• Adult Registration Packet

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

  • Client Information

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  • Emergency Information

  • Insurance Information

    (Please do not leave blanks; must be completed.)
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  • I authorize my insurance company to pay directly to Northlight for services rendered for me, my children, ward or spouse. 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 authorize 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 patients.

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  • Additional Client Information Required

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

  • Treatment Agreement

  • 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.

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  • HIPAA Consent

    Consent to Use and Disclose Your Health Information
  • This form is an agreement between and Northlight Counseling Associates, Inc. When we use the word “you” below, it will mean your child, relative, or other person if you have written his or her name .

  • When we examine, diagnose, treat, or refer you we will be collecting what the law calls Protected Health Information (PHI) about you.  We need to use this information to decide on what treatment is best for you and to provide treatment to you.  We may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions.

    By signing this form, you are agreeing to let us use your information here and to send it to others.  The Notice of Privacy Practices explains in more detail your rights and how we can use and share your information.  Please read this before you sign this Consent form.

    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.

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  • Northlight Clients Responsibilities

  • By initialing this form, I acknowledge I have read and understood the items below.
  • Co-Payments
    Co-payments are due at time of service. Please be prepared to pay prior to appointment. If you are unable to provide your copay, you will not be able to reschedule until fee is paid.

  • No Show Late Cancellation Policy
    Missed appointments or appointments cancelled with less then 24 business hours’ notice (Monday 8am to Friday 5pm) will incur a $60.00 charge payable by the client. Monday cancellations require phone call notice by previous Friday. 

    After two no-shows, any additional previously scheduled appointments will be cancelled and not rescheduled until fees have been paid.

  • Medication Refill Request
    Refills are usually allowed if the doctor has seen you within the last 90 days. Request for medication refills must go through your pharmacy. Do not wait until you have run out of medication. You are encouraged to contact your pharmacy to request your refill 4 days prior to the day of your last dosage to prevent going without medication. 

    If you cancelled, no showed, or failed to make an appointment, and you request and receive a refill; there will be an additional $30.00 fee for this service. This fee is in addition to the no-show/late cancellation fees.

  • Disability, FMLA and Other Forms/Paperwork
    Forms and special paperwork require an appointment and requires you to be present with the provider to complete. This means that you will need to have a scheduled appointment with your provider. This office does not consider these items as emergencies so please allow adequate time for scheduling these appointments.

  • EAP Reminder
    If you are planning to use your EAP benefits (employee assistance program) you must have all required information at the time of your first appointment. You must have the EAP name, authorization number, telephone number of EAP, how many sessions authorized, and dates the authorization is valid. If you do not have this information at the time of your first appointment, your medical/behavioral health insurance will be billed. Your copays and other payments that are your responsibility will be due at your first session. We will not back bill for sessions already used and billed for.

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  • PCP Notification Form

    Northlight Provider/Primary Care Physician Communication Form
  • This is not a request for records.

    Client Consent to Exchange Information (to be completed by client): I,

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  • , my Northlight provider and

  • to exchange information regarding my mental health/substance abuse treatment and medical healthcare for coordination of care purposes as may be necessary for the administration and provision of my healthcare coverage. The information exchanged may include information on mental health care or substance abuse care and/or treatment such as diagnosis and treatment plan.

    I understand that this authorization shall remain in effect until 6 months after termination of treatment. I understand that I may revoke this authorization at any time by written notice to the above Northlight provider. I also understand that it is my responsibility to notify my Northlight provider if I choose to change my Primary Care Provider.

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  • A copy of this form must be sent to the Primary Care Provider, retaining the original in the client’s chart. If the form is sent by fax, attach confirmation that fax was sent.

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  • Sent by .

  • Pre-Visit Questionnaire/Clinical History

  • Section 1. Main reason for a visit (select all that apply):

  • Section 2. Mental Health Treatment History:


  • Previous Psychiatric Medications (see attached list, select medications you have tried).

  • Section 3. Family History (check all that apply):

  • Section 4. Chemical Dependency/other dependency problems:

  • Section 5. Medical History:

  • Females:

  • Section 6. Current Medications:

  • Section 7. Social History:

  • I was born in and raised in by my    .

  • I am the #  of biological children.

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  • Previous List of Psychiatric Medications

    Please list any medications prescribed for the following:
  • Protecting Your Privacy

  • To increase your privacy, confidentiality and security: While you are always welcome to use your insurance to cover some or all of the cost of services we want you to know as part of informed consent that certain risks are taken by you when your insurance is used:

    • Insurances require a diagnosis, which can follow you throughout your life and in some instances preclude you from future insurance coverage.

    • Insurance usage may require a social security number, which increases your risk of identity theft.

    • Once your insurance company completes it’s own records, your Protected Health Information may be sent to a national clearinghouse that may not be required to operate by the same confidentiality protocols as your provider or your insurance company.

    Paying for services privately (out of pocket) can eliminate most if not all of the above risks and considerations. Please feel free to ask your provider if you would like more information regarding paying privately.

    You may also speak with your provider about ways you may be able to minimize one or more of these risks if you are unable to pay out of pocket for services.

  • Notice of Privacy Practices

  • 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.

  • Financial Agreement

  • 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).

  • Payments Due at Time of Service: I understand and agree that insurance co-pays or private payments are due at the time of service unless other arrangements have been made. If I am unable to pay at the time of service and have not made other arrangements, my appointments will be cancelled, and I will be charged a late cancellation fee. * .

  • Late Cancellation, Missed Appointments, Late Arrivals: I understand that my clinician requires a minimum of 24 hours notice to cancel or reschedule my appointment. Late cancellations and missed appointments (no-shows) will be charged at the private pay rate for my visit type. (For prescribers, if you arrive later than 15 minutes to your appointment, the appointment will be cancelled, and you will be charged a late cancellation fee. For therapists, if you arrive later than 20 minutes to your appointment, the appointment will be cancelled, and you will be charged for a late cancellation.) * .

  • Other Charges: I understand that if I request my clinician complete a legal/school document or form, or any other service outside a normal clinical appointment, there will be a charge associated with that service. (In some instances, your clinician may request you schedule an appointment to assist in the accurate completion or review of a document/form or other service. Your clinician will discuss the fee with you at the time of the request.) I understand that payment for the completion of any document or form will be due prior to receiving the completed service. * .

  • Acknowledgement of Self-Pay: By initialing this paragraph am agreeing to the terms and conditions of a self-pay client with my assigned provider. I understand that my private insurance will not be utilized for billing, nor will my insurance information be retained on file. * .

  • Unpaid Fees for Service: I understand that when fees for services are not paid in a timely manner, a collections agency may be utilized in collecting unpaid balances. The specific content of the services is not disclosed. If a balance remains unpaid it may be reported to credit agencies and the patient’s financially responsible parties credit report may state that amount owed, time frame and the name of the clinic. I understand that unpaid fees may cause a break or termination of treatment services. (Should any aspect of these payment policies present a special challenge for you, please feel free to discuss any concerns with
    administrative staff or your provider. Under special circumstances, billing arrangements may be made if they are addressed before the account balance is past due.). * .

  • Credit Card Authorization

  • Authorization to Charge Credit Card for Time-of-Service Fees (copays or self-pay fees):
    I agree that Northlight Counseling Associates may charge my credit card, at the time of service, in the amount of * agreed upon by myself and my provider * .

  • I acknowledge and understand that should my card not process, I am voluntarily suspending services until I provide updated credit card information or have settled my debt. I also understand that should I not give updated credit card information, nor settle my debt within a timely manner, this debt will go to a collection agency. * .

  • 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.

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