Transforming Lives, Connecting Marriages & Families
IMPORTANT!INFORMATION!FOR!CLIENTS!
Welcome to Li e onnection o nseling We as t at o read t e ollowing in ormation and ring
an
estions o mig t ave to o r attention
Fee
e ee or a
ƈ
min te session is
We re est t at pa ment or all services e made
at t e time o services are rendered
t is t e polic o t is o ice to t rn delin ent acco nts over to
a collection agenc
nl in ormation w ic is non ƈclinical in nat re will e given to t e collection
agenc or t is p rpose
elep one
alls
r o ice is open Monda t ro g Frida rom : a m
: pm
ter o rs
o ma leave a message on o r voice mail
o r t erapist determines t at it is necessar or o to
e a le to contact im er, special arrangements will e made n t e case o an emergenc or li e
t reatening event, call
and not L
p p o i n t m e n t s W en o ma e an appointment, a speci ic time is reserved or o
o s o ld ave
to e late, o will e seen or t e remaining portion o o r reserved time
ver e ort will e
made to see o on time, owever, in some n s al circ mstances o ma ave to wait e ore eing
seen n s c cases o will e seen or o r ll visit
If#you#must#cancel#an#appointment,#please#do#so#at#least#24#hours#in#advance.#
If#not,#you#will#be#charged#$150.00#for#the#full#session.#
Ins ran e Services in t is o ice ma e covered
medical ins rance plans However, ew policies
cover
o t e cost
o re est, t e o ice sta will assist o wit ins rance iling,
t
collection of insurance claims is ultimately the insured client’s responsibility, regardless of your in
network or out of network benefits
o will e responsi le or w atever ins rance does not cover
according to o r c arges Please
n erstan
that
o
are f ll res onsi le for the
a ment of all fees for ser i es ro i e re ar less of the e tent of an ins ran e
o era e o ma ha e
t e t erapist is not in networ wit t e client s ins rance compan , it is not
o r polic to accept t e amo nt an ins rance compan ma o er as pa ment, i t e amo nt is less t an
t e reg lar ee
CC
ill e notifie of an
ersonal a ress han e or han es in
ins ran e o era e
Ps holo i al estin
itional Fees
n order to etter nderstand a client s pro lems
and to acilitate treatment, ps c ological tests are re entl
tili ed
n s c cases t e p rpose o
ta ing t e tests will e e plained and t e res lts will e reviewed wit
o
Fees or testing are
separate rom ees or reg lar visits and var according to t e test sed
stimates o t e cost o
testing will e rnis ed pon re est and in advance o test administration lso, an assessments,
report writing, p one cons ltations, and emails will e additional ees and will e e plained
o r
t erapists i t e need arises
Confi entialit
ll in ormation t at o reveal to o r t erapist, incl ding test res lts, notes
and records, is con idential and will not e released to an o tside person or agenc wit o t o r written
a t ori ation W en more t an one amil mem er is seen d ring a session, eac o t ese legall
competent individ als m st sign s c a t ori ation
ere are several limitations to t is w ic
incl de:
) i , in t e t erapist s opinion, revealing t e in ormation wo ld e necessar to prevent a
person s deat or serio s in r , ) ins rance compan re ests or a diagnosis and general
description o services rendered, and ) ot er circ mstances w ere it is legall re ired, s c as t e
p sical or se al a se o a minor
I have read and understand the ab o v e p o l i c i e s a n d c l i e n t i n f o r m a t i o n . I a m
r e s p o n s i b l e for any unpaid balance on my account.
lient Signat re ______________________________________________________ Date ______________
arent
ardian Signat re _____________________________________________ Date ______________
Patient Health Information Consent Form
We want o to now ow o r atient Healt n ormation (PHI) is going to e sed in t is o ice
and o r rig ts concerning t ose records e ore we will egin an ealt care operations we m st
re ire o to read and sign t is consent orm stating t at o nderstand and agree wit ow o r
records will e sed
o wo ld li e to ave a more detailed acco nt o o r policies and
proced res concerning t e privac o o r atient Healt n ormation we enco rage o to read
t eH
N
t at is availa le to o at t e ront des e ore signing t is consent
e patient nderstands and agrees to allow t is o ice to se t eir atient Healt n ormation (PHI) or t e
p rpose o treatment, pa ment, ealt care operations, and coordination o care s an e ample, t e patient
agrees to allow t is o ice to s mit re ested H to t e Healt ns rance ompan (or companies)
provided to s
t e patient or t e p rpose o pa ment e ass red t at t is o ice will limit t e release o
all H to t e minim m needed or w at t e ins rance companies re ire or pa ment
e patient as t e rig t to e amine and o tain a cop o is or er own ealt records at an time and
re est corrections
e patient ma re est to now w at disclos res ave een made and s mit in
writing an
rt er restrictions on t e se o t eir H
r o ice is o ligated to agree to t ose restrictions
onl to t e e tent t e coincide wit state and ederal law
patient s written consent need onl
o ice
e o tained one time or all s
se
ent care given t e patient in t is
e patient ma provide a written re est to revo e consent at an time d ring care
t e se o t ose records or t e care given prior to t e written re est to revo e consent
care given a ter t e re est as een presented
r o ice ma contact
c arita le wor per ormed
comm nications at an time
o
is wo ld not e ect
t wo ld appl to an
periodicall regarding appointments, treatments, prod cts, services, or
o r o ice
o ma c oose to opt΀o t o an mar eting or
ndraising
For o r sec rit and rig t to privac , all sta
as een trained in t e area o patient record privac and a
privac o icial as een designated to en orce t ose proced res in o r o ice We ave ta en all preca tions
t at are nown
t is o ice to ass re t at o r records are not readil availa le to t ose w o do not need
t em
atients ave t e rig t to ile a ormal complaint wit o r privac o icial and t e Secretar
a o t an possi le violations o t ese policies and proced res wit o t retaliation
t is o ice
o HHS
r o ice reserves t e rig t to ma e c anges to t is notice and to ma e t e new notice provisions
e ective or all protected ealt in ormation t at it maintains o will e provided wit a new notice at o r
ne t visit ollowing an c ange
is notice is e ective on t e date stated elow
t e patient re ses to sign t is consent or t e p rpose o treatment, pa ment and
operations, t e t erapist as t e rig t to re se to give care
ealt
care
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For#further#information#regarding#this#notice,#please#contact#LCC#at#918G946G9588#!
Date:!___________________!
CLIENT
Last Name _________________________ First Name ________________________________ MI________
Address ___________________________________ City, State ___________________ Zip _____________
Date of Birth ____________________ Age ____________ Social Security#__________________________
Employer ___________________________________________ Occupation _________________________
Highest Education Completed ______________ Church Affiliation _________________________________
Phone: Home ____________________Work ___________________ Cell __________________________
Contactѧmeѧby:ѧHomeѧNumberѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧWorkѧNumberѧ
Email___________________________________________
ѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧѧCellѧNumber
May we contact you via email:
Yes
No
SPOUSE/PARENT/GUARDIAN
Last Name ____________________________ First Name ____________________________ MI ________
Address ___________________________________City, State _______________________Zip __________
Date of Birth _________________ Age ______________ Social Security # __________________________
Employer ___________________________________________ Occupation _________________________
Highest Education Completed _____________ Church Affiliation ________________________________
Phone: Home ____________________ Work _______________________ Cell ____________________
Email:_____________________________ѧMayѧweѧcontactѧyouѧviaѧemail:ѧYesѧѧ
ѧѧѧѧѧNo
INSURANCE PROVIDER: In order for us to verify your insurance, we will need a photo copy
of your insurance card and driver’s license. W e w i l l n o t file your insurance without them.
InsuranceѧCo.ѧ
Name:ѧ__________________________________ѧ Policy/Group#ѧ_______________________ѧ
Owner of Policy: ____________________________________________
ID# ________________________
Address of Insurance Co. ________________________________________Phone # _______________
**Please note that we file insurance as a courtesy. You will ultimately be responsible for
your account and whatever they do not cover according to our charges**
arital
tat s
____Married, Separated)
____ Single, Never Married
____Remarried
____ Single, Widowed
(How Long :_________)
____ Single, Divorced
____ First Marriage
Please!Circle:!
(How Long :________)
mer en
Conta t
Husband’s:!1st,!2nd,!3rd,!4th!!!!Wife’s:!1st,!2nd,!3rd,!4th!
erson ot er t an o se old mem er Name:@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@Relations ip@@@@@@@@@@@@@@@@@@@@@@@@@@@@
ddress:__________________________________ it :_____________ State: ___________ ip:
________
one: Home:________________ Wor : ___________________
itional Famil
em ers (List all c ildren
ell: _____________________
an marriages w et er living at ome or not)
!!!!!!Name!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Sex!!!!!Age!!!!!!!!!DOB!!!!!!!!!!!!!!!!Education!!!!!!!!!!!!!Occupation!!!!!!!!!!!!!!!Living!@!Home?!
$IJME@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@
$IJME@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@
$IJME@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@
$IJME@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@
$IJME@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@
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Please list an re ent stressf l e ents or han es hi h ha e o
rre in the last ear
eaths of frien s or relati es marria es
i or es
han es in or
s hool
resi en e
h r h et
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e i al Histor
Family!Member!
!!!!!!!!List!Any!Recent!Illness,!
!Tests,!or!Hospitalizations!
List!All! !
!!!!!!Medications!Taken!
Physician!
@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@
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W o re erred o
Have o
ere ______________________________________________
een in co nseling t erap previo sl
W en ________________
__________________________
W om _________________ How Long ________________
n w at wa wo ld o li e t e co nselor t erapist to assist o
_______________________________________________________________________________
_______________________________________________________________________________
Do o consider
ristian Fait to e an important reso rce __ es __no
redit
ard
arantee Form
N NS R D L N S
lients w o are nins red or w ose ins rance does not cover t e cost o mental ealt
co nseling, eca se o ig ded cti les or eit er limitations are personall responsi le or
pa ment n alance not paid
t e end o t e wee will e a tomaticall c arged to o r
designated card elow
is proced re will ena le o to spread o t o r pa ments i o wis
and ma e t em smaller w ile eeping o r acco nt c rrent
NS R N
SS
NM N
r ns rance ssignment rogram is designed to eep o r o t o poc et e pense to a
minim m s a co rtes to o , we will ill o r ealt ins rance carrier on o r e al and wait
p to
da s or pa ment lease remem er, t at o are responsi le or pa ment n Da
,i
t e ill as not een paid
o r ins rance compan , we will c arge o r designated credit card
elow or t e amo nt o t e claim n pa ment made on t ese claims t erea ter will e
immediatel re nded to o
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______________________#
DATE
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R D
RD:
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RDH LD R S N M _______________________________________________________
LL N
DDR SS __________________________________________________________
__________________ S
M L DDR SS
RDN M
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__________________
R
_______________
S _______________________________________
R ______________________________________________________________
______________________
HR
D
DN M
R: _____________