Client Information
A. IDENTIFICATION
Client Name: ______Sex: ___Date of Birth:_____/_____/____
Age: ______
Employer/School: ______SS #: ______-______-______
Home Address: ______
City: ______State: ______Zip: ______
Phone~ Home: (_____) ______Work: (_____) ______
Cell: (_____)______
Email: ______
Which numbers/email listed above may we leave a message on? ______
If client is a minor: Names of Parent(s)/Guardian(s): ______
Emergency Contact Name and Number:______
B. RESPONSIBLE PARTY INFORMATION: Check if the same as client (skip this section)
Guardian Name: ______Sex: ______
Date of Birth: _____/_____/_____
Relation to Patient: ______SS #: ______-______-______
Employer: ______
Same address as client: Different address than the client (Please complete address below)
Home Address: ______
City: ______State: ______Zip: ______
Same home phone as client Different home phone: Home: (_____) ______
Other Phones: Work: (_____) ______Cell: (_____) ______Email: ______
C. INSURANCE INFORMATION ~Please provide insurance card~ Skip if self-pay
Policyholder’s Name ______
Policyholder’s SSN: _____-_____-_____
Date of Birth _____/_____/______
Primary Insurance Co. Name ______
Insurance Company’s Customer Service Phone # ______
Insurance ID #______
Policyholder’s Employer: ______
Group #______
Co-pay $ ______Deductible? Yes No Amount $______
Authorization Required? Yes No Authorization # ______
Number of Sessions Authorized ______
Maximum Number of Sessions Allowed Per Year ______
Is the patient covered under a secondary insurance policy? Yes No
I, ______(client or legal guardian) authorize Shaketa Robinson Bruce, LPC /Open Arms Counseling Center, LLC, or any holder of medical information about me to release to my insurance company or its representative, any information needed concerning the examination or treatment rendered to me that is necessary to process the insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits to be paid directly to Shaketa Robinson Bruce, LPC/ Open Arms Counseling Center, LLC in such amount as my benefits allow. This authorization is effective until terminated in writing by the client or their guardian.
______
Client or Legal Guardian Date
D. Medical History
*Please list all Physician Names& Numbers:
______
Medication: ______Dosage: ______Reason: ______DateStarted: ______
Medication: ______Dosage: ______Reason: ______Date Started: ______
Allergies: ______
List any serious accidents, illnesses, operations or hospitalizations and what year.______
E. Family of Origin______
Relative / Name / Age / Illness(s) / Education / Occupation / Quality of RelationshipFather
Mother
Step-Father
Step-Mother
Sister(s)
Brother
F. Marital History
Spouse's Name: ______Years Married: ______
Previous Married? Yes No Reason for Divorce: ______
G. Symptoms
Physical Health/Symptoms
___Headache ___Vomiting ___Diarrhea ___Dizziness ____Chest Pain ___Shortness of Breath
Function/Activity
___Fatigue ___Little/No Sleep ___Weight Loss ___Weight Gain ___Academic/Work Inhibition ___Loss of Interest/Pleasure ___Excessive Worry ___Self Injury ___Substance Use/Abuse (Alcohol___Drugs___Other___)
Emotional Symptoms
___Hopelessness ___Panic/Anxiety ___Anger ___Tearful ___Suicidal Thoughts ___Indecisive ___Fearful ___Other
The three biggest problems in my life right now are:
1.______2. ______3. ______
Open Arms Counseling Center, LLC
Financial Agreement and Promise to Pay Account
For in and consideration of services rendered and to be rendered to ______(client name), I will promise to Open Arms Counseling Center, LLC (OACC). I understand the total charges are due when services are rendered. I agree to make available any and all insurance information to OACC. I understand that OACC bills One hundred and twenty-five dollars for sessions lasting 45-60 minutes. I agree to provide insurance claims forms of any insurance company and/or will complete the HCFA 1500 form. I agree to assign any and all benefits to OACC and sign in the designated areas on the insurance claim form. I agree to pay the entire deductible amount, as well as any co-payment amount due.
I understand that I am financially responsible for missed appointments, in which I do not give a 24 hour notice and that my credit will be charged if I do not give the 24 hour notice. The fee for a missed visit (in which less than 24 hour notice is given) is $75.
In addition, if my insurance company fails to pay for each date of service within four weeks, I will be billed for the date of service. I will be provided with a superbill so you can be reimbursed by my insurance company. In this process, if payment is received after the four week date of service, I will be reimbursed by OACC. By signing this agreement I completely understand that it is my responsibility to handle all insurance matters, including getting authorization and untimely payment by my insurance company (more than 4 weeks after the date of service). I understand that OACC will file each date of service one time and any rejection payment from my insurance company will be taken care of by me.
I understand that I am financially responsible for all charges not covered or denied by my insurance company. I understand that if I should receive payment from the insurance company by mistake, which payment was/should be assigned to OACC, I will sign this payment over to OACC and OACC has the right to seek legal action to receive payment for this agreement, relative to payment fees, OACC shall be entitled to reasonable attorney fees and costs of collection.
I further understand that no records (written or verbal) will be released to me or on my behalf if I have an outstanding balance due to OACC.
OACC does not accept checks. Please provide us with your credit card information. The card will ONLY be billed if less than 24 hour notice is given or on accounts that are 60 days past due.
Type of Card:______Name as it appears on card:______
Card #:______
Expiration:______Security:______
By singing below, I am agreeing to the terms and conditions of this financial contract.
______
Signature Date
RELEASE OF INFORMATION
I, ______, do hereby authorize
______or any related representative at Open Arms Counseling Center, LLC to
release receive exchange
information concerning ______(Name of Client, DOB)
to from with ______
I understand that such disclosure will be made for the following purposes:
Treatment Progress Psychiatric Evaluation Child Custody / Visitation
Treatment Planning Social History Competency to stand trial
Medical Treatment Treatment Summary Other ______
Reimbursement for Treatment Diagnosis
I understand that unless otherwise limited by state or federal regulations, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time by giving written notice to Shaketa Robinson Bruce, LPC
If no prior notice of revocation is received, this consent will expire automatically two (2) years after the date indicated thereon.
I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.
I have read, or had read to me, the above, and understand the contents.
______I authorize this information to be faxed to the party indicated above, and
Initial understand the limits of confidentiality which doing so creates.
______I have received and read the ROI, however at this time, I do not have anyone I wish to release Initial information to. I am aware that I can make additions/changes as necessary and at anytime by completing this form.
______
Signature of client, parent, or legal guardian Date
Training of Professionals:
Open Arms Counseling Center, LLC is committed to providing excellent mental health services to the community. Because of this, from time to time we will engage in training interns and/or newly licensed professionals. This can result in more affordable fees to those who are in need as well as the professional growth of those we train. In order to provide this opportunity, sometimes trainees are required to sit in on sessions, record/take notes of sessions or discuss the case with a fully licensed mental health supervisor. During this, none of your identifying information is ever disclosed and your confidentiality will remain of upmost regard. If you wish to participate in this training opportunity, please sign. You can opt out at any time simply through verbal or written communication.
______
Signature and date
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THE PROFESSIONAL SERVICES
AGREEMENT AND AGREE TO ITS TERMS. YOUR SIGNATURE ALSO SERVES AS AN
ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED
ON THE FOLLOWING PAGES.
PATIENT (or PARENTS/GUARDIANS, IF PATIENT IS A MINOR)
______
Signature of Patient or Parent(s)/Guardian(s) Date
______
Name of Patient or Parent(s)/Guardian(s) (Please print) Relationship(s) to Patient
OTHER ADULT PARTY/PARTIES INVOLVED IN TREATMENT NOT APPLICABLE
______
Signature of Secondary Party/Parties Date
______
Name of Secondary Party/Parties (Please print) Relationship(s) to Patient
______
Signature of Therapist Date
______
Name of Therapist
PROFESSIONAL SERVICES AGREEMENT
Welcome to my practice, Open Arms Counseling Center, LLC. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
Psychological Services
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you or your child are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you or your child will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Before we begin working together, it is important to understand that I cannot guarantee that you or your child will benefit from therapy. No therapist can make such a guarantee because each client responds differently to this experience. Our first few sessions will involve an evaluation of needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you obtain an appropriate consultation with another mental health professional.
Sessions
I normally conduct an evaluation that will last from 1 to 2 sessions. During this time, we can both decide if I am the best person to provide the services you or your child needs in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one 45-50 minute session (one appointment hour of 45-50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours notice of cancellation. Failure to cancel within 24 hours will result in you being charged the missed visit amount.
Distance Counseling
I offer counseling via face-to-face, video conferencing, and phone. Distance counseling is considered any of those methods other than face-to-face. If your counseling need is appropriate for distance counseling, you can either solely receive counseling via one medium, or any combination of them.
Face-to-face sessions are held at the following location: 2801 Buford Highway NE Ste. 540 Atlanta, GA 30329
Video conferencing counseling sessions are held via VSee telemedicine application/www.vsee.com. It is recommended that you sign on to your VSee account at least 5 minutes prior to you session start time. You are responsible for initiating the connection with me at the time of your session.Whenever there is communication that lacks visual or audio cues there is a risk of misunderstanding. When this happens it is important to assume that your counselor has positive regard for you, and to check out your assumptions. This will reduce any unnecessary hardship.
If at any time you do not have internet access at your home, or private location you can contact me via phone to help you locate internet service that will be appropriate for distance counseling.
Limitations of Distance Counseling
Distance counseling should not be viewed as a substitute for face-to-face counseling or medication by a physician. It is an alternative form of counseling with certain limitations.
By signing this document you agree that you understand that distance counseling:
• may lack of visual and/or audio cues, which may cause misunderstanding.
• may have disruptions in the service and quality of the technology used.
• may not be appropriate if you are having a crisis, acute psychosis, or suicidal or homicidal thoughts.