The Somers Trust

Psychological Associates

Center for Comprehensive Psychological Services

873 Turnpike St., North Andover, MA 01845-6105

TEL. (978) 688-8004 FAX (978) 686-8554

Client Information

Name:______Today’s date______

Address______Birth date______

Town______State:_____Zip______Work Phone______x______

Home Phone ______Cell Phone______

SS#______Subscriber’s Information

Insurance co.______

Marital Status______Subscriber’s Name______

Subscriber’s No.:______

Group Number______

Subscriber’s SS#______

Previous illness or hospitalizationEmployer (include address)______

Subscriber’s Date of Birth______

List Names Of Spouse/Parent/Child/Sibling-including birth dates

______Relation______Birthdate:______

Who were you referred by: ______

Primary Care Physician: ______Phone Number:______

I authorize payment of medical/psychological benefits to the Somers Trust for

services rendered. Signature______

We ask that you pay at the time of your visit. If you have insurance, please let us know. We would like you to know we require a 24 hours notice for all cancellation. If we do not receive a 24-hour notification you, not your insurance company, will be charged. You may leave a message on our answering service 24 hours a day if we are unavailable. ______ your initials

Have you seen another therapist in this calendar year Yes/ NO? If so, how many times______.

The Somers Trust

Psychological Associates

Center for Comprehensive Psychological Services

873 Turnpike St., North Andover, MA 01845-6105

TEL. (978) 688-8004 FAX (978) 686-8554

Client Consent and Fee Agreement

Client Name:______DOB:______

Parent or legal guardian must sign for client under 18.

Please initialeach line to indicate understanding and agreement.

Information re: Services, Confidentiality & Informed Consent:

_____1. I have available to meat the Somers Trust the Client Rights and Responsibilities notice, the

Client Information sheet and the Limits of Confidentiality fact sheet. I understand and accept my rights & responsibilities, limits of confidentiality and know to discuss my concerns with my provider .

Consent to Treatment:

_____2. I agree to become a client of Somers Trust and give my consent totreatment. If recommended

services are acceptable to me after anevaluation, I consent to therapy with my provider. I understand that if I do not adhere to these agreements, services may be terminated.

Fee Arrangements:

_____3. I understand my co-payment is _____/session and that the charge for a evaluation is $225.00

and all other psychotherapy sessions are $175.00, medication management $150.00. I agree to pay my co-payment or hourly charge on the day of my appointment unless otherwise arranged with my provider. In the event that my insurance plan does not cover the cost of this service due to termination of insurance, provision of a non-reimbursable service or my providing inaccurate information, I agree to be responsible for payment of any charges.

Cancellation Policy:

_____4. I understand that I am required to cancel a scheduled appointmentwith a minimum of 24 hours

notice. I agree to pay a $65 fee if I fail to do so. Timely and appropriate cancellation and reschedule of appointments indicates mutual respect and consideration.

Insurance Release and Assignment of Benefits:

_____5. I understand that my insurance plan will be contacted to verify benefits. I also understand that

my insurance plan is entitled toreceive information about my care and diagnosis.

_____6. I authorize my insurance plan to make payment directly to Somers Trust for services received.

I also authorize Somers Trust to submit information to my insurer necessary to obtain reimbursement.

Client/parent signature:______Date:______

Witness:______Date:______

Email Appointment Reminds:

Client Name: ______DOB:______

Parent or legal guardian must sign for client under 18.

We will soon have the ability to send you an appointment reminder by email. The appointment reminder will include only the date and time of your appointment and your service providers name. We will not encrypt the message. Health care information sent by regular e-mail could be lost, delayed, intercepted, delivered to the wrong address, or arrive incomplete or corrupted. If you understand these risks and would like to receive an appointment reminder by email, please confirm you accept responsibility for these risks, and will not hold Somers Trust and/or its associates responsible for any event that occurs after we send the message.

EMAIL ADDRESS: ______

Please print

By signing below you provide consent for Somers Trust to send email reminders.

Client/parent signature:______Date:______

Witness:______Date:______