Client Intake Form
Demographics
Today's Date
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Month
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Day
Year
Date
Client Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Email
example@example.com
May we contact you by email?
Yes
No
Marital Status
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Single
Married
Widowed
Divorced
Sex
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Male
Female
Please enter your 9-digit Social Security Number with no dashes:
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Client Date of Birth
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Month
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Day
Year
Date
Client Employer
Client Occupation
Who do we call in case of emergency?
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What is their relationship to client?
Their Phone Number
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Area Code
Phone Number
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Client Intake Form
If you are not financially responsible for all professional services rendered to you at this office, please inform us what party is responsible by completing the next section:
Responsible Party:
Name of Organization:
Individuals Name:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Their Home Phone Number
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Area Code
Phone Number
Their Work Phone Number
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Area Code
Phone Number
Were you referred to our office
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Yes
No
If YES, by whom?
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Client Intake Form
Primary Care Physical/Medical Information
Do we have permission to contact your/the client's physician?
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Yes
No
Name of your/ client Doctor
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Office Phone Number
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Area Code
Phone Number
Clients that provide us with permission to contact their primary physician will have a brief letter sent to their doctor indicating that contact has been made at our office. Diagnosis information may also be released to the physicain. Do we have your permission to contact your physician?
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Yes
No
If yes, please sign below indicating you give us permission to inform your doctor of you rmental health therapy.
Current medication that you/client are taking:
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Are you/client allergic to any medications?
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Yes
No
If yes, which medications?
Please list medical conditions that you are currently being treated for:
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Client Intake Form
Insurance Policy Holder Information
Insurance Member ID
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Policy Holder Name:
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First Name
Last Name
Policy Holder Date of Birth:
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Month
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Day
Year
Date
Insured's Relationship to Client:
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Area Code
Phone Number
Sex:
Male
Female
Please take a photo of the front of your insurance card (please utilize a flat, dark surface for the photo. We have to be able to read the numbers):
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Please take a photo of the back of your insurance card (please utilize a flat, dark surface for the photo. We ahve to be able to read the numbers):
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Please submit a photo of your drivers license, photo ID, or passport (please utilize a flat, dark surface for the photo. We have to be able to read the numbers):
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Client Intake Form
Informed Consent
Counseling Relationship: During the time we work together, we will meet for sessions lasting approximately 50-60minutes. The first session will be history gathering and paperwork and willlast approximately 60-90 minutes. Effects of Counseling: At any time, you may initiate a discussion of possible positive or negativeeffects of entering, not entering, continuing, or discontinuing counseling. While benefits are expected from counseling, specific results are notguaranteed. Counseling is a personal exploration and may lead to major changesin your life perspectives and decisions. These changes may affect significant relationships, your job, and/or your understanding of yourself. Some of these changes could be temporarily distressing. The exact nature of these changes cannot be predicted. Together we will work to achieve the best possible result for you. Client Rights: Some clients need only a few counseling sessions to achieve their goals; others may require months or even years of counseling. As a client, you are in complete control and may request referral at any time. You also have the right to refuse or discuss modification of any of my counseling techniques or suggestions that you believe might be harmful. I assure you that our services will be rendered in a professional manner consistent with accepted legal and ethical standards. If at any time for any reason you are dissatisfied with my services, please let me know. If I am not able to resolve your concerns, I will help you find another counselor. Referrals: Should you and/or I believe that a referral is needed, I will provide some alternatives including programs and/or people who may be able to assist you. A verbal exploration of alternatives to counseling will also be made available upon request. You will be responsible for contacting and evaluating those referrals and/or alternatives. Cancellation: In the event that you will not be able to keep an appointment, please notify me at least 24 hours in advance. You will be charged a $30 no show fee if you don’t cancel 24 hours in advance, unless you can show documentation of an emergency. Other Fees Not Covered by Insurance: Health insurance does cover fees for completion of forms such as for Disability forms, Leave of Absence forms, Homebound forms, and other legal documents, or written letters requested for court, school, work or other. Any request for such forms will have a $30 fee, for which the client is responsible. If Counselor is requested or subpoenaed for court testimony there will be a charge equal to that of a session for $110 per hour for time spent in preparation and testimony. Records and Confidentiality: All of our communication becomes part of the clinical record. The clinical records will only be accessed by employees authorized to view the records. Electronic records will be password protected and physical records will be under lock and key. Adult and minor records will be disposed of in accordance with the agency’s policies. Most of our communication is confidential, but the following limitations and exceptions may exist: (1) when I need to use your case records for purposes of supervision, professional development, and research; (2) if I determine that you are a danger to yourself or someone else;(3) if you disclose abuse, neglect, or exploitation of a child, elderly, or disabled person; (4) if you disclose sexual contact with another mental health professional; (5) if I am ordered by a court to disclose information; (6) if you direct me to release your records; (7) if I am otherwise required by law to disclose information; (8) if you disclose that you are a victim of spousal domestic violence; or (9) for insurance billing. If I see you in public, I will attempt to protect your confidentiality by acknowledging you only if you approach me first. By your signature below, you are indicating that you read and understood this statement, any questions you had about this statement were answered to your satisfaction, and you understand you can request a copy of this statement. By my signature, I verify the accuracy of this statement and acknowledge my commitment to conform to its specifications.
Is the client currently a minor under the age of 18?
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Yes
No
If yes, please input the name of the minor client's custodial parent or legal guardian here today giving consent for their treatment:
Printed name of the client:
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Signiture of the client/ custodial parent/ legal guardian:
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Date
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Month
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Day
Year
Date
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Client Intake Form
Telehealth Patient Consent /Refusal Form
Name:
First Name
Last Name
Date of Birth:
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Month
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Year
Date
1. Purpose: The purpose of this form is to obtain your consent to participate in a telehealth consultation/psychotherapy session. 2. Nature of telehealth consult/psychotherapy session: During the telehealth consultation/psychotherapy session: a. Details of your medial history, evaluations, diagnosis, and psychotherapy session will be discussed through the use of interactive video, audio, and telecommunication technology. b. A video, audio and/or photo recordings may be taken of you during the consultation / psychotherapy session with an separate expressed written consent. 3. Medical information and records: All existing laws regarding your access to medical information and copies of your medical recordsapply to this telehealth consultation / psychotherapy session. Please note, not all telecommunications are recorded and stored. Additionally, dissemination of any patient-identifiable images or information for this telehealth interaction to researchers of otherentities share not occur without you consent. 4. Confidentiality: Reasonable and appropriate efforts have been made to eliminate any confidential risks associated with the telehealth consultation / psychotherapy session, and all existing confidentiality protections under federal and Kentucky state lawapply to information disclosed during this telehealth consultation / Psychotherapy session. 5. Rights: You may withhold or withdraw consent to the telehealth consultation / psychotherapy session without affecting your right tofuture care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. 6. Disputes: You agree that any dispute arriving from the telehealth consultation / psychotherapy session will be resolved in Kentucky,and that Kentucky law shall apply to all disputes. 7. Risk, consequences, and benefits: You have been advised of all the potential risk, consequences and benefits of telehealth. Your healthcare practitioner has discussed with you the information provided above. You have had the opportunity to ask questions about the information present on this form and the telehealth consultation / psychotherapy session. All your questions have been answered, and you understand the written information provided above.
I agree to participate in a telehealth consultation / psychotherapy session.
Date
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Month
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Day
Year
Date
If you refuse to participate in a telehealth consultation / psychotherapy session.
Date
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Month
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Day
Year
Date
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Client Intake Form
Authorization to Bill Health Insurance/ Assignment of Benefits
By signing this form, I do hearby give full permission and authorize Crimson Dove Counseling Services, to bill my insurance company for services rendered by Crimson Dove Counseling services. I also agree to have any checks or payment made by said insurance company to be payable and deliverable to: Crimson Dove Counseling Services, Inc. 214 Breckenridge Ln, Ste 205 Louisville,KY 40207 By signing this document, I also agree to the following statements below: I understand that I am responsible for understanding information about my health insurance policy and providing such information to Crimson Dove Counseling Services, for correct billing. I am also responsible to notify Crimson Dove Counseling Services in the case of change of my health insurance status – benefits and any information I receive relating to care I have or will receive in this office. I understand that Crimson Dove Counseling Services will be providing services and billing my health insurance for those services at various times during the course of my care at this office. I understand that ultimately I am responsible for all payment relating to any and all charges relating to treatment and services that I have received at Crimson Dove Counseling Services during my care. I also understand that my insurance company and related policy plan may offer benefits for services provided at Crimson Dove Counseling Services, but that such benefits do not necessarily guarantee payment for those services. I understand that the policy of Crimson Dove Counseling Services requires payment in full for all services rendered at the time of visit including copay and/or coinsurance. If my account is not paid within 90 days of the date of service and no other financial arrangements have been made, I will be responsible for all legal fees, collection agency fees, and any other expenses incurred in collecting my account (normal charge - 33% in addition to your outstanding balance due in our office). I understand the above information and agree that my history and related information was completed correctly to the best of my knowledge and understand that it is my responsibility to alert Crimson Dove Counseling Services of any change in my insurance coverage. I, the undersigned does agree to observe and abide by all of the statements made above.
Signiture of patient, custodial parent, or legal guardian:
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Client Intake Form
Office Fee Schedule/Financial Policy
Service
New Patient/Initial Session $150 Individual Session $110 Family Counseling/Initial Session $150 Family Counseling (up to 3) $110 Family Counseling (4 or more) $150
Financial Policy
Mental or Behavioral health services are covered under many insurance plans. Most of our patients that have health insurance will fall under one of the plans discussed below. We ask that you read and understand as it applies to your situation.
Patients without insurance -- We request that 100% of the visit be paid at the time of service.
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Group or individual insurance: When possible, we will call to verify benefits on your insurance. However, benefits quoted to us by your insurance company are not a guarantee of payment. Payments will be due by you at the time of service for any non-covered services, deductibles or co pays. Remember, your agreement with your insurance company is between you and them. There may be times that you have to actively participate in getting your insurance company to pay. We will advise you on what you need to do and it is up to you to follow through in getting issue resolved. We will assist in helping them contribute to your care but ultimately the responsibility is yours.
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By signing below, I have read and I understand the above policies.
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Date
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Client Intake Form
Notice of Privacy Policies
THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I. Confidentiality As a rule, we will disclose no information about you, or the fact that you are our client, without your written consent. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. We will supply only what information is needed to bill your insurance provider. II. “Limits of Confidentiality” Possible Uses and Disclosures of Mental Health Records without Consent or Authorization There are some important exceptions to this rule of confidentiality – We may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required: · Domestic Violence - If you report you are a victim or perpetrator of spousal abuse then it will be reported to the Cabinet for Health and Family Services. · Child Abuse Reporting: If your therapist has reason to suspect that a child is abused or neglected, he or she is required by law to report the matter immediately to the Cabinet for Health and Family Services. · Adult Abuse Reporting: If your therapist has reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, he or she is required by law to immediately make a report and provide relevant information to the Cabinet for Health and Family Services. · Court Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and we will not release information unless you provide written authorization or a judge issues a court order. · Serious Threat to Health or Safety: Under Kentucky law, if you communicate to your therapist a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and he or she believes you have the intent and ability to carry out that threat immediately or imminently, your therapist is legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By this agency policy, your therapist may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, we can be required to provide your records to the magistrate, your attorney or guardian ad litem, or law enforcement officer, whether you are a minor or an adult. Other uses and disclosures of information not covered by this notice or by the laws that apply to professional counseling relationship will be made only with your written permission. III. Patient’s Rights and Provider’s Duties: · Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care. If you ask us to disclose information to another party, you may request that we limit the information that is disclosed. However, we are not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell us: 1) what information you want to limit; 2) whether you want to limit use, disclosure or both; and 3) to whom you want the limits to apply. · Right to Receive Confidential Communications by Alternative Means and at Alternative Locations — You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted. · Right to an Accounting of Disclosures – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice). On your written request, we will discuss with you the details of the accounting process . · Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, we may charge a fee for costs of copying and mailing. We may deny your request to inspect and copy in some circumstances. We may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding. · Right to Amend – If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, your request must be made in writing. In addition, you must provide a reason that supports your request. We may deny your request if you ask us to amend information that: 1) was not created by us; We will add your request to the information record; 2) is not part of the medical information kept by us; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete. · Right to a copy of this notice – You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Changes to this notice: We reserve the right to change policies and/or to change this notice, and to make the changed notice effective for medical information we already have about you as well as any information we receive in the future. The notice will contain the effective date. A new copy will be given to you or posted in a visible location. We will have copies of the current notice available on request. Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to our office. You may also send a written complaint to the U.S. Department of Health and Human Services.
Receipt of Notice of Privacy Policies
By signing below, I acknowledge that I have been provided a copy of Notice of Privacy Practices. We have discussed these policies, and I understand that I may ask questions about them at any time in the future. I consent to accept these policies as a condition of receiving mental health services.
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