ADVANTAGE COUNSELING SERVICES, LLC - Advantage …



Advantage Counseling Services New Client QuestionnairePlease fill in the information below and bring it with you to your first session or email to advcounservllc@ prior to your first session. Please note: information provided on this form is protected as confidential information. PERSONAL INFORMATIONName:Click or tap here to enter text. Date: Click or tap here to enter text.Address: Click or tap here to enter text. Best Phone to Contact You: Click or tap here to enter text. May we leave a message? ?Yes ? No Email: Click or tap here to enter text. DOB: Click or tap here to enter text. Age:Click or tap here to enter text. Gender: Click or tap here to enter text. Marital Status: ?Never Married ?Domestic Partnership ?Married ?Separated ?Divorced ?Widowed Referred By (if any): Click or tap here to enter text.REASON FOR SEEKING COUNSELINGWhat is brining you into counseling? Click or tap here to enter text.HISTORYHave you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? ?No ? Yes, previous therapist/practitioner: Click or tap here to enter text. Are you currently taking any prescription medication? ? Yes ? No If yes, please list: Click or tap here to enter text. Have you ever been prescribed psychiatric medication? ? Yes ? No If yes, please list and provide dates: Click or tap here to enter text.GENERAL AND MENTAL HEALTH INFORMATION1. How would you rate your current physical health? (Please check one) ?Poor ?Unsatisfactory ?Satisfactory ?Good ? Very good Please list any specific health problems you are currently experiencing: Click or tap here to enter text.2. How would you rate your current sleeping habits? (Please check one) ?Poor ?Unsatisfactory ?Satisfactory ?Good ?Very good Please list any specific sleep problems you are currently experiencing: Click or tap here to enter text.3. How many times per week do you generally exercise? Click or tap here to enter text. What types of exercise do you participate in? Click or tap here to enter text. 4. Please list any difficulties you experience with your appetite or eating problems: Click or tap here to enter text. 5. Are you currently experiencing overwhelming sadness, grief or depression? ?No ?Yes If yes, for approximately how long?Click or tap here to enter text. 6. Are you currently experiencing anxiety, panics attacks or have any phobias? ?No ?Yes If yes, when did you begin experiencing this? Click or tap here to enter text. 7. Are you currently experiencing any chronic pain? ?No ?Yes If yes, please describe: Click or tap here to enter text.Do you take prescription opioids for control of your pain? ? Yes ? No 8. Do you drink alcohol more than once a week? ?No ?Yes If yes, how frequently are you drinking and what amount? Click or tap here to enter text.Are you concerned about your drinking? Click or tap here to enter text. 9. How often do you engage in street/ illicit drug use? ?Daily ?Weekly ?Monthly ?Infrequently ?Never Are you concerned about your drug use? ?Yes ? No 10. Are you currently in a romantic relationship? ?No ?Yes If yes, for how long? Click or tap here to enter text.On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship? Click or tap here to enter text.11. What significant life changes or stressful events have you experienced recently? Click or tap here to enter text. FAMILY MENTAL HEALTH HISTORYIn the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.) Please Check All That ApplyList Family MemberAlcohol/Substance Use ? Yes ? No Click or tap here to enter text.Anxiety ? Yes ? No Click or tap here to enter text.Depression ? Yes ?No Click or tap here to enter text.Domestic Violence ?Yes ? No Click or tap here to enter text.Eating Disorders ?Yes ? No Click or tap here to enter text.Obesity ? Yes ?No Click or tap here to enter text.Schizophrenia ? Yes ?No Click or tap here to enter text.Obsessive Compulsive Behavior ? Yes ? No Click or tap here to enter text.Suicide Attempts ?Yes ? No Click or tap here to enter text.Other: Click or tap here to enter text.Click or tap here to enter text.Family Medical HistoryPlease Check All That ApplyList Family MemberCancer ? Yes ? No Click or tap here to enter text.Diabetes ? Yes ? No Click or tap here to enter text.Heart Disease ? Yes ?No Click or tap here to enter text.Other: ?Yes ? No Click or tap here to enter text.ADDITIONAL INFORMATION1. Are you currently employed? ?No ?Yes If yes, what is your current employment situation? Click or tap here to enter text.Do you enjoy your work? Is there anything stressful about your current work? Click or tap here to enter text. 2. Do you consider yourself to be spiritual or religious? ?No ?Yes 3. What do you consider to be some of your strengths? Click or tap here to enter text. 4. What would you like to accomplish out of your time in therapy? Click or tap here to enter text.Advantage Counseling Services LLC HIPAA NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.Effective Date March 18, 2019/ Updated May 2, 2020.This notice serves as Advantage Counseling Services LLC policy related to the use and disclosure of your healthcare information.Advantage Counseling LLC will only release information in accordance with state and federal laws and the ethics of the counseling profession. This includes any protected health information and substance use information. This practice uses and discloses protected health information for the purposes of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes. The following are examples of how you protected health information may be used:TREATMENT Use and disclose health information to: Provide, manage or coordinate careConsultants Referral sourcesPAYMENT Use and disclose health information to: Verify insurance and coverage Process claims and collect fees HEALTHCARE OPERATIONS Use and disclose health information for: Review of treatment proceduresReview of business activities CertificationStaff trainingCompliance and licensing activitiesOTHER USES AND DISCLOSURES WITHOUT YOUR CONSENTMandated reportingEmergencies Criminal damage Appointment schedulingTreatment alternativesAs required by lawCLIENT RIGHTSRIGHT TO REQUEST WHERE WE CONTACT YOU Preferred contact method: Click or tap here to enter text.RIGHT TO REQUEST RESTRICTIONS ON USES AND DISCLOSURES OF YOUR HEALTHCARE INFORMATION Must be in writing You are not obligated to agreeRIGHT TO RELEASE YOUR MEDICAL RECORDS Written authorization to release records to others Right to revoke release in writing Revocation is not valid to the extent that you have acted in reliance on such previous authorizationRIGHT TO COMPLAIN Please discuss any concerns with me so we can attempt to resolve them If not satisfied, right to complain to the U.S. Dept. of Health and Human Services No retaliationRIGHT TO INSPECT AND COPY YOUR MEDICAL BILLING RECORDSRight to inspect and copy records Counselor may deny this request Charges for copying, mailing, etc.RIGHT TO RECEIVE CHANGES IN POLICY May request any future changesRIGHT TO ADD INFORMATION OR AMEND YOUR MEDICAL RECORDS May request to amend record Number of days to decideMay deny the request If denied, right to file disagreement statementDisagreement state and your response will be filled in the record Amendment request must be in writingRIGHT TO ACCOUNTING OF DISCLOSURESFor a six year period beginning (with 3/18/2019)Exceptions: Disclosure for treatment, payment or healthcare operations Disclosures pursuant to a signed releaseDisclosure made to clientDisclosures for national security or law enforcementClient Signature/ Date Click or tap here to enter text.Advantage Counseling Services LLC Fees/Payment/Cancellation/Freedom to ChooseIndividual Therapy:Initial Evaluation Session $15050-60 Minute Sessions??$95Sliding scale fees and flat fee for service plans available for qualifying clients ++For clients paying sliding scale or flat fees for services, payment is expected at the time of session.Couples/Marital Therapy:Initial Evaluation Session $15060-90 Minute Sessions$95-$140 +Sliding scale fees and flat fee for service plans available for qualifying clients ++For clients paying sliding scale or flat fees for services, payment is expected at the time of session.Court Ordered Services (not billed to insurance):Court/Employer Ordered Substance Use Disorder Evaluations $150 per evaluationVASAP Treatment Assessments $80 per assessmentDOT SAP Evaluations/ Case Management $450 Other Services:Supervision for licensure for residents in counseling or CSAC $50 per hour or negotiated ratePayment: You will be expected to pay for either each session in full, or your insurance co-payment at the time of your appointment. Accepted methods of payment are cash, check, or credit cards. There is an additional $3 charge to process credit card payments. Checks should be made payable to Advantage Counseling Services.Secondary Insurance:I do not bill secondary insurance. You are expected to pay the difference in the amount paid by your primary insurance carrier and their contracted rate for services. Upon request, I will provide you with a copy of the adjusted claim once the primary insurance has processed your claim.+++ Sliding Fee Qualifying IncomesClients wishing to apply for the sliding scale fees need to bring their last year's tax returns to the first session.$6,245.00 - $21,330.00 = $25 per session$21,331.00 - 30,170.00 = $35 per session$30,171.00 - $39,010.00 = $45 per session$39,011.00 - $52,270.00 = $60 per sessionAppointment CancellationsIf you are unable to attend an appointment, I request that you provide at least 24 hours advanced notice for cancellations. Since I am unable to use this time for another client, please note that you will be billed $45 if your appointment is not cancelled with a 24 hour notice or if your appointment is missed altogether. Late cancelation/ missed appointment fees are not paid by insurance and are billed directly to the client.Missed appointment/ late cancelation fee (canceled less than 24 hours) $45 Initial Here: Click or tap here to enter text.Checks returned due to insufficient funds will incur a fee of $25.00 Initial Here: Click or tap here to enter text. Client Signature/ Date: Click or tap here to enter text.Freedom to Choose Form (Medicaid Clients Only)I understand that I have a choice in whom I choose to see for individual or group therapy. By signing below, I acknowledge this choice and indicate that I am choosing Advantage Counseling Services, LLC to provide my counseling services.Client Signature/ Date: Click or tap here to enter text. Advantage Counseling Services, LLC Telebehavioral Health Informed ConsentPlease review each statement and check the corresponding box signifying your acknowledgement and agreement with each statement.Introduction of Telebehavioral Health:?Telebehavioral health is the delivery of behavioral health services using interactive technologies (use of audio, video or other electronic communications) between a practitioner and a client/patient who are not in the same physical location.Software Security Protocols:?Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.Benefits & Limitations:?This service is provided by technology (including but not limited to video, phone, text, apps and email) and may not involve direct face to face communication. There are benefits and limitations to this service.Technology Requirements:?I will need access to, and familiarity with, the appropriate technology in order to participate in the service provided. I will be given a basic instruction sheet. Risks of Technology:?These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.Modification Plan:?My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies, and modify our plan as needed.Client Communication:?It is my responsibility to maintain privacy on the client end of communication. Insurance companies, those authorized by the client, and those permitted by law may also have access to records or communications. I am giving Advantage Counseling Services, LLC permission to bill my insurance company for these services.Laws & Standards:?The laws and professional standards that apply to in-person behavioral services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.Laws & Standards:?The same limits of confidentiality that apply to face to face sessions also apply to telebehavioral health sessions.Confirmation of Agreement:Client Printed Name Click or tap here to enter text. (Typed Name Serves As Client Signature & Consent To Treat/ Bill Client’s Insurance For Telebehavioral Health Services)DateClick or tap here to enter text. Please email completed form to advcounservllc@ before your first telebehavioral Health appointment.Advantage Counseling Services, LLC Consent for Treatment and Limits of LiabilityPlease review each statement and check (X) the corresponding box signifying your acknowledgement and agreement with each statement.Limits of Services and Assumption of Risks: ?Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions. Limits of Confidentiality: ?What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian. THE FOLLOWING IS A LIST OF EXCEPTIONS Duty to Warn and Protect: ?If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan or threat to harm another person, the therapist is required to warn the possible victim and notify legal authorities. Abuse of Children and Vulnerable Adults:?If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities. Prenatal Exposure to Controlled Substances:?Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child. Guardianship:? Legal guardians have the right to access the clients’ records. Insurance Providers:?Insurance companies and other third-party payers are given information that they request regarding services to clients in order to process your claim. The type of information that may be requested includes: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc. By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications. I also give permission for Advantage Counseling Services to bill my insurance/ EAP service and provide any needed information to assure accurate billing.EMERGENCY / AFTER HOURS PRECEDURES?My normal business hours are 9:00am-6:00pm Wednesday-Friday. I can respond to email/ text on a limited basis on Monday/ Tuesday. My direct number is 540-836-3659.If you should have a mental health emergency after my business hours, please contact:Either Emergency Services at Valley Community Services Board at 540-885-0866, 540-943-1590, or toll free 866-274-7475; Or go to Augusta Health Emergency Room.Client Signature & Date: Click or tap here to enter text.Please email completed form to advcounservllc@ before your first telebehavioral health appointment. ................
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