LLC
Today’s Date:______
SUE MOCNIAK, MSW,
500 W. Wilson Bridge Road, Suite 75, Worthington, OH 43085
Welcome!
The counseling process is about YOU at this point on the timeline of your life’s journey. Counseling can help you process and reduce your emotional and relational distress so you may discover a new sense of freedom and a renewed outlook on life and relationships.
Please answer the following questions as a starting place.
What problem (s)prompted you to seek counseling?
How long have you been coping with this problem?
What are you hoping to get from your counseling sessions?
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First name / Last nameStreet address
City: State / Zip
Email / Phone
Your Date of Birth: / Emergency Contact Person & Phone #
Fees
All fees are due at time of service otherwise your appointment will need to be rescheduled. The following are standard fees for services – unless a sliding fee was arranged for you.
First session:130
Follow-up session/ 45 min:110
Follow-up / 60 min:120
Extended 90-minute session:165
Group session:30 – 40
30-minute session:50
*Sliding Fee:______
(Based on household size/income)
No show /
Less than 24 hr cancellation:45
*Sliding fee rates are provided as a courtesy to you to improve access to therapy services. If your status financially should improve-please return the courtesy by informing me so we may renegotiate your sliding fee. Conversely, please notify me if a downgrade in your financial status is limiting or restricting your access to services. I am willing to work with you.
Important Note
Sue Mocniak, MSW, LISW & Restore Counseling, LLC, do not provide emergency mental health services. If you or someone you care about experiences a life-threatening mental health issue- Do Not Wait :
(1) Go to the nearest emergency room OR (2) Call 911 or local police OR (3) Call Netcare Access 24 hr mental health services at: 614.276.2273
Communications
The Restore Counseling, LLC phone number allows for communication to be received via phone, voicemail and text. Clients are asked to restrict text communication to issues concerning scheduling, directions, and billing due to the risks inherent in this form of communication.
Notice of Privacy Information and Disclosure
Without your expressed consent for the release, no information shall be released to any other provider, with the exception provided by Ohio Revised Code 4757-5-02 (D1): Expressed imminent danger to yourself or another person or the report of abuse of a minor or incapacitated adult person. And with the exceptions as provided by HIPAA which may include electronic transmission of information deemed necessary to process remittance of payment, requested clinical or billing information you have given consent to be released by signing this document and the HIPAA acknowledgement document.
This practice is a HIPAA covered entity according to the guidelines set forth at:
Downloads/CoveredEntitycharts.pdf
You should have received a copy of your HIPAA privacy rights either digitally or on paper. If you need help understanding this document or the document explaining your privacy rights please inform this provider.
PLEASE SIGN BELOW INDICATING YOU HAVE RECEIVED, UNDERSTAND, and AGREE WITH THE INFORMATION IN THIS DOCUMENT:
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PRINTED FULL NAME
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SIGNATURE
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DATE
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