Client Data Information

Blue Skyy Therapeutic Services, LLC.
Client Information
Date:*

MonthDayYear
Date
Client Name:*
Date of Birth:*

MonthDayYear
Date
Age:*
Sex (biological):*
Gender (how you identify):*
Ethnicity:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email address:*
example@example.com
Referral Source
Who may we thank for your referral to our office, or how did you learn about our practice?*
Emergency Contact Information
In case of an emergency, who should we contact?
Name:*
Relationship:*
Phone Number*

Area CodePhone Number
Client History
Who is providing the history here?*
Please provide any details regarding what brought you to counseling: *
Previous Treatment
Have you received or participated in previous mental health therapy services?*
Was the treatment you received helpful?*
Have you ever been hospitalized for psychological concerns?*
Additional Information:
Medical
List any current or important past medications:
Medication & Dose:*
Response to Medication:*
Any current health concerns, serious illnesses, or conditions:*
Indicate any allergies you have:*
How would you rate your current physical health?*
What was the approx date of your last physical or routine health check up? *
Family
What best describes your marital status?*
Do you have children (please include stepchildren or any children for whom you are responsible)? *
If yes, please give first name, gender, and age for each one:
Do you have custody of your children? *
Are there presently any child custody issues involving you or your family?*
Does your family currently have Child Protective Services Involvement?*
Legal
Do you currently have any pending criminal charges? *
Are you on probation?*
Have you ever been arrested/convicted of a crime other than traffic misdemeanors?*
If you answered yes to any of these three questions, please explain:
Safety
Have you recently (within the last two weeks) experienced any thoughts of harming either yourself or someone else?*
Have you in the past experienced thoughts of harming either yourself or someone else?*
Have you ever attempted to kill yourself?*
Have you ever physically attacked or been in a physical altercation with someone else?*
If you answered yes to any of the above please explain in as much detail as possible:
Fee Agreement
Name*

First NameLast Name
Date:*

MonthDayYear
Date
Insurance Provider*
Insurer ID*
*No copay or out of pocket costs for clients with Medicaid plans.

*Clients with a commercial plan will be required to provide Blue Skyy Therapeutic Services, LLC with a credit/debit card in the event that your insurance, for whatever reason, does not pay for your services - you will be responsible for the payment of your session at the self pay rates.

Self Pay Rates: 

Individual Session: $120

Couples/Family Session: $150

Sliding scale available on a case by case basis.

*Payment information will be collected prior to initial session.

Cancellation Policy:

Self Pay Clients - You will be charged 100% of the amount of your scheduled therapy session if you fail to show and do not cancel within 24 hours of your scheduled session. This must be paid prior to scheduling another session with your therapist.

Commercial Clients - You will be charged the amount equal to your copay if you fail to show and do not cancel within 24 hours of your scheduled session. This must be paid prior to scheduling another session with your therapist.
Client Responsibilities and Fee Information
- Each person is expected to pay his/her fee at the time of service.
- Notify your therapist if there are any changes to your insurance benefits or if your insurance is discontinued.
- No shows or cancellations without a 24 hour notice will be charged according to Blue Skyy Therapeutic Services, LLC's cancellation policy, which is not reimbursable by insurance.
- All inquiries into pre-certification, benefits, treatment plans (if necessary), coverage, etc. are the client’s responsibility.
- Payment is expected at the time of service and the client has the ultimate responsibility for their account and making sure insurance payment is received if using insurance. If a claim is denied it is the client’s responsibility to pay their account upon notification of denial at the insurance reimbursement rate.
- If payment is not received for services rendered in a timely manner I understand that Blue Skyy Therapeutic Services, LLC will release my information to a third party Credit agency to attempt to collect my debt. The information provided to the Credit agency will only be demographic information in order to collect this debt.
- Blue Skyy Therapeutic Services, LLC has your permission to release your protected health information to your insurance company.
- In order to receive services from Blue Skyy Therapeutic Services, LLC you are agreeing to the conditions outlined above.
Signature or Parent/Guardian Signature*

Clear
relationship to Client*
Date*

MonthDayYear
Date
Should be Empty:

Client Information

Referral Source

Emergency Contact Information

Client History

Previous Treatment

Medical

Family

Legal

Safety

Fee Agreement