Initial Paperwork

Name of Provider*

Today's date*

Date

Name*

Address*

Address

Street Address Line 2

CityState

Zip

Date of Birth*

Date

Cell Phone Number

Home Phone Number

For your cell, which company do you use?

Is it okay to send appointment reminders to that number?

Employer Name*

In case of emergency, please call: (Emergency Contact Name)*

Emergency Contact Phone Number*

Relationship to emergency contact*

How will you be paying for Services? (Select One)*

InsuranceSelf-Pay

If you are opting out of using your insurance, please complete the Opt Out Form.

Insurance:

By providing your insurance information, you are giving your provider permission to bill and release any information requested by your insurance company.

Insurance Company*

Member/Contract Id #*

Group #*

If the insurance is not in your name who is the policyholder:

Name (Last Name, First Name, Middle Initial)

Relationship to Policyholder

Insured's SS Number

Date of birth

Date

Insured's address if different than yours

City

State

Zip code

Insured's Phone Number

For secondary mental health benefit plan fill out all information below:

Insured's name

DOB

Insurance company name

Policy number

Healing Solutions Policies

Confidentiality: All verbal and written information in your session is strictly confidential and can be released only with your prior written permission. The exceptions are 1) in situations where there is a threat of immediate danger to you, other individuals or society; 2) when a judge writes an order to release our records to the court.

Individual Therapy Appointments: Therapy sessions are 55 minutes in length unless pre-scheduled otherwise. Physician appointments are 1.5 hours for initial appointments and 15-30 minutes for follow-up appointments.

Cancellations: Scheduled appointments are times for you specifically. A minimum of twenty four (24) hours' advanced notice is requested for changes in the appointment time. With notice less than 24 hours, a fee of $135.00 will be charged for a missed therapy appointment. Please see Dr. Paddocks patient contract for fee information regarding no show fees.

Group therapy: Group sessions are 80 minutes in length. There is a 15 group commitment for group and the fee is due whether you attend or not.

Payment: It is our policy that payment is due at the time of service. We accept and file insurance and our administrative assistant will check your insurance for benefit, costs, need for referral, etc. If we accept your insurance you are responsible for the co-pay at the time of service and we will file a claim with your insurance company. If we are out of network with your insurance company, you are responsible for the bill at time of service and will be provided with a super bill which you can use to file with your insurance company.

Phone service: We do not have 24 hour phone coverage. If you have an emergency please go to your local emergency room or call 911 or the crisis line at 205-323-7777. If you leave a message your call will be returned within 2 business days.

Continuity of care: Your therapist and/or psychiatrist may at times be out of touch with the office and unable to meet an acute need. This practice is not an acute care practice and at times you may not be able to make immediate contact with your provider. We will work to provide coverage and give notification of times we will be unavailable. We do not have on call services. Our expectation is that if you are using this practice you are stable enough to coordinate and manage your counseling and psychiatric needs within the times we are available. If an emergency or crisis situation arises please go to your local emergency room, call the crisis line, (205) 323-7777 or dial 911 for help.

My signature below acknowledges my understanding and acceptance that each practitioner here operates as the sole proprietor of her own practice and clientele. Each practitioner is committed to the ethical code of conduct for her expertise and is solely responsible for her own behavior. Any questions you may have regarding your practitioner's practices or conduct should be addressed with her.

I have read and understood the above and consent to treatment.

Signature of client or responsible party*

Date*

Date