CLIENT INFORMATION SHEET - Navigation Counseling …
Welcome!
We are so glad that you have chosen Navigation Counseling Services, llc for counseling. We look forward to our sessions and beginning this journey with you.
Please complete the following forms.
• General New Client Form
• Informed Consent – Includes consent for counseling, confidentiality, and payment
• Authorization for Disclosure (If needed)
• Credit Card Authorization (Optional)
Our goal at Navigation Counseling Services, llc is to provide the utmost in quality counseling and therapeutic services. If you have any questions while completing paperwork, please don’t hesitate to ask at the start of your session.
Warmly,
Caroline Bedel, MA, LPC
Owner and Clinical Director
Statement of Understanding/Informed Consent
Informed Consent
I give my consent to the counseling/therapy process with Navigation Counseling Services, LLC. I understand that this process may include myself and/or other family members. I understand that counseling may involve discussing relationships, psychological, and/or emotional issues that may at times be distressing. However, I understand that this process is intended to help me personally and with relationships. I am aware that I have the right to withdraw from counseling at any time.
_____________________________________________________________________________________
Signature of Client (if Minor, Parent or Legal Guardian Signature) Date
_____________________________________________________________________________________
Signature of Child/Adolescent (Age 12 and older) Date
Confidentiality
All information about each client of Navigation Counseling Services, llc is kept strictly confidential. You must give written authorization before any information about you is given to anyone. However, it is important that you are aware of the following exceptions to confidentiality:
1. If you or others are in clear or imminent danger, Navigation Counseling Services, llc must take reasonable action to prevent injury or death. This action may include informing others of your intent to harm yourself or others. All counselors are mandated reporters.
2. Suspected incidents of physical, sexual, and verbal/emotional abuse of elders and children must be reported to the proper authorities.
3. Medical records can be subject to court order.
Fees and Payment Policy
Payment of fees for services is due at the time of service. All fees are private pay and agreed upon during first session. No services will be submitted to insurance.
I understand that I will be responsible for all agreed upon fees.
In event that a subpoena is issued to your therapist please be aware that the fee for appearing in court is $1000.00 payable before the appearance and will be subject to all attached attorney, collection, and legal fees.
Fees are re-evaluated periodically, and all changes will be discussed prior to charge. Please provide 48 hours notice before canceling an appointment to avoid a fee for the full amount of the session being charged for a missed session.
I HAVE READ AND UNDERSTAND THE ABOVE STATEMENTS DESCRIBING CONFIDENTIALITY and FEES. MY SIGNATURE BELOW INDICATES THAT I ACCEPT AND AGREE TO THESE TERMS.
_____________________________________________________________________________________
Signature of Client (if Minor, Parent or Legal Guardian Signature) Date
A. CLIENT INFORMATION Date: _________________
Client Name: ____________________________________________________________________________
First Middle Last
Address: ____________________________________________________________________________
Street City State Zip
Phone Number: ____________________________________________________________________________
Cell Work Home (optional)
Email: ________________________________ Date of Birth: _____________ Age: _________
Education level:__________________________Occupation:___________________________
Employer/School: _______________________Marital Status: _________________________
Race:_____________________________
How did you hear about about Navigation Counseling Services? ________________________
B. FAMILY INFORMATION
Spouse/Significant Other: (if applicable) ____________________________________________________________________________
First MI Last
Address (if different from above):
____________________________________________________________________________
Street City State Zip
Phone Number: ____________________________________________________________________________
Cell Home Work
Names and ages of other people currently living in your home: ____________________________________________________________________________
C. IN CASE OF EMERGENCY, PLEASE NOTIFY
Name/Relationship: ______________________________Phone: ________________________
Name/Relationship: ______________________________Phone: ________________________
D. MENTAL HEALTH HISTORY
Diagnosis from other mental health providers: ________________________________________
______________________________________________________________________________
What are your symptoms: ____________________________________________________________________________________________________________________________________________________________
History of Suicidal or Self-Harm Actions: _____________________________________________
Any other emotional concerns you would like to mention? ______________________________________________________________________________
MENTAL HEALTH Treatment HISTORY:
( No Previous Treatment or Formal Evaluation
( Hospitalization(s) (number) :____________ Most recent(Dates):________________________
( Outpatient Treatment: ________________ Most recent(Dates):________________________
Have you previously met with other counselors/therapists? ( No ( Yes
Was is helpful? ( No ( Yes
SUBSTANCE ABUSE:
Any current substance use and if so which substances: ________________________________
E. MEDICAL CONCERNS
Diagnosis from other physical health providers: _______________________________________
______________________________________________________________________________
What are your symptoms: ____________________________________________________________________________________________________________________________________________________________
Any other wellness concerns you would like to mention? ______________________________________________________________________________
All current prescribed medications: ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
E-MESSAGING SERVICES
In order to best serve you, we sometimes need to contact our clients. Please let us know how you would like to receive information. Please circle your preferred ways:
Home-Phone Work-Phone Cell (Phone Call),
Text Messages Email
CLIENT CONFIDENTIALITY QUESTIONNAIRE
1. Please list the person(s), if any, whom we may inform about your general condition and diagnosis: ____________________________________________________________________________
2. Please list the family member(s) or significant other, if any, whom we may inform about your symptoms ONLY IN AN EMERGENCY: _____________________________________________
3. Please print the address where you would like your billing statements and/or correspondence from our office be sent, if other than your home: ___________________________________________________________________________
4. Please print the telephone number, if any, where you want to receive calls about your appointments, if other than those listed: _________________________________________
5. May we leave confidential messages, such as appointment reminders, on your home answering machine or voice mail? Please circle one: Yes No
Client Name: ___________________________________
Client Signature: ________________________________ Date: ________________________
Authorization for Disclosure of Consumer Medical/Health Information
I, ___________________________________ authorize and request ______________________
Client's Printed Name Therapist Name
to disclose/release the below specified information of client ____________________________, (DOB): ______________________, (social security number) _____________________, who received services from _____________________ (date) to _____________________ (date) to
(Identify those to whom you wish to have information released) Name and Phone #
______________________________________________________________________________
The purposes of this disclosure are continuity of services/care and the gathering of collateral information. Unless otherwise specified, this request is for all relevant treatment information.
1. READ CAREFULLY: I understand that my medical/health information records are confidential. I
understand that by signing this authorization, I am allowing the release of my medical/health information. The protected health information (PHI) in my medical records includes mental/behavioral information. In addition, it may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome, human immunodeficiency virus, other communicable diseases, and/or alcohol/drug abuse.
2. Alcohol and drug abuse information records are specifically protected by federal regulations and by signing this authorization without restrictions I am allowing the release of any alcohol and/or drug information records (if any) to the agency or person specified above. Please sign if you are authorizing the release of alcohol and drug abuse information (client):____________________________________.
3. This authorization becomes effective on ________________ (date). This authorization automatically
expires in one year, or on: ______________________________(date)
6. I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing. I further understand that action already taken based on this authorization, prior revocation, will not be affected.
7. I understand that I have the right to receive a copy of this authorization. A copy of this authorization is as valid as the original.
8. I understand that authorizing the disclosure of this medical/health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may request to inspect or request a copy of information to be used or disclosed. If I have questions about disclosure of my medical/health information, I can contact Navigation Counseling Services, LLC.
My signature below acknowledges that I have read, understand, and authorize the release of my PHI.
Client: _______________________________________________________________________________________
Signature Printed Name Date
Witness: _____________________________________________________________________________________
Signature Printed Name Date
Parent/Legal Guardian/Representative: ___________________________________________________________
Signature Printed Name Date
Credit Card on File (CCOF) Payment Authorization Form
Conveniently have your payments automatically charged to your credit card.
Here’s How CCOF Payments Work:
You authorize charges to your Visa, MasterCard, American Express or Discover card. You will be charged after each individual session for the amount due after that session. A receipt will be emailed to you and the charge will appear on your credit card statement. Cards are typically run on Fridays or Saturdays.
A 48 hour notice of cancellation will prevent any charge to your credit card for your missed appointment.
Please complete the information below:
I ____________________________ authorize Navigation Counseling Services, LLC to charge my credit card indicated below for payment of my therapy bill. I also authorize Navigation Counseling Services, LLC to charge my card for a missed appointment fee if I do not cancel within 48 hours of the appointment.
Billing Information (phone and email will be used to contact you if needed concerning your bill or payment)
Card Billing Address____________________________ Phone# ________________________
Card City, State, Zip ____________________________ Email ________________________
|Account Type: Visa MasterCard Discover |
| |
|Cardholder Name _________________________________________________ |
|Card Number _____________________________________________ |
|Expiration Date ________________ CVV ___________________________ Zip Code __________________________ |
SIGNATURE DATE
More fine print: I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.
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