PFA Client Application Packet

Psychology For All | PO Box 49556, Charlotte, NC 28277 www.psychologyforall.org

Date*

Date

Name*

First NameLast Name

Age*

Date of Birth*

Date

Race*

Gender*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Phone Number*

Please enter a valid phone number.

Do we have permission to call and leave a message?*

YesNo

Email*

example@example.com

Do we have permission to email you?*

YesNo

Please list monthly income from each of the following:

Salary/Wages:

Social/Supplemental Security:

Retirement/Pension:

Unemployment Benefits:

Disability:

Child Support/Alimony/TANF:

Total Gross Monthly Income:*

Annual Income Range*

PLEASE SEND PROOF OF ALL INCOME (including your last 3 paystubs) BY UPLOADING SCANNED COPIES OR PHOTOS HERE.*

Number of people in your household*

Number of dependents under your care*

Gender Preference for Provider:*

MaleFemale

Language Preference for Provider:*

EnglishSpanish

How would you prefer to receive therapy?*

When are you available for therapy? Please choose all the options that reflect your availability, not just your preference.*

If student, school currently attending

By whom were you referred?*

May we have permission to thank the referral source (without identifying you by name)?*

YesNo

Please initial*

The following questions will help us provide appropriate referral(s):

What are you experiencing/ or what has happened that has caused you to seek counseling?*

Have you received previous counseling?*

YesNo

If yes, please explain:

Please indicate any geographic preference within Mecklenburg County?

I hereby certify that the information provided herein is true and correct.

Signed*

Date*

Date

This Client Participation Agreement (this "Agreement") is made on*

Date

between Psychology for All, Inc. ("PFA") and the individual named on the signature ("Client" or "you").

1. Services. PFA has established a network of licensed mental health practitioners (the "Network") who have agreed to provide limited professional mental health care services to individuals who apply to PFA for assistance and who are approved to receive assistance from PFA. As a client of PFA, you are eligible (a) to receive a referral to a licensed mental health practitioner (each, a "Provider") in the Network and (b) to receive up to 8 45-60 minute counseling sessions to be conducted within 6 months of your first session with a Provider at no charge and, if recommended by a Provider and approved by PFA, receive an additional 8 45-60 minute counseling sessions to be conducted within 12 months of your first session with the Provider at $20 per session to be paid to the Provider (the "Services"), subject to the terms and conditions set forth in this Agreement.

2. Client Rights and Responsiblities.

As a client of PFA, you are entitled to:

Receive the Services, unless earlier terminated in accordance herewith.
Information about any procedures, methods of counseling, techniques and possible duration of therapy.
Participate in treatment decisions during his or her care.
Be treated at all times with dignity and respect.
End counseling at any time without any moral, legal or financial obligations other than those already accrued.

You agree to:

Give updated information to PFA about your eligibility to participate in PFA's program.
Give information the applicable Provider needs to give appropriate care.
Follow the applicable Provider's recommended plans and instructions for care.
Participate in the treatment process through a focus on problems and the development of mutually agreed upon treatment plans and goals.
Keep your scheduled appointment.
Comply with other guidelines established by PFA and/or the Provider.

If you do not comply with any of the above requirements, or if you do not satisfy PFA's eligibility criteria at any time (which are listed below and may be updated by PFA in its sole discretion from time to time), you will become ineligible for the Services and PFA may terminate this Agreement immediately.

3. Appointment Scheduling, Cancellation and No-Show Policies. All appointments must be schedule between you and the applicable Provider. If you cannot keep your scheduled appointment, you must give the applicable Provider at least 24 hours notice. The applicable Provider may require a longer notice period. Without this notice, you will be treated as having used one counseling session. If you miss two appointments without giving the applicable Provider at least 24 hours notice, you will become ineligible for the Services and PFA may terminate this Agreement immediately.

4. Emergencies. If you have a clinical emergency after the applicable Provider's regular business hours, call 911 or go to your nearest hospital emergency waiting room.

5. Termination of Services and Agreement: Transfer of Records. You may terminate the Services for any reason. Upon termination or completion of the Services, this Agreement will terminate automatically. Sections 8 and 9 shall survive any termination of this Agreement. After termination, if you ask, PFA will make every effort to give you a referral to another provider. You may request that the applicable Provider transfer your records to a new provider by signing an authorization to release your medical information.

6. Privacy and Confidentiality. Each Provider is subject to federal and state laws protecting medical and mental health records. The applicable Provider will give you a notice of privacy practices and information explaining how your information is collected, how it is protected and how it may be shared. PFA will not receive any information about your services other than (a) confirmation that you have attended counseling sessions in order to process payment for those sessions to the applicable Provider, and (b) as authorized by you pursuant to a release of medical information.

7. Fees.

Counseling (45-60 Min.) (first 8 sessions): $0.00 per session

Counseling (45-60 Min.) (next 8 sessions, if approved): $20.00 per session (to be paid by you directly to the applicable Provider)

8. Indemnity: Role of PFA. PFA's role under this Agreement is to maintain a network of mental health practitioners and to reimburse the applicable Provider for Services provided under this Agreement. All providers in PFA's network are independent contractors. You agree to indemnify and hold harmless PFA, its employees, officers, trustees, affiliates, agents and representatives from and against any losses, costs, damages, and expenses (including, without limitation, reasonable attorneys' fees and costs) that arise or relate in any way to the Services or this Agreement.

9. Arbitration, Governing Law. Any controversy or claim arising out of or relating to this Agreement, or the breach thereof, shall be settled by arbitration administered by the American Arbitration Association in accordance with its Commercial Arbitration Rules. The laws of the State of North Carolina shall be applied in any arbitration proceedings, without regard to principles of conflict of laws. The arbitration hearing shall take place in Mecklenburg County, North Carolina before a single arbitrator. Judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof.

10. Discrimination. PFA does not discriminate based upon age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, or language.

11. Client Agreement. You have read and you understand this Agreement. You agree to the terms and conditions set forth herein. You acknowledge that you may request a copy of this Agreement at no charge.

Name*

First NameLast Name

Signature*

Date*

Date

Eligibility Criteria

Must be over the age of 18.
Must be uninsured and ineligible for Medicare, Medicaid, or other state or federal health insurance.
Must be at or below 200% of the Federal Poverty Guidelines (see https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines), as updated from time to time. Guidelines for 2024 are as follows:

200%

Family of 1:	$30,120 a year ($2,510/month)
Family of 2:	$30,880 a year ($3,407/month)
Family of 3:	$51,640 a year ($4,303/month)
Family of 4:	$62,400 a year ($5,200/month)
Family of 5:	$73,160 a year ($6,097/month)
Family of 6:	$83,920 a year ($6,993/month)
Family of 7:	$94,680 a year ($7,890/month)
Family of 8:	$105,440 a year ($8,787/month)

Must give proof of household income (tax return, Form W-2, paystub, proof of unemployment).
Must be able to see a mental health provider in Mecklenburg County, North Carolina.

1. "I like most parts of my personality."*

2. "When I look at the story of my life, I am pleased with how things have turned out so far."*

3. "Some people wander aimlessly through life, but I am not one of them."*

4. "The demands of everyday life often get me down."*

5. "In many ways I feel disappointed about my achievements in life."*

6. "Maintaining close relationships has been difficult and frustrating for me."*

7. "I live life one day at a time and don't really think about the future."*

8. "In general, I feel I am in charge of the situation in which I live."*

9. "I am good at managing the responsibilities of daily life."*

10. "I sometimes feel as if I've done all there is to do in life."*

11. "For me, life has been a continuous process of learning, changing, and growth."*

12. "I think it is important to have new experiences that challenge how I think about myself and the world."*

13. "People would describe me as a giving person, willing to share my time with others."*

14. "I gave up trying to make big improvements or changes in my life a long time ago."*

15. "I tend to be influenced by people with strong opinions."*

16. "I have not experienced many warm and trusting relationships with others."*

17. "I have confidence in my own opinions, even if they are different from the way most other people think."*

18. "I judge myself by what I think is important, not by the values of what others think is important."*

CLIENT APPLICATION FOR ENROLLMENT

Psychology For All (PFA ) Client Participation Agreement

Psychology For All

Psychological Well-Being (PWB) Scale