Adult Intake Form

Adult Intake Form
Who is completing this form? *

Client / Patient (Self) Tutor or Legal Representative

Primary Insurance Holder

Please fully complete this section
Policy Holder Name (write exactly as written on card!) *
Primary Health Insurance Company *
Member/ID Number *
Relationship to Client *

Self Spouse Parent
If you have a picture of your drivers license and insurance card, please upload it here

Cancel of
Secondary Health Insurance Company (if any)
Member/ID Number
Relationship to Client

Self Spouse Parent
Employee Assistance Program (EAP): Are you are using your EAP for services here?

Yes No
Name

First Name Last Name
I, {name167} certify that the information stated above is true and accurate to the best of my knowledge. I hereby authorize Compass Counseling Services, LLC (CCS), to bill my health insurance company, myself, and/or its representative for all services that I receive. I further authorize my health insurance company or its representative to make direct payment of benefits to CCS or its providers under the terms and conditions of my health care contract. It is my responsibility to understand my coverage, including co-pays, co-insurance, and deductibles. This also includes understanding what services are covered or not. It is also my responsibility to let CCS know if there is a change in my insurance or coverage.

I understand that I am ultimately responsible for payment of all services. I agree that parents, guardians, or personal representatives are responsible for all fees and services rendered for treatment of a minor/child. I will be held liable for any care provided to me, or to the client for whom I am legally responsible for, even when not covered by the insurance company. I agree to all payments, including co-pays, co-insurances, specimen collection, and deductibles. I understand that filing a claim with my insurance company does not relieve me from my responsibility for the payment of all charges.

In addition, I authorize the appropriate staff at CCS to fill out any and all necessary paperwork or electronic claims required by my insurance carrier or managed care company, including but not limited to: treatment plans, insurance claim forms and termination of care information. I affirm that I have read, understand, and agree to the authorizations stated above.
Signature of Client *

Clear
Today's Date *

Month Day Year
Date

	Approximate Date	Length of Stay	Hospital	Reason for Admission
When?

Authorization to Obtain/Release Protected Mental Health Information: Primary Care Physician/Doctor

This is an authorization for Compass Counseling Services, LLC (CCS) to release, obtain, and/or exchange protected mental health information with your primary care physician/medical doctor for the purposes of coordinating medical care and treatment. By signing this form, confidential psychological and psychiatric information can be released to and/or discussed with the provider/agency listed below unless noted by exclusions or limitations. This form is signed voluntarily and may be revoked at any time. All disclosures made pursuant to this form are valid as long as they were made before the date of revocation.
Client Name *
Client Date of Birth *

Month Day Year
Date
1. Please Select *

I AUTHORIZE CCS to receive and obtain information from my primary care physician, in addition to release a copy of the initial visit record to my doctor/physician and/or release copies of my visit notes when requested by physician. I hereby REFUSE to give CCS authorization to release any treatment information to my primary care physician (PCP) at this time.
2. Primary Care Physician/Doctor Name *
Group/Office Name *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *
Fax Number
3. TYPE OF INFORMATION TO BE DISCLOSED:

This authorization does not represent a complete medical records access request. For a primary care physician/doctor to access the full record, a separate authorization will need to be completed.
4. Note any exclusions or limitations here
I certify that my health information is being disclosed at my request or at the request of my personal representative. I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is not dependent on my signing this authorization. By signing below, I acknowledge that I have read and understand this document and that I have voluntarily given CCS/my provider authorization to disclose my records. I understand that I may revoke this authorization at any time by providing a written notice to my provider. However, the revocation will not have an effect on any actions taken prior to the date my revocation is received. I understand that my information may be redisclosed by the authorized person/organization receiving the information, and at that point, the information may no longer be protected under the terms of this agreement. I am also aware that utilizing my health and or my mental health records for legal purposes are left up to the interpretation by legal representatives and may or may not be beneficial to my legal case. This authorization will expire one year following the date signed unless revoked in writing.
Print Client's Name *
Signature of Client *

Clear
Today's Date *

Month Day Year
Date
Print Name of Legal Guardian or Representative
Signature of Legal Guardian or Representative

Clear
Today's Date

Month Day Year
Date

Acknowledgement of Receipt of the Client Handbook
This page is an Acknowledgment of Receipt of the Client Handbook which outlines expectations, policies, and practices regarding CCS services. The Client Handbook provided for you is to review and keep. The Client Handbook includes but is not limited to: client/patient rights and responsibilities, process of treatment services, risks and benefits of mental health treatment, privacy policies, treatment options and medical necessity, urine drug screening (UDS) policy, fees and service costs, minors and custody issues, health and safety, emergency and crisis resources. Please complete and sign this Acknowledgement page to confirm that you have received a copy of the Client Handbook prior to the start of treatment.

Your initials below indicate your understanding and agreement to these policies and practices written below and the Client Handbook.

Please write your initials on the lines to show your agreement and understanding:
Do you want to received the Client Handbook directly in your email?

Yes No
Email
example@example.com
I acknowledge that I have received and reviewed my copy of the Client Handbook and any questions have been know that printed and electronic versions are available at my request. *
I have reviewed and understand the Client/Patient Rights and Responsibilities for services at CCS. This includes fees, no show/cancellation policies, and my rights. *
I have reviewed and understand the expectations and policies related to CCS service costs and fees. If I cancel within 24 hours or do not show for an appointment, I will pay $25 (not billed to insurance). I am responsible for payment of co pays, co deductibles, and fees not covered by my plan. *
I have reviewed and understand the Informed Consent for Assessment & Treatment Form. I voluntarily request and consent to behavioral health assessment, care, treatment, or services and authorize my provider to provide such care, treatment, or services as are considered necessary and advisable. I understand the practice of behavioral health treatment is not an exact science and acknowledge that no one has made guarantees or promises as to the results that I may receive. I understand the risks and benefits of mental health treatment. *
I have reviewed and understand the Informed Consent for Telehealth Services. I certify that If services are I consent to this and understand any risks that may be associated with this service. I also agree to remain in the Florida during my virtual appointment with my CCS provider (who is licensed/registered for services in FL). *
I acknowledge receipt of the Notice of Privacy Practices, which explains my rights and the limits on ways my provider disclose personal health information to provide service. I understand that CCS will share basic information with my provider unless I ask to "restrict" this disclosure. This includes privacy and exceptions to confidentiality. Any questions regarding these practices have been answered. *
I have reviewed and understand the Urine Drug Screening (UDS) Policy at CCS. If it is determined by a provider that benefit from a screening, a new consent form will be provided to the parent/guardian. *
I have reviewed and understand CCS expectations and response to client crisis situations. I understand that my CCS provider may not be available to provide me with immediate support. I have received crisis resources that I may contact. *
Print Client's Name *
Date of Birth *

Month Day Year
DOB
Signature of Client *

Clear
Today's Date

Month Day Year
Date
Print Name of Legal Guardian or Representative
Signature of Legal Guardian or Representative

Clear
Today's Date

Month Day Year
Date
Should be Empty:

Adult Intake Form

Adult Intake Form

Client Information

Primary Insurance Holder

Primary Care Physician/Doctor

Authorization for Family Member / Personal Representative

Family Member 1

Family Member 2

Family Member 3

Acknowledgement of Receipt of the Client Handbook