Wellness Counseling Center of Dallas
Wellness Counseling Center of Dallas
5601 Democracy Drive, Ste. 225
Plano, TX 75024
(972) 403-1359 Fax: (972) 403-1378
CHILD INTAKE FORM
Child/Adolescent Information
Name__________________________________________ Date of Birth________________
SSN _______-_____-________ Age_______________
School:________________________ Teacher:________________ Phone:_________________
Primary Care Physician: __________________________Phone #:______________________
Parent Information
Mother:_______________________________________________________________
Phone: Home__________________ Work__________________ Cell____________________
Email address________________________________________________________________
Preferred contact number:_________________________________
Home Address__________________________________________________________________
Street City State Zip
Father: _______________________________________________________________
Phone: Home__________________ Work__________________ Cell____________________
Email address________________________________________________________________
Preferred contact number:_________________________________
Home Address__________________________________________________________________
Street City State Zip
Parents: ___Married ___Separated ___Divorced
If Divorced: Year Divorced _______ Age of Child at the Time of Divorce___________
Please provide documentation from Divorce Decree stating who has legal authority to consent to psychological treatment.
Person Financially Responsible for this bill________________________________________
Referred by ________________________________________________________
Reason for Seeking Therapy
_______________________________________________________________________________________________________________________________________________________________________________________________________________________
Consent for Treatment
I authorize Marcella Fooks, PhD to provide psychological services to me and/or my child. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered. I have read all of the information on this form and have completed the above questions. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in the above information.
Signature of Client (or Parent if applicable) ______________________________ Date________________
Wellness Counseling Center of Dallas
5601 Democracy Drive, Ste. 225
Plano, TX 75024
(972) 403-1359 Fax: (972) 403-1378
Insurance Information
Insurance Company/Mental Health Network______________________________________
Phone Number from Insurance Card_________________ Group/Policy #________________
Name of Employer______________________________________
Primary Cardholder’s Name______________________________
Primary Cardholder’s SSN ________________________________
Primary Cardholder’s Date of Birth__________________________
I hereby instruct and direct the insurance company named above to pay by check made payable to: Wellness Counseling Center of Dallas, 5601 Democracy Drive, Ste. 225, Plano, TX 75024; the professional or medical expenses allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered.
This is a direct assignment of my rights and benefits from this policy. This payment will not exceed my indebtedness to the above mentioned assigned, and I agree to pay any balance of said professional services charges over and above this insurance payment at the time service is rendered. I also authorize the release of any information pertinent to my case to any insurance company. A photocopy or facsimile of the assignment shall be considered as effective and valid as the original.
Signature of Client or Policy Holder _________________________________ Date___________________
Payment Policy
Full payment for each session is due at the time the service is rendered. Payment may be made by cash, check, Visa, MasterCard, or Discover Card. A co-payment of insurance will be accepted after insurance coverage is verified.
Filing of insurance is a courtesy provided by this office. If you prefer to file your own claim, a duplicate receipt will be provided. Secondary insurance is not filed by this office.
There will be a $30 fee for any NSF check returned.
Your session time is reserved for you. If you are unable to keep your appointment, please notify us at least 24 hours in advance. In the absence of 24 hour notification, you will be billed for the session as follows unless we are able to fill the appointment time. Missed appointments cannot be filed with insurance. Late Cancellation Fee and/or No Show Fee: $75.
Fees For Services
Diagnostic Interview/Intake $175 Parent Reporting Conference $125
Therapy session 45-50 min. $125 Psychological Evaluation $125/hour
Therapy session 25-30 min. $ 75 Review of Records/Consultation $125/hour
Therapy session 75 min. $150 Copy of Records/Summary Report $50
Therapy session 90 min. $175
I have read, understand and agree to abide by the above policy.
Signature of Client (or Parent if applicable) ______________________________ Date________________
Wellness Counseling Center of Dallas
5601 Democracy Drive, Ste. 225
Plano, TX 75024
(972) 403-1359 Fax: (972) 403-1378
Notice of Privacy Practices Acknowledgment
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand this information can and will be used to:
1. Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and/or indirectly;
2. Obtain payment from third-party payers; and
3. Conduct normal healthcare operations such as quality assessments and physician certifications.
I acknowledge I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand this organization has the right to change its Notice of Privacy Practices from time to time, and I may contact this organization at any time at the address listed above to obtain a current copy of the Notice of Privacy Practices.
I understand I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restriction, but if you do agree, you are bound to abide by such restrictions.
Client Name ___________________________________________________
Signature of Client (or Parent if applicable) ________________________ Date________________
Relationship to Client__________________________________
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