Northlight Counseling Associates, Inc.
4121 E. Valley Auto Drive, Suite 122, Mesa, AZ 85206
Phone: 602-285-9696 Fax: 480-632-0822

List only phone numbers that we may contact you or leave a message.

I authorize my insurance company to pay Northlight Counseling Associates, Inc. directly for services rendered, for my children, my ward, my spouse and me. I authorize the release of any information pertinent to my case to any insurance company or adjustor involved in this case. A photocopy of this Assignment shall be considered as effective and valid as the original. This is a direct assignment of my rights and benefits under the policy. I also authorized Northlight Counseling Associates, Inc. to initiate a complaint to the Insurance Commissioner for any reason on my behalf. I understand that the filing of a claim to my insurance company is a courtesy to clients.

If divorced: Please note – copy of the court documents are required and will be part of the child’s chart

Does your child have...

Has your child or any of your family members struggled with any of the following?
Check all that apply.

*******This form is required and must be filled out completely********

Please review this information and ask about anything you do not fully understand.

BENEFITS AND EMOTIONAL RISKS: The majority of individuals and families that obtain psychotherapy counseling benefit from the process. Self-exploration, gaining insight, exploring options for dealing with problems, learning new skills, or venting difficult feelings/experiences are generally quite useful, but some risks do exist.  As counseling is begun, please understand that some people experience uncomfortable feelings and that examining issues may trigger feelings of unhappiness, anger, guilt, grief or frustration.  These feelings are a difficult, but natural part of the psycho therapeutic process and often provide the basis for change.  Important personal decisions are often an outcome of counseling and are likely to produce new opportunities and as well as unique challenges.  Your provider will discuss treatment goals, procedures, or your impressions of the services that are being provided.  If at anytime you are uncomfortable with a suggestion or comment that has been made,please discuss with your provider.

CONFIDENTIALITY: A client’s confidentiality is important and is legally protected.  See Notice of Privacy Practice for complete information.  Information may be shared with medical/behavioral health providers involved in your care.   Confidentiality will be waived if a client sues the provider for a breach of duty. In the event that group, family or couple’s counseling services are provided, information maybe disclosed by the provider to another individual if it appears advisable for the treatment process.   In such cases the provider or practice will not be held responsible for breech of confidentiality.  In addition the provider or practice will not be held responsible for breech of confidentiality by other participants.

AVAILABILITY: The offices are normally open from 8:00 a.m. to5:00 p.m. Monday - Friday, evenings and Saturdays by appointment.  Calling the main office number provides instructions and telephone numbers for non-business hours emergency.  The provider may be paged but if unavailable contact 911 or the number on the back of your insurance card, your primary care physician, or go to an emergency room.

PAYMENT AND FEES: You may pay for services at the time they are rendered or you may assign health insurance benefits to us and pay any deductible and/or co-payment.  Most insurance plans require a co-payment which is payable at the time of each visit.  While we can assist you in filing insurance claims you are responsible for any payment of services that your insurance or health benefit plan does not cover.  It is your responsibility to know what your health plan will and will not cover. Feel free to discuss insurance coverage with the office manager.  There is a $25 charge on all returned checks.  NSF checks must be redeemed with cash, certified check, or money order. Delinquent accounts are referred for collections and interest at a rate of 10% annum will apply to balances over 60 days.  We cannot enforce the terms of divorce decrees for payment of psychological, counseling, medical services.  A charge of $60 will apply to any appointment missed or cancelled without allowing a 24 hours advanced notice.  

The following standard charges apply and are subject to change without notice:

	MD	PhD	MA
Intake/Assessment	$350	$250	$250
Medication Management	$125
Individual/Family Therapy (Per Session)	$150	$150	$150
Group Counseling (Per Individual)	$90	$50	$40
Psychological Testing (Per Hour)		$110	$80
Court Services (As Arranged)	$200	$150	$150
Court Testimony (As Arranged)	$300	$200	$150

You are responsible for the full hourly fees accrued in the preparation of legal court documents or time (including travel) spent in court, as these charges are not covered by insurance.

CONSENT/AGREEMENT
I have read the above information and have had my questions answered to my satisfaction. I consent to participate in treatment.  I certify that I am the legal guardian or custodial parent with the legal right to request and approve evaluation and treatment for my son/daughter/ward and hereby consent to their treatment.

If you do not sign this consent form agreeing to what is in our Notice of Privacy Practices, we cannot treat you.

In the future we may change how we use and share your information and so may change our Notice of Privacy Practices.  If we do change it, you can get a copy from our Privacy Offices by calling 602-285-9696.

See Protecting Your Privacy handout for additional important information about your rights.

If you are concerned about some of your information, you have the right to ask us to not use or share some of your information for treatment, payment, or administrative purposes.  You will have to tell us what you want in writing.  Although we will try to respect your wishes, we are not required to agree to these limitations.  However, if we do agree, we promise to comply with your wish.

After you have signed this consent, you have the right to revoke it (by writing a letter telling us you no longer consent) and we will comply with your wishes about using or sharing your information from that time on but we may already have used or shared some of your information and cannot change that.

By initialing this form, I acknowledge I have read and understood the items below.

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

Privacy is a very important concern for all those who come to this office.  It is also complicated because of federal and state laws and our professional standards.  The Health Insurance Portability and Accountability Act of 1996 (HIPPA) law requires us to keep your information private and to give you this notice of our legal duties and our privacy practices.  After reading this notice if questions arise our Privacy Office will be happy to help you.  His or her name and address are at the end of this Notice.

This notice will tell you about how we handle information about you.  It tells how we use this information here in this office, how we share it with other professionals and organizations, and how you can see it.  We want you to know all of this so that you can make the best decision. Because of some very complicated federal and state laws, we have simplified some parts.

The information we collect from you is called Protected Health Information (PHI).  In this office PHI is likely to include these kinds of information:

-Your history. As a child, school, work, marital and personal history.
-Reasons you came for treatment.
-Diagnoses (medical term for your problems or symptoms.)
-A treatment plan. These are treatments and other services, which we think will best help you.
-Progress notes.  Each time you come in we write down some things about how you are doing, what we observe about you, and what you tell us.
-Records we get from other who have treated or evaluated you.
-Information about medications you took or are taking.
-Legal matters
-Billing and insurance information

This list is just to give you an idea and there may be other kinds of information that go into your healthcare record here.  We do not maintain process notes.

Although your health record is the physical property of the healthcare practitioner or facility that collected it, the information belongs to you.  You can inspect, read, or review it.  If you want a copy, we can make one for you, but we may charge you for the costs of copying and mailing.  In some very unusual situations, you cannot see all of what is in your records.  If you find anything in your records that you think is incorrect or something important is missing you can ask to amend your record although in some rare situations we don’t have to agree to do that.  Our Privacy officer can explain more about this. 

The law gives you rights to know about your PHI, how it is used and to have a say in how it is disclosed (shared).  Mainly, we will use and disclose it for routine purposes.  For other uses, we must tell you about them and have a written authorization from you.  However, the law also says that we are allowed to make some uses and disclosures without your consent or authorization.  We will inform you of any breach of your PHI.

We may use or disclose your PHI for three purposes: treatment, obtaining payment, and what are called healthcare operations.

If we want to use your information for any purpose other than those listed above, we need your permission on an Authorization to Release Information Form.  If you do authorize us to use or disclose your PRI, you can revoke (cancel) that permission, in writing, at any time.

In some cases, laws let us use and disclose some of your PHI without your consent or Authorization.  We have to report suspected child or elder abuse and may release information to law enforcement official to investigate a crime.  If you are involved in a lawsuit or legal proceeding and we receive 

a court order or other lawful process, we may have to release some of your PHI.  We must disclose some information to government agencies that check on us to see that we are obeying the privacy laws.  If we come to believe that there is a serious threat to your health or safety or that of another person or the public, we can disclose some of your PHI.  We will only do this to persons who can prevent the danger.

When we disclose your PHI, we keep some records of whom we sent it to, when we sent it, and what we sent.  You can get an accounting (a list) of many of these disclosures.  From the date of service when you elect to become self pay those record will not be available to previous insurance companies.

If you need more information or have questions about the privacy practices described above, please speak to the Privacy Office whose name and telephone are listed below.  If you have a problem with how your PHI has been handled, or if you believe your privacy rights have been violated, contact the Privacy Office.  You have the right to file a complaint with us and with the Secretary of the Federal Department of Health and Human Services.  We promise that we will not in anyway limit your care here or take any actions against you if you complain.

If you have any questions regarding this notice or our health information privacy policies, please contact our Privacy officer, Javier Perez, or Bobbi Vogelsang.  They can be reached by phone at 602-285-9696 or by mail 4121 E. Valley Auto Dr. Suite 122, Mesa AZ 85206.

The effective date of this notice is April 14, 2003.

Please read and familiarize yourself with the financial policies detailed in this disclosure prior to starting treatment. Your signature/initials below indicate that you have read, understood, and are accepting full financial responsibility for all balances on your account(s).

I authorize Northlight Counseling Associates to retain the above referenced credit card information to pay my invoices as they are generated. Payments shall be processed within 24 hours of my appointment or charge, or on the day of the month agreed upon if using a payment plan. This authorization may be rescinded with written notes at any time. Receipts can be mailed or emailed upon patient’s request.