Adult Intake Packet

PAYMENT POLICY

Insurance – The insurance benefits quoted by your insurance company and/or HGCC are not a guarantee of payment. Benefits can change periodically and may affect the amount that your insurance company will pay. The final confirmation of your benefits and copay will appear on the Explanation of Benefits you receive from the insurance company. You are financially responsible for any and all charges not covered by your individual policy.

Out of Pocket – All fees, including copays are due at the time of service. Our billing staff is not authorized to split payments or to run a specific dollar amount on certain days of the month. We accept cash, checks, (payable to Healing Grace) major credit cards, debit cards and health saving cards.

**Please be aware all outstanding balances over 90 days are subject to be sent to a collection agency**
Do you plan to use Insurance for your therapy services?*

YesNo - private pay
*If a rate reduction is needed, please fill out our online scholarship application for further consideration*
Primary Insurance *

Company

Policy Holder Name

ID #Group #
Upload Insurance Card

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Cancelof
Policy Holder*
Secondary Insurance

Company

Policy Holder Name

ID #Group #
Policy Holder
CREDIT CARD AUTHORIZATION

Healing Grace highly recommends keeping a credit card on file. It keeps accounts current and avoids getting behind on payment. Keeping a card on file authorizes Healing Grace to charge that card for any outstanding balances, including, but not limited to: deductible, co-pay, co-insurance, private pay fees, missed/late cancellation fees; along with any other outstanding balances.
Please be aware you will not receive a notification (phone call, email, text) prior to us running your card. You will however, receive an email receipt of the transaction ran if you provide an email.

* Please let the front desk know at 'check in' if you would like to leave a credit card on file. We can give you the form 'in person' to update. If you have access to our portal, you can update your card or make a payment at any time.*
CANCELLATION POLICY

Therapy sessions are scheduled in advance and are a time reserved exclusively for our clients. When a session is cancelled without adequate notice, we are unable to fill this time slot by offering it to another current client, a client on the waiting list, or a client with a clinical emergency.

For these reasons, we kindly ask for at least 24-hour cancellation notice by phone, directly to your therapist extension. If you cancel or no show after the 24-hour period, no matter what the reason is for cancellation, you will be charged a missed flat rate fee of $100.00, regardless of what you currently pay per session. The missed fee is your responsibility and cannot be billed to your insurance company.

You can avoid a cancellation/missed session fee by:
- Have a Telehealth session instead - this is where a counselor provides psychological counseling and support over video conferencing or a telephone call. This is especially beneficial during inclement weather, transportation issues, sick kids, etc. This is not our preferred method of therapy, however within good reason, can be approved by a supervisor. Remember to keep in mind the state that your therapist is licensed in, as they are not all licensed to provide therapy in states other than Missouri. Please note: Internet, a computer or mobile device, an integrated or external microphone and camera are required for video conferencing.
Would you be willing to have a Telehealth session (virtual appointment) at any time during your therapy journey?*

YesNo
INFORMED CONSENT FOR TELEHEALTH

This Informed Consent for Telehealth contains important information focusing on doing psychotherapy using the phone or video conferencing through the Internet. Please read this carefully and let us know if you have any questions. When you sign this document, it will represent an agreement between us.

Benefits and Risks of Telehealth
Telehealth refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telehealth is that the client and clinician can engage in services without being in the same physical location. This can be helpful if bad weather is expected, if the client or clinician moves to a different location, has transportation issues, or is otherwise unable to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person psychotherapy and telehealth, as well as some risks. For example:

Risks to confidentiality We have a legal and ethical responsibility to make our best efforts to protect all communications that are a part of our telehealth. However, the nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. On our end we will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.

Issues related to technology There are many ways that technology issues might impact telehealth. If the session is interrupted for any reason and you are not having an emergency, disconnect from the session and we will wait two (2) minutes and then re-contact you via the telehealth platform on which we agreed to conduct therapy. If you do not receive an attempt to reconnect within two (2) minutes, then call your therapist directly using the telephone.
If a technological connection fails, and you are having an emergency, do not call us back; instead, call 911, or go to your nearest emergency room. Call us back after you have called or obtained emergency services.

Informed Consent This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together and does not amend any of the terms of that agreement.
Your initials below indicates you understand the risk of telehealth and agree to engage in therapy through the means of video conferencing or telephone. *
The information I have given is true and correct. I have read all the above policies and by signing below agree to it's terms and conditions.
Client Name*
Client Signature*

Clear
Hold down your left mouse button and write your name
Today's Date*

MonthDayYear
Date
_________________________________________________________________
(If applicable) Spouse Name
Spouse Signature

Clear
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(If applicable) Parent/Guardian Name
Parent/Guardian Signature

Clear
Hold down your left mouse button and write your name

CONSENT FOR TREATMENT

We are committed to providing you with the best possible care. Please read below and initial/check each box indicating you fully understand our conditions.
THERAPY I understand there are no guarantees made to me regarding therapy treatment. My decision is voluntary, and I understand that I may terminate these services at any time. I understand that during treatment I may need to discuss material of any upsetting nature in order to resolve my problems. I also understand it cannot be guaranteed that I will feel better after completion of treatment.COMPLIANCE WITH TREATMENT PLAN I agree to participate in the development of an individualized treatment plan. I understand that consistent attendance is essential to the success of my treatment. Frequent "no shows" and/or late cancellations may force Healing Grace to transfer my care to a different counseling practice.PAYMENT I understand all fees are due at the time of session. If I choose to use insurance, I authorize my insurance carrier to pay HGCC for billed services. I understand any and all charges not covered by my insurance are my financial responsibility. All outstanding balances over 90 days are subject to being sent to a collection agency. Healing Grace Counseling Center is unable to bill Medicaid.CONFIDENTIALITY All information shared in session is confidential except in circumstances governed by Federal and State law, including 1) to warn others of life-threatening concerns should it become necessary, 2) to notify appropriate state agencies of any suspicion of child or dependent adult abuse and 3) to provide information in legal cases when under court order.RELEASE OF INFORMATION I authorize the release of any medical or other information necessary to process claims, or otherwise collect payment on my account. In the case that a client changes providers within Healing Grace all current records will be transferred to the new provider. All other medical records request require a separate signed authorization document and records cannot be released until we receive that form.MINOR CHILDREN We require at least one parent signature to authorize treatment for a minor. (Missouri law states those under the age of 18 is considered a minor)r. Please be aware additional signatures/authorizations may be required depending on custody or other legal disputes. I agree to read the Parental Agreement document provided and bring a signed copy to my first session.NO HARM AGREEMENT I agree that I will not engage in self harm and/or harm to others. I agree I will take the following actions if I violate this agreement. 1) I will call 911 if I believe that I am in immediate danger of harming myself/ or others. 2) I will call any or all 24-hour suicide prevention lines (1-800-SUICIDE) and I will continue talking on the phone for as long as necessary until the suicidal thoughts have subsided. For non-life-threatening, clinical emergencies, please call 816-246-4465 and leave a message on your therapist voicemail box.SERVICES NOT PROVIDED HGCC therapists are not qualified as legal experts in court cases. HGCC does not provide custody evaluations, sexual abuse investigations, or anything related to such matters.PRIVACY PRACTICES A list of patient rights and responsibilities are available for your review below. They are also posted in our waiting room.
Client Name*
Client Signature*

Clear
Hold down your left mouse button and write your name
Should be Empty:

	Never	Seldom	Often	Always
Frequent worry or tension
Fear of many things
Discomfort in social situations
Phobias - unusual fears about specific things
Panic Attacks - heart palpitations, sweating, etc.
Recurring, distressing thoughts about trauma\
"Flashbacks" as if reliving the traumatic event
Avoiding people/places associated with trauma
Nightmares about traumatic experience

	Never	Seldom	Often	Always
Decreased interest in pleasurable activities
Social Isolation, Loneliness
Suicidal thoughts
Bereavement or feelings of loss
Changes in sleep (too little or too much)
Normal, daily tasks require more effort
Sad, hopeless about future
Excessive feelings of guilt
Low self-esteem

	Never	Seldom	Often	Always
i am angry, irritable, hostile
I feel euphoric, energized and highly optimistic
I have racing thoughts
I need less sleep than usual
I am more talkative
My moods fluctuate: go up and down

	Never	Seldom	Often	Always
Memory problems or trouble concentrating
Trouble explaining myself to others
Problems understanding what others tell me
Intrusive or strange thoughts
Obsessive thoughts
Been hearing voices when alone
Problems with my speech
Risk taking behaviors
Compulsive or repetitive behaviors
Been acting without concern for consequence
Been physically harming myself
Been violent toward other(s)
Concern about my sexual function
Discomfort engaging in sexual activity
Questions about my sexual orientation

	Never	Seldom	Often	Always
Alcohol
Nicotine (Cigarettes)
Marijuana
Cocaine
Opiates
Sedatives
Hallucinogens
Stimulants
Methamphetamines

	Never	Seldom	Often	Always
Restriction of food consumption
Bigeing and purging
Binge eating
A lot of weight loss or gain

	Cannot Function	Serious Problems	Mild Problems	No Problems	N/A
How well you are doing on your job?
How well you are doing in your martial/significant other relationship?
How well you are doing in your family relationships?
How well you are doing in relationships with people outside your family?

ADULT INTAKE PACKET