DemographicsandProfessionalServiceAgreement..DOC.html.doc.docx



Hauser Family Therapy, LLC

Catherine Hauser, LLC

Client Demographic Form

DATE: __________ CLINICIAN NAME: ________________________________________

PLEASE PROVIDE YOUR IDENTIFICATION & INSURANCE CARDS.

IF CLIENT IS AN ADULT, PLEASE COMPLETE:

Client Name:_________________________________________________________

Address:_____________________________________________________________

Street City, State, Zip

Phone: ( )______________________ Is it ok to leave messages? ____________

Email: __________________________________

Date of Birth: _______________________ Gender: _________________

Emergency Contact/Phone: ______________________________________________

IF CLIENT IS A MINOR, PLEASE COMPLETE THE FOLLOWING:

Client Name:________________________________________________________

Address:_____________________________________________________________

Street City, State, Zip

Gender: ____________________ Date of Birth: ____________

School:____________________________________ Grade:_____________

Parent’s/Legal Guardian’s Marital Status: __________________________

Is there a formal custody arrangement with regard to this minor? ________________

Are both parents aware that the minor is receiving treatment? ___________________

Do both parents consent to the minor receiving treatment? _____________________

Parent’s Name:___________________________Parent’s email:___________________

Address (if different):

______________________________________________________________________

Street City, State, Zip

Phone: ( )___________________________________( )_______________________

Home Cell

Parents’s Name:__________________________________________________________

Address (if different):

_______________________________________________________________________

Street City, State, Zip

Phone: ( )___________________________________( )_______________________

Home Cell

REFERRAL INFORMATION:

Whom were you referred by: ________________________________________________

Are you comfortable with the therapist thanking the person that referred you?_________

Hauser Family Therapy, LLC

Catherine Hauser, LLC

Professional Service Agreement

We welcome the opportunity to be of service to you and your family.

As a client you agree to the following:

CANCELLATION POLICY

We require at least 24 hours advance notice of the cancellation. If less than 24 hour notice is given, your clinician may charge you the full agreed upon rate of services. Please note that standing appointments times and the provision of services may be terminated at the clinician’s discretion due to appointment cancellations. Missed visits and cancellations less than 24 hours in advance are billed at the full session rate and billed directly to the client since insurance does not cover missed services.

____ Client’s Initials

FEES: Session length is determined based on mutually agreed upon goals. Unpaid bills are turned over to collection after an appropriate attempt to collect. Your fee will be $_______ for the initial consultations and $______ per 45 - 60 minute session.  Please note that telephone conferences over 10 minutes and court related clinical services may be invoiced at 10 minute intervals and are not covered by insurance. Services will not be continued if fees are not paid in a timely manner. Additionally, accounts that have no payments for over 90 days may be sent to an outside collection agency. You agree that in the event the clinician is forced to file legal proceedings for payment of fees, in addition to the fee owed, you are responsible for all legal fees and court costs incurred by the clinician in the collection proceedings. ___________ Client’s Initials

EMERGENCIES: Although I check messages regularly during normal business hours, if you believe you have a life threatening emergency please contact 911 or go to your nearest hospital emergency room. ___________ Client’s Initials

CONFIDENTIALITY: The information you share in session with me is confidential and will not be disclosed without your written permission except when you may pose a danger to yourself or others, or as required under Illinois and Federal law. If you disclose information related to suspected child or elder abuse, I am obligated to report it. If I receive a court order to release your information, I am obligated to honor it. ____ Client’s Initials

FOID MENTAL HEALTH REPORTING REQUIREMENT:  As per the Illinois Firearm Concealed and Carry Act, all physicians, clinical psychologists, and qualified examiners are required to notify the Department of Human Services (DHS) within 24 hours of determining a person to be a Clear and Present Danger to themselves or others, Developmentally Disabled, or Intellectually Disabled, regardless of the provider’s practice, the person’s age, or any other diagnosis of the person.   ____ Client’s Initials

ELECTRONICALLY MEDIATED PSYCHOTHERAPY:  Hauser Family Therapy, LLC/Catherine Hauser, LLC cannot guarantee the privacy of email or phone therapy.  Therefore clients acknowledge the potential risk to confidentiality by using these technologies. Because of the nature of email, it also may not be viewed immediately and it may be viewed by others. I understand that I should call 911 in an emergency, and not use email to ask for help in a crisis. Additionally, at this time insurance companies do not provide coverage for these services and clients are expected to pay the therapist’s regular fee.  ______ Client’s Initials

LICENSURE AND SUPERVISION: Hauser Family Therapy, LLC/Catherine Hauser, LLC has been able to hire well-qualified professionals who have not yet gotten their clinical license. These professionals have their Masters Degrees and Associate Licenses and are qualified to practice individual, family, couple and group psychotherapy under the supervision of a licensed therapist. Each Associate receives weekly supervision to discuss cases and have oversight of any clinically significant issues. Insurance will pay for the services of the Associates in the same manner that it will pay for licensed therapists. As a client of Hauser Family Therapy, LLC/Catherine Hauser, LLC being seen by an Associate, you are agreeing to allow your therapist to discuss your clinical case with their supervisor on a weekly basis.

____ Client’s Initials

CONSENT TO TREATMENT: By signing this letter, I consent to treatment. I understand that I always retain the right to terminate treatment or obtain a second opinion.

I certify that I have read this Professional Service Agreement and understand and agree to abide by all its terms.

_______________________________________________ Date:__________________

Patient Signature (for Patients 12 years old and above)

_______________________________________________ Date:__________________

Parent/Legal Guardian Signature (for Patients under 18 years old)

_______________________________________________ Date:__________________

Therapist’s Signature

INSURANCE INFORMATION

Please provide your insurance card to obtain a photocopy.

As a courtesy, I will bill your in-network insurance company. Please be aware that I will provide you with a receipt of services to submit on your own accord and for out of network insurance. Insurance coverage is a contract between the patient and their insurance carrier. I will assist you in maximizing your insurance benefits for BCBS PPO by verifying your benefits before the initial date of service; however, please be advised that this is not a guarantee of payment. By law, the insurance carrier must remit payment or deny the insurance claim within 30 days of initial notice of a claim. It is the responsibility of the patient to know and understand the benefits of his/her insurance plan. If an insurance problem occurs, the patient may be asked to assist our office in contacting the carrier or in filing a complaint with the State Insurance Commissioner. If an insurance company has not settled a claim within 90 days, the responsibility for the balance will transfer to the patient. I will provide you with the information we have received from the insurance company regarding non-payment of a claim(s). Prompt payment is appreciated. Accounts that have no payments for over 90 days may be sent to an outside collection agency.

Insurance Change

It is your responsibility to notify me as soon as possible when you have any policy or insurance changes. Failure to do so result in a denied claim(s) and you will be responsible for the full balance due.

Disclosure/Agreement

I agree to pay for any and all services that my insurance company refuses to pay for, regardless of the reason. If my insurance company denies payment for any reason, I will be responsible for the unpaid balance (which may include: non-covered expenses, co-pays, coinsurance, and deductibles). I understand that if my policy is subject to a deductible, the insurance company will not pay Hauser Family Therapy, LLC/Catherine Hauser, LLC for any sessions until my deductible is satisfied and I am responsible for the charges subject to my deductible.

Failure of the insurance company to pay within 90 days of filing is for the purpose of this agreement, a refusal to pay. In the event that I do not pay for these or any other services provided me when due, I agree to pay all associated late fees and collection fees. I also agree that in the event I am forced to file legal proceedings for payment of fees, in addition to the fee owed, I am responsible for all legal fees and court costs incurred by the clinician in the collection proceedings. ___________ Client Initials

I hereby authorize the release of medical information necessary to process my claims:

_______________________________________________ Date:__________________

Patient Signature (for Patients 12 years old and above)

_______________________________________________ Date:__________________

Parent/Legal Guardian Signature (for Patients under 18 years old)

I authorize payment of medical benefits to Hauser Family Therapy, LLC/Catherine Hauser, LLC and understand that I am responsible for charges not covered by my insurance:

________________________________________________ Date: ________________

Patient or Responsible Party’s Signature

Please complete if Hauser Family Therapy, LLC/Catherine Hauser, LLC is out-of-network with your carrier.

OUT-OF-NETWORK VERIFICATION STATEMENT

I, ______________________________________, understand that my insurance has been verified by Hauser Family Therapy, LLC/Catherine Hauser, LLC

I understand that the clinician, is not in my insurance network and that I am responsible for payment of services provided on an out-of- network basis. My signature on this form will represent the fact that I have read and understand that I am responsible for all fees not covered by insurance.

________________________________________________ Date: ________________

Patient or Responsible Party’s Signature

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