that what is outlined in this Notice. For instance, HIV/AIDS, substance abuse, and mental health information is often given more protection. In the event your protected information is afforded greater protection under federal or state law, we will comply with the applicable law.
Breach Notification: In the case of a breach of unsecured protected health information, we will notify you as required by law. We will communicate with you about information related to the breach. We may also provide notification by other methods as appropriate.

Our Responsibilities

In the course of treatment, information regarding your care may be created and/or received by us. Information which can be used to identify you and which relates to your past, present or future physical or mental condition, receipt of care or payment for care is considered protected information and is protected by federal and state law. Federal law imposes certain obligations and duties upon providers of services with respect to your protected information. Specifically, we are required to:

Provide you with notice of our legal duties and policies regarding the use and disclosure of your protected information;
Maintain the confidentiality of your protected information in accordance with state and federal law;
Honor your requested restrictions regarding the use and disclosure of your protected information, unless under the law we are authorized to release your protected information without your authorization.
Allow you to inspect and copy your protected information;
Act on your request to amend protected information, although we are not required to amend the protected information, within sixty (60) days and notify you of any delay which would require us to extend the deadline by the permitted thirty (30) day extension;
Accommodate reasonable requests to communicate protected information by alternative means or methods; and
Abide by the terms of this notice.

We reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, we are required by law to comply with the terms of this Notice currently in effect. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our office, and a copy will be available at your request. We will also post the current notice on our website.

This notice has been provided to you as a summary of how we will use your protected information and what your rights with respect to your protected information are. If you have any questions or would like more information regarding your protected information, please contact your direct worker or the supervisor of the program in which you participate. If you believe your privacy rights have been violated, you may file a complaint with our office by contacting your direct worker or the supervisor or the program in which you participate. He or she will provide you with specific information regarding the agency’s grievance policy. You may also file a complaint with the Secretary of Health and Human Services. There will be no retaliation for the filing of a complaint.

I, Full Name* , I hereby acknowledge I have been given an opportunity to read a copy of Synergy Clinical Services of Central Iowa L.L.C. Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can discuss this with my provider. I am aware that this notice educates me on the way my identifiable health information may be used and disclosed. I understand that this notice also informs me of my rights in regard to my protected information.

Signature of Client/Legal Representative*

Clear

Date*

Date

Relationship to Client*

Witness

Date

Physician Information

Primary Physician

Specialty

Address

Phone #

*

Please EXCHANGE information with my primary physician for care coordinationPlease DO NOT exchange information with my primary physician for care coordination at this timeI DO NOT have a primary care physician, please do not exchange information at this time

I understand that Synergy Clinical Services of Central Iowa L.L.C.s, my health plan representative, and my primary care physician may exchange any and all information pertaining to my services to the extent such disclosure is necessary for claims processing, case management, coordination of treatment, quality assurance, and/ or utilization review purposes. I understand that I can revoke my consent at any time except to the extent that treatment has already been rendered or that action has been taken in reliance on this consent. I understand that if I do not revoke this consent, it will expire automatically one year after all claims for treatment have been paid as provided in the benefit plan. Part of this exchange includes sending treatment plans, quarterly/progress reports and summary letters upon termination of our services with your family.

Patient ( if over age 18) or Parent/ Guardian Signature*

Clear

Date*

Date

Relationship/ PRINTED NAME*

Witness Signature

Clear

Each year, almost 44 million Americans experience a mental disorder. In fact, mental illness are among the most common conditions affecting health today. The good news is that most people who have mental illness, even serious ones, can lead productive lives with proper treatment. Therapy is interpersonal treatment for problems in living. It involves talking with a trained professional about conditions ranging from depression and anxiety to relationship conflicts and career frustrations. Therapy provides ways to express feelings, understand patterns of thinking, gain perspective on past events and current relationships, set goals, and clarify dreams for the future. Therapy can both alleviate pain and suffering and add meaning and richness to life. Therapists employ a range of techniques and methods, some suited to particular mental health issues and some that can be applied to clients dealing with a variety of issues. All therapists seek to increase their client’s mental health and to act as a confidential and careful listener. (From Psychology Today at http://therapists.psychologytoday.com/)

Therapy will include, but is not limited to, the following elements:

Psychosocial Assessment - During your initial appointment, your counselor will meet with you and assess your current situation and needs through a variety of questions. During you assessment, you will be asked questions about your physical and mental health, substance abuse, family and social life, education, strengths, etc. This session will differ from typical ongoing sessions as your therapist works with you to identify and focus on goals for therapy. Our therapists use a variety of techniques and approaches based on individual or family needs and individualized therapeutic goals. This session typically ranges from 45-60 minutes.

Individual therapy – Individual sessions involve meeting with your therapist one on one to work toward your goals. The approach and techniques used in these sessions will depend on the individualized goals set by you and your therapist. These sessions range from 30-50 minutes.

Family therapy – These sessions typically focus on family relationships and sessions involve other family members. The approach and techniques used in these sessions will depend on the individualized goals set by you and your therapist. Family sessions typically last 45-50 minutes.

Individual assessments – Throughout the therapy process you may be asked to read certain things, to complete written assignments, or to try new behaviors aligned with your therapy goals. These assignments are designed to foster insight, change and growth needed to achieve your goals.

1. Be treated with respect and dignity

2. Be protected against physical, emotional, or psychological abuse and/or harassment

3. Receive care based on your individual situations and needs

4. Have the quality of your care assured

5. Play an active role in planning for the services you receive

6. Be treated fairly and not discriminated against based on race, religion, culture and/or sexual orientation

7. Confidentiality, no information will be released without your written consent except as required by law (more specifically suicide, homicide and child or adult abuse or neglect

8. Refuse treatment even if recommended by your therapist. Should you refuse treatment, you will be advised of possible consequences and given alternative forms of treatment if available.

9. Be informed about the purpose of the services you are receiving

10. Express your opinions about services you receive

1. Participate honestly and openly in treatment

2. Be respectful of others and their property

3. Work cooperatively with staff in setting and reaching goals for yourself regarding your treatment program, family life, and behavior

4. Ask questions when you need clarification

5. Discuss any reservations you have about your treatment

6. Report changes or unexpected events as related to your problem

7. Keep appointments whenever possible and, if necessary, make any cancellations at least 24 hours prior to your scheduled appointment. Three missed appointments may cause you to be discharged from therapy services.

8. Remember you are responsible for your thoughts, feelings, actions, and growth. We are here to help you to the best of our ability.

9. Be financially responsible for your portion of the session. Make any insurance co-payments at the time of your appointment. Pay outstanding invoices upon receipt.

Staff will respect the need for confidentiality of information concerning each individual and family served. Staff at Synergy Clinical Services of Central Iowa L.L.C. will do all in their power to protect the privacy and security of each patient.

Mandatory Reporters are required by law to report within twenty-four (24) hours if they reasonably believe a child or dependent adult has suffered abuse or neglect. A report of child or dependent adult abuse or neglect is not an accusation, but a request to determine whether child or dependent adult abuse or neglect exists and begin the helping process.

Clients of Synergy Clinical Services of Central Iowa have the right to file a grievance or complaint with Managing Partners. Should a client feel Synergy Clinical Services of Central Iowa engaged inappropriately or unethically or an attempt to resolve the situation directly with the party involved failed, the client should submit a written statement to Managing Partners. The complaint will be reviewed by Managing Partners and if deemed to be valid will be addressed with the employee(s) involved. Appropriate corrective action will be taken. If the complainant is not satisfied with the action or lack of action taken, the client has a right to an appeal. A written appeal must be presented within fifteen days after the alleged event or action which is being appealed.

If a client wishes to file a grievance with Synergy Clinical Services of Central Iowa, the following steps must be taken:

The name, address, and telephone number of the petitioner.
The name, address, and telephone number of the person on whose behalf of the petition is being filed.
The specific action which gives rise to the complaint.
The statute, rule, policy, or decision which has been violated by any action or intended action.
A statement discussing the issue at hand, the reason for petition, facts, persons involved, and identify efforts made to attempt to resolve the dispute prior to the appeal.

Synergy Clinical Services of Central Iowa will pursue any and all necessary steps to resolve the dispute. Synergy Clinical Services of Central Iowa will give each client, parent/guardian the opportunity to sign the grievance procedure at the initiation of services and annually thereafter. This document will be filed in the client’s file; a copy will be given to the client, parent/guardian upon request.”

The Synergy Clinical Services of Central Iowa L.L.C. office staffs the phones from: 8am – 8pm on Monday Thursday and 8am – 12pm on Friday to handle mental health emergencies. If you have a mental health crisis in your family and need assistance after hours please call 911. Be clear with the dispatcher what the situation is, that it is a mental health crisis, and you need the Des Moines Mobile Mental Health Crisis Unit to assist. The goal is to keep everyone safe and to seek the appropriate level of assistance for the ill family member or friend. The non-emergency phone number for the mobile crisis team is 515-283-4811. A mobile crisis team member will call you back when they are not on a mobile crisis call. In response to your phone call, the first people to arrive to the situation will be Des Moines police officers. Officers will determine if it is a mental health related issue and maintain safety at the scene. Officers make a request through dispatch if the Mobile Crisis Unit is needed. Mobile Crisis only takes referrals from law enforcement.

By signing below, I certify that I have read and understand the following:

- Patient Intake Forms

- Patient Insurance Information

- Financial Policy

- Patient Informed Consent / Consent for Treatment

- Counseling Center Client Handbook

Signature of Client/Legal Representative*

Clear

Date*

Date

Relationship to Client*

Witness

Date

Synergy Clinical Services of Central Iowa L.L.C. strives to offer better services to our clients and would appreciate your feedback. Would you prefer this to be completed by telephone or through a mailed questionnaire?

By TelephoneMailed Questionnaire

Please choose only one reminder!

Please choose only one reminder!

I wish to receive e-mail appointment remindersI wish to receive text message appointment remindersI wish to receive phone call appointment reminders

E-Mail Address

example@example.com

Cell Phone Number

Phone Number

Client Intake Form

Acknowledgement of Receipt of Notice of Privacy Practices

Counseling Center Client Handbook

Mental Health:

You Have the Right to

We Expect You to...

Confidentiality

Mandatory Reporters

Grievance Process

Crisis Plan