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Name:Date of Birth:Parent or Guardian name if under 18:Address:Home Phone:Cell: May I leave a message at this umber? Y NMay I leave a message at this umber? Y NEmail: Insurance Information (No information will be treated as self-pay)Primary Insurance NameSecondary Insurance NamePolicy/ ID NumberPolicy/ ID NumberGroup NumberGroup NumberPolicy Holders NamePolicy Holders NamePolicy holder SS#Policy Holder SS#EmployerEmployerPolicy holder DOBPolicy holder DOBI authorize Imagine The Possibilities to release any information necessary to expedite my insurance claims including documentation required by my managed care provider should my plan require it. Client Name (Please Print): ____________________________________________________________Client or guardian signature: ___________________________________________________________Date: _______________________________________________________________________________2134235000Information, Authorization and ConsentWelcome to Imagine the Possibilities Family Therapy. I am pleased to begin working with you. Please carefully read each section and initial to indicate that you accept and understand the information provided. Thank you._______ Theoretical Views and Services: Imagine the Possibilities provides therapy services to children, adolescents, adults, couples and families. Developing a trusting relationship with you and your family is important for the success of therapy. I will work together with you to identify therapy goals and implement therapeutic interventions to support those goals. Interventions include art and play with children, conversations and therapeutic tools such as genograms with adolescents, adults, couples and families. It is my intention to empower and support you towards growth and self-understanding. Therapy is a collaborative relationship. Your disclosure will assist us in determining the best course of treatment, including making referrals to other or higher levels of treatment if necessary. ______ Working with Minors: To support the therapeutic goals of trust, when working with a minor (under 18 years of age) I will offer parents/guardians general information about the therapeutic process and overall themes, but not specific details about the information exchanged during session. If at any time I feel that your child is engaging in dangerous behaviors I will inform you of any concerns or have your child do so as part of family therapy. If you would like to speak with me about any concerns you may have about your child, please contact me by phone or e-mail and we can arrange a time to discuss or meet as necessary. If at any time I believe your child is in harm it is my duty and responsibility to report any suspicions of abuse. ______ Working with Couples: When working with couples, we may meet individually or together to work towards therapy goals. Privacy in couples’ session will be maintained as a high priority for the effectiveness of therapy. I will not release any information about either member of the couple without the consent of both. This also means that I will not hold individual confidences of either party that will jeopardize the therapeutic allegiance to the members of the couple. _______ Use of Technology: In the ever developing world of technology, there are several ways that we could potentially communicate electronically. It is my priority to maintain confidentiality and professional boundaries. Cell phones: When using a cell phone please be mindful that all communication may not be completely secure and confidential. When taking or making calls related to your therapy please consider your surroundings and those who have access to your devices. Text message and e-mail: Both text message and e-mail are not secure forms of communication; therefore it is suggested that these forms of contact only be used to arrange a session or phone call to discuss any needs further with greater privacy. ______ Structure and Fees: Imagine the Possibilities participates with Cigna and Horizon BC/BS Insurance. Copays will be determined by your plan coverage. Please reach out to your insurance company if you are not clear about the coverage provided for mental health services. Payment is due at the time of the session. Cash and check is accepted and a receipt will be provided. For all self-pay sessions: therapy services are provided at a fee of $150.00 per hour. A statement of services including the necessary codes for therapy services and diagnosis will be provided for those clients that are interested in submitting for out-of-network reimbursement. Please be advised that most insurance companies require a diagnosis for reimbursement to occur. It is your responsibility to stay informed of and comply with your insurance company’s policies for reimbursement.Additional fees: Phone calls will be billed additionally if in excess of 10 minutes.Returned checks: There will be a fee of $30 for any returned checks.________ Cancelation Policy: Your appointment times are set aside specifically for you. Should you need to cancel your appointment please give as much notice as possible. If you need to cancel and appointment with less than 24 hours notice, or you miss the scheduled session, you will be charged the full fee for the session. Please note that insurance companies will not reimburse for missed sessions. Session time begins at the scheduled time, not the time you arrive if arriving late. _________ Ethical Considerations and Privacy: Services will be provided in an ethical and considerate manner consistent with the American Association of Marriage and Family Therapy (AAMFT). If at any time you have concerns about your treatment please discuss them with me immediately. Contacts for the professional licensing board can be provided as needed. Your Health information will remain confidential in accordance with HIPPA. The law protects the relationship between a client and a therapist, and information cannot be disclosed without written permission. Exceptions include:Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.Agreement to Enter into a Therapeutic RelationshipI am looking forward to begin this therapeutic experience with you. If you have any questions about the above document please feel free to discuss it with me. By signing below, you agree that you have read and understand the “information, authorization and consent” content. Your Signature indicates that you agree to the policies outlined in this document and are authorizing for me to begin treatment with you/your child._________________________________________ ______________________________________Name of client: PrintSignature of client________________________________________________________________________________Name of parent/guardian: PrintSignature of parent/guardian________________________________________________________________________________Relationship to clientDate signed ................
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