Southland Child, Adult, and Family Counseling
Jessica Jaramillo, LCSW
2039 Regency Rd Suite 1, Lexington, KY 40503
Phone 859-285-2959
Client InformationNew Client Form
Who is filling out paperwork and relationship to client:
Last Name:First Name:M.I. :
Date of Birth:Social Security #:
AddressGenderMaleFemale
Phone Number that we can call, text, or leave messages at:
Is this a number that we can call, text, or leave a message regarding appointments? YesNo
Is this a number that we can call or leave a message regarding billing questions? YesNo
Email Address:
Emergency ContactName:Relationship to Client:
Phone Number:Marital Status:SingleMarriedDivorced
Employment Status:
School/Grade (If client is a minor):
Insurance InformationPreferred Method for Reminders:TextEmailCall
Insurance Company:Insurance ID Number:
Insurance Group Number:Policy Effective Date:
Client’s Relationship to Insured:
Primary Cardholder Information (If Different from Patient)
Last Name:First Name:M.I. :
Date of Birth:Social Security #:
Address
Phone #:(Home)(Cell)
Employer Name:Number:
Today’s SessionHow did you hear about Southland Child, Adult, and Family Counseling/Jessica Jaramillo, LCSW:
What is the Reason for Your Visit?
How long have symptoms been present?
Do you have a history of mental illness in your family?
Have you ever had suicidal thoughts or thoughts of harming yourself?
If answered yes, when?
Please list all current medications:
Who is your prescribing provider?
Client/Responsible Party Date
Client name if different from Responsible Party: ______
Informed Consent and Permission to Treat
This consent is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your health care information.
Consent Related to Privacy Notice: I have had a chance to review the Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. I understand I have the right to request how my protected health information (PHI) has been disclosed. You have the right to confidentiality and Southland Child, Adult and Family Counseling will protect your information. All records and sessions will be maintained in a confidential electronic manner. This is a shared office space, so there is the risk of someone overhearing or seeing your name. Wewill do our best to keep that from occurring, and will inform you in the event that this information is disclosed. Consent forms will be required to release any of your information except in certain situations. State and Federal laws may require the release of information without written or verbal consent in the follow specific situations:
1. Medical or mental health emergencies
2. A patient that is a danger to themselves or to others (suicidal or homicidal behaviors/attempts). The person threatened and the police will be notified if homicidal intent is discussed.
3. Any reported or suspected child abuse or neglect
4. Any reported or suspected domestic violence
5. A court order or subpoena directing the release of information or testimony in a court proceeding.
6. Any litigation initiated by the patient related to treatment or complaints
7. Any abuse of the elderly with mental illness or who cannot care for themselves properly
Consent for Care: I, with my signature, authorize (this practice), and any employee working under the direction of the mental health therapist, to provide mental health care for me, or to this client for which I am the legal guardian. Also this consent agrees to the use of a third party dual password protected program, Therapy Appointment.com to have access to patient scheduling, medical records, and insurance billing information.
I consent to release any personal or clinical information required to process my claim to my insurance or my EAP provider. I authorize any payments made by my insurance company or EAP provider to be paid directly to Southland Child, Adult, and Family Counseling, or Jessica Jaramillo, LCSW. This form will serve as signature on file for all insurance claims. I understand that Southland Child, Adult, and Family Counselingis a Professional Limited Liability Company.
I agree and understand that any services provided by Southland Child, Adult, and Family Counseling will not be used for court hearing, litigation, and or child custody hearings. I agree and understand that no FMLA and or disability documentation will be provided unless otherwise pre-authorized by the clinician.
I understand and agree to the limits of confidentiality as indicated above. I agree to hold the clinician at Southland Child, Adult, and Family Counseling harmless for any loss, cost and or damages sustained by my spouse, child, or me. By signing this form, I hereby authorize the clinician at Southland Child, Adult, and Family Counseling to assess, diagnosis, and treat mental health problems for myself, family, or my child. I understand appointment reminders, if I choose to receive those, could be intercepted.
Financial Policy:
We appreciate you choosing us. We will adhere to the following financial policy in order to consistently deliver high quality care and services. The patient/responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the health care services received.
● I understand that I am responsible for all co-payments, amounts applied to deductibles, and other amounts that may be deemed my responsibility by the payment sources, as required by my contract with my insurance plan and state regulations. We will make an attempt to bill your insurance when authorized to do so. Any payments not made by your insurance provider will be your responsibility including, but not limited to: deductibles, co pays, and any other fees not covered by your insurance provider. All co-payments and deductible payments are due at the time of service. Cash, check and credit card are accepted forms of payment.
● I understand that my contract with my insurance entity may or may not cover some services. All insurance policies are not the same. They vary by employer group. Southland Child, Adult and Family Counseling are not responsible or able to know every policy available. It is my responsibility to verify applicable coverage prior to receiving the services. For example, not all health plans include screenings as a benefit. If I seek care outside of the contract terms, I am aware that I may be responsible for all charges that are incurred.
Thank you for your understanding and cooperation with this policy. It is our privilege to provide your mental health care.
By signing I acknowledge that I have read and understand the Informed Consent and Financial Policy and agree to accept full responsibility as described above.
Patient/Responsible Party Date
Patient name if different from Responsible Party: ______
Fee Agreement
Individual Session / $100.00Couples / $125.00
Family / $100.00
Returned Check Fee / $50.00
Missed appointment if not canceled 24 hours in advance / $ 75.00
Appearing or Testifying at Court / $500.00 plus $175.00 an hour
For insured clients the co-payment and amount applied to deductibles will be based on your insurance plan and will be due at the time of your appointment.
Please initial if you would like to keep your charge card on file stored securely for co-payments.
Please initial if you give Southland Child, Adult, and Family Counseling permission to charge this card every session. If you wish to pay with a different form of payment, please let your therapist know at the time of service.
Signing below acknowledges that you understand the fees stated above and will pay the agreed amount at the time of service.
Client NameName of Responsible Party
SignatureDate