Welcome to the Touch of Healing Counseling Center! We provide services by licensed therapist and counselors. In cooperation with the ministries of First Assembly of God in Griffin and Dr. Randy Valimont, Senior Pastor has initiated this counseling ministry to provide to all parties who seek professional assistance for individual, marriage, or family issues, regardless of their race, color, or religious affiliation. It is the goal of this counseling ministry to assist those struggling with the cares of this life to find wholeness, which can only be found in Christ Jesus, our Lord and Savior.

Christian Counseling is a joint venture of the counselor and the client, whereby healing and restoration are sought through mutual insight exchange, behavioral change, and spiritual renewal. As such, your therapist greatly depends upon you to adhere strictly to the following criterion in order that your investment reaps optimal results.

Our Therapists

Sandra Rawlings, MS, LPC, Director

Terry Borsare, MA, LPC

Karyn Kochan, MS, LPC, CLC

Amanda Scott, MA, LMFT, CST

Cathy Kleinschmit, MA, APC

Cynthia Midgett, LPC

Tonya Shirey, MS

APPOINTMENTS:

Please contact the counseling office to schedule a counseling session. Unless prior arrangements have been made all co-pays and fees are due at time of service. If it becomes necessary to cancel, please notify the office 24 hours prior to your scheduled appointment session. Should failure to attend by no/little advance notice become an issue, you will be subject to a fee of $25.00. In the event of your 2nd no show, you must pay those fees prior to your next scheduled session.

Date:______

Have you ever been seen in our office before? ______

PATIENT INFORMATION

Patient Name: ______

Patient date of birth: ______

Patient gender: M______F______

Legal Guardian name ______Relationship______

Patient Address: ______City ______State _____ Zip ______

Email: ______

Phone: ______(home)

Phone: ______(cell) ______

Emergency contact: ______Phone______

How did you hear about us? ______

Does your insurance require an authorization for services? ______

If you choose not to call your insurance to verify then you will be responsible for the session fee should they deny payment.

INSURANCE POLICY HOLDER

Policy holder name: ______Date of birth:______

Patient relationship to policy holder (self / child / spouse): ______

Name of insurance company: ______Member ID #: ______

Group/policy number: ______

Policy holder employer name: ______

NEW OFFICE POLICY-NOW REQUIRED TO BE FILLED OUT BY ALL CLIENTS OR APPOINTMENT WILL BE RESCHEDULED UNTIL CREDIT CARD CAN BE PROVIDED.

Please provide the card to the receptionist in order to securely scan in the information into your private secure chart.

I ______GIVE MY PERMISSION TO CHARGE MY CREDIT CARD IN THE EVENT WHERE I HAVE AN OUTSTANDING BALANCE FROM NO-SHOW FEES, LATE CANCELLATION FEES, AN UNPAID BALANCE THAT MY INSURANCE DID NOT COVER, COINSURANCE OR COPAYS THAT WERE NOT COLLECTED AT THE TIME OF MY SESSION.

TOUCH OF HEALING WILL MAKE SEVERAL ATTEMPTS TO CONTACT ME PRIOR TO PROCESSING THE PAYMENT. HOWEVER, IF I AM UNREACHABLE DUE TO DISCONNECTED PHONE NUMBER, UNDELIVERABLE MAIL, EMAIL, NO VOICEMAIL OPTIONS OR I SIMPLY DO NOT RETURN A MESSAGE LEFT BY THE OFFICE WITHIN 24 HRS, THEN PAYMENT WILL BE PROCESSED AND RECEIPT WILL BE HELD FOR 30 DAYS FOR ME TO PICK UP.

Name shown on credit card______

Credit card type (Visa, MC, AE, Discover)______

Credit card number______

Exp date____/_____

CVC______(3 or 4 digits on back of card)

ALL SESSIONS ARE 45-60 MINUTES LONG. LATE ARRIVALS WILL SHORTEN YOUR SESSION DUE TO OUR SCHEDULE.

Patient Personal Information

Name: ______Marital status: ______

Religious Affiliation: ______Church: ______

Employed: Yes _____ No _____ Name of Employer: ______

Type of work: ______

Family Members

Relationship / Name / Age / Last Grade Completed / Occupation
Spouse
Father
Mother
Brother (s)
Sister (s)
Children

Describe any physical problems you have that require medication or physical care:______

Are you currently receiving medical treatment or taking prescription medications?  yes  no

If yes, please list:______

Have you had previous counseling?  yes  no If yes, when? ______

Where and with whom?

NameAddress

In your own words, briefly describe the main problem which prompted you to seek counseling at this time:

Have there been times when the problem got better or disappeared?  yes  no

What do you think helped?

Were there times when the problem was especially bad?  yes  no

What made it so bad?

Are there other people who play a major role in causing your problem or are helping you to cope with your problem?  yes  no

Explain briefly:______

Problem Area

In the following list, place a check mark next to each item which identifies an area of concern to you. Place two check by those items which are most important. (You may add comments after areas checked.)

AngerReligious/Spiritual Concerns

DepressionSexual Concerns

EducationThoughts of suicide

Eating difficulties Trouble making decisions

FearfulnessUnhappy most of the time

Financial problemsUse of alcohol

Marital problems______Use of alcohol by family member

Physical problemsUse of drugs

Problems with social relationships_____Use of drugs by a family member

Problems with childrenWork

Problems with parentsWorry

REGARDING TESTIFYING IN COURT:

  1. Only Current Licensed or Ph.D level therapist are to testify.
  2. To testify, the therapist must receive a subpoena.
  3. Signed authorization is a must if testifying for someone as a spouse or child.

4.Client’s rights are waived by testifying in court, in that they are givingpermission to reveal confidential information.

During the course of the counseling session it may be necessary to request documentation information from your therapist for Attorneys, Human Resources Managers, Correction Officers, Courts, etc. Our practice guidelines are to provide a notarized affidavit for a cost of $75.00 to the client. Affidavits are legal documents used in court. In the event the therapist is subpoenaed to court, the client agrees to pay $125.00 per hour for each hour the therapist is out of the office, with a minimum of two hours to be paid prior to Court. Payment is the responsibility of the client, as insurance companies do not cover court costs or loss of income for the therapist. The balance is due within 7 days after the hearing. Fees will be charged to your credit card on file unless other arrangements have been made.

ALL CLIENTS:

Payment from cash clients is due at the time of service. We accept cash, check, Visa, Master Card, and/or Debit Card. A $30.00 fee is charged for all checks returned from the bank for any reason. A billing statement or receipt is generated only upon request. In order to maintain standing appointments, your account must be kept current. All accounts past 60 days will be sent to collections.

Clients who are Minors:

The adult accompanying a minor of the parent/guardian (s) is responsible for full payment.

Minors unaccompanied by an adult will be denied services (except in an emergency) unless payment has been prearranged.

In addition to the above, I hereby waive the statute of limitations on collection and/or recovery in the state of Georgia.

EMERGENCY PROCEDURES:

All phone contact should be directed primarily to (678) 688- 3133. In cases of crisis where the therapist has not made other arrangements, notify 911 or the local emergency room.

I have read the above statements and acknowledge by my signature below that I fully understand them and have no further questions.

Signature______Date______

Witness______Date______

STATEMENT OF CLIENT RIGHTS

  1. You have the right to be treated in a consistently competent, ethical, and respectful manner.
  1. You have the right to stop receiving therapy without any obligation other than to pay for the services you have already received.
  1. You have the right to ask questions about the approach and methods utilized, and to decline the use of certain therapeutic techniques.
  1. You have the right to review your individual clinical records at any time.
  1. You have the right of confidentiality. This means that, within the limits described below, we will not release identifying information about you to any person or agency without your permission.
  1. In certain situations, we are required by law to reveal information about you to other persons or agencies WITHOUT YOUR PERMISSION.
  1. If you threaten grave bodily harm or death to another person, we are required to inform the intended victim and/or appropriate law enforcement agencies.
  1. We are required to release to a court of law any information specifically described by a court order.
  1. We are required to report to the Department of Family and Children’s Services any reasonable suspicion we have that a minor is being abused or neglected by you.
  1. If a court of law has ordered you to have treatment or testing, the results of that treatment or testing must be revealed to the court requesting the information.

I have read the above statements and acknowledge by my signature below that I fully understand them and have no further questions.

______

Signature of Client or GuardianDate

______

WitnessDate

Notice and Agreement of Legal Issues, c/o Fresh Touch of Healing, LLC

Legal issues in the clinical relationship can include, but are not limited to, the following: Court room procedures, depositions, testimonies, clinical summaries, and court appearances

Disclaimer: Fresh Touch of Healing, LLC, hereinafter referred to as FTOH, understands that there are certain situations that require clients to become involved in legal proceedings. Such legal proceedings can include, but are not limited to: criminal hearings/trials, drug court, mental health court, custody issues, divorce, visitation rights, and DFCS referrals. FTOH is willing to cooperate with the client and other parties upon the following stipulations:

1. ______FTOH is willing to provide a comprehensive, clinical summary detailing assessments, diagnoses, session notes, treatment plans, and clinical progress. An adequate and reliable summary requires a minimum of six (6) sessions, at standard industry duration and at standard rate, in order to complete a comprehensive, clinical summary. The fee for the clinical summary, which does not include the fee for the minimum six (6) sessions, is one hundred fifty and 00/100 ($150.00) dollars per clinical summary.

2. ______FTOH is willing to appear in court as a witness on behalf of the client upon the following stipulations:

  • FTOH is requested to appear in court without being subpoenaed.
  • Receiving a subpoena to appear in court will be understood as a change of relationship between the client and the counselor. The relationship will change from a clinical relationship to a legal relationship. This change may result in termination of the client from the practice of FTOH due to the broken clinical relationship.

3. ______If FTOH agrees to testify as a witness, expert or otherwise, on the client’s behalf, FTOH would request to be allowed to stay on site at the practice and be given a one-hour notice (or other reasonable time necessary to appear depending on location of the courthouse) prior to being called as a witness in court or any other legal proceedings. The client understands that there is a fee of one hundred fifty and 00/100 ($150.00) dollars charged, per hour, in order to reimburse FTOH for loss of clinical time during court or any other legal proceedings. This fee is not reimbursable by insurance and will be paid by the client prior to appearing in court or any other involvement of legal proceedings.

FINANCIAL POLICY

Promise to Pay Account

Forservices rendered, I promise to pay Touch of Healing Counseling Center all charges for services. I hereby authorize insurance payments to be sent to Touch of Healing Counseling Center for services rendered. I am aware that I am financially responsible to Touch of Healing Counseling Center for all charges regardless of insurance payment outcomes.

I acknowledge that I have received a copy of Touch of Healing Notice of Privacy Practice for Protected Health Information. I understand that Touch of Healing has the right to change its notice of Privacy Practice for Protected Health Information.

Payments for all services will be due at the time services are rendered. In order to better serve you, we accept cash, check, Visa, and MasterCard. As a courtesy to you, we will verify your coverage and bill your insurance carrier on your behalf; however, you are ultimately responsible for the entire bill.

As the responsible party, please understand:

(PLEASE INITIAL THE FOLLOWING)

______Your insurance policy is a contract between you, your employer (if applicable), and your insurance provider. We will not become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance and “usual” and “customary” charges. As your medical provider, we will only supply factual information to facilitate claims processing.

______I understand that I may have an insurance plan that restricts my therapy, either by units or by payable dollar amount, and that it is my financial responsibility for the differences between services covered by my policy and the actual services provided.

______I understand that FTOH does not participate with or file claims to Medicare.

______Returned checks and unpaid balances may be subject to collection placement and collection fees. I will be responsible for all costs of collecting monies owed including processingfees.

We understand financial problems may affect timely payment. We encourage you to communicate any such problems so that we may assist you in keeping your account in good standing.

Name______Date______

Witness______Date______

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW CAREFULLY.

Summary:

By law, we are required to provide you with our Notice of Privacy Practices (NPP). This notice describes how medical information may be used and disclosed by us. It also tells you how you can obtain access to this information. As a client, you have the following rights:

1. The right to inspect and copy your information.

2. The right to request corrections to your information.

3. The right to request that your information be restricted.

4. The right to request confidential communication.

5. The right to a report of disclosures of your information.

6. The right to a paper copy of this Notice.

7. The right to file a complaint if you feel your privacy has been violated.

We want to assure you that your medical/protected health information is secure with us. This notice contains information about how we will insure that your information remains private.

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have received a copy of Fresh Touch of Healing Counseling Center, LLC NOTICE OF PRIVACY PRACTICES. I understand that if I have questions or complaints regarding my privacy rights, that I may contact the person named as the Privacy Officer. I further understand Fresh Touch of Healing Counseling Center, LLC will offer updates to me regarding this NOTICE OF PRIVACY PRACTICES, should it be amended, modified, or changed in anyway.

Client Name/Person Authorized To Sign______Date______

Witness______Date______

Client unable to sign because______

Client refused to sign______

CONFIDENTIALITY:

I understand that information obtained during the course of treatment will not be released without consent, except in the case of emergency or as required by law. I understand that confidentiality is waived in the following circumstances: (1) If a client becomes a danger to self or others, (2) if session records are subpoenaed by court of law, (3) in case of physical or sexual abuse of minors, the elderly, disabled, or incompetent others. I also authorize Fresh Touch of Healing to release any and all information regarding diagnosis, treatment, and prognosis with respect to any mental condition and / or treatment to my insurance company (s) or its legal representative as indicated. Any such disclosure shall be limited to information that is reasonably necessary for the discharge of legal and contractual obligation of the insurance company (s). I understand the information obtained by use of this authorization will be used by the insurance company (s) to determine eligibility benefits under existing policy. In the event that Fresh Touch of Healing experiences a breach in security, we will contact clients and law enforcement.

AUTHORIZED PATIENT NOTIFICATION LIST

(Required of HIPAA) Health Insurance Portability and Accountability Act

I authorize all Fresh Touch of Healing Counseling Center, LLC employees and / or whomsoever he/she may designate as his/her professional representative/assistant to discuss any aspect of my care.

I am giving the following designated people permission to inquire about my care:

______

______

This document will be a part of your permanent record. In the event that any of the selected representatives that you have designated change, it will be necessary to update our records with written notification. You will need to state who you would like to have removed and/or added to the Authorized Notification List.

______

Client/Other Person Authorized To Sign: Date:

______

Witness Date:

I hereby consent for Fresh Touch of Healing Counseling Center to treat the undersigned person. I authorize Sandra B. Rawlings, MS, LPC and/or her designated staff to render to the patient customary care, tests, and procedures ordered by Sandra B. Rawlings, MS, LPC. No identifying information will be released without written consent, except in the case of emergency or as required by law. Information regarding my involvement in outpatient counseling will be kept confidential by Fresh Touch of Healing Counseling Center. For clients age 17 or under, the signature of his/her legal guardian or custodial parent is required.

SignatureDate

Parent or GuardianDate

WitnessDate

RELEASE OF INFORMATION AUTHORIZATION

I hereby request and authorize: Fresh Touch of Healing, LLC (Sandra Rawlings MS., LPC)

(Name of Persons or Agency Requesting / Receiving Information)

2000 West McIntosh Road, Griffin, Georgia 30223

(Address)

And

______

(Name of Persons or Agency Sending / Receiving Information)

______

(Address)

To obtain from each other the following type (s) of information from my records (and any specific portion thereof): ______

______

For the purpose of: ______

______

______This authorization shall remain in effect for one year from the date of the signature below.

______The consent can be withdrawn upon notification.

______

Client Signature: Date:

______

Signature of Parent or Authorized Representative:

______

Signature of Witness/Title: Date:

The following form, which will become a part of your confidential record, will enable us to gain a quicker understanding of you. Please answer each question as completely and carefully as you can. You may use the back of any page for additional information.