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  • Testing Agreement

    Client Information
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  • Your intake from your therapist will be sent to Dr. Nadin Rizk.

  • CHILD EVALUATION

    Parents/Guardians, please complete this child evaluation and give it to their therapist at the time of your first appointment. This information will help your child’s therapist identify problem areas and provide the best treatment possible.

  • Name of parent with joint custody if separated or divorced 
        

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  • FAMILY HISTORY

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  • DEVELOPMENT HISTORY

  • EMOTIONAL & BEHAVIORAL HISTORY

  • MEDICAL HISTORY

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  • SCHOOL FUNCTIONING

  • CURRENT SYMPTOMS

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  • HEALTH AND MEDICAL

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  • EMERGENCY CONTACT INFORMATION

  • INVOLVEMENT OF CARE

    I hereby request the following person(s) to be allowed to participate in my care and/or payment decision-making process. I understand these person(s) may be given health or payment information about me.

  • ADDITIONAL INFORMATION

  • Please fill out the following new client intake

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  • HEALTH AND MEDICAL

     

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  • EMERGENCY CONTACT INFORMATION   

     

  • INVOLVEMENT OF CARE

    I hereby request the following person(s) to be allowed to participate in my care and/or payment decision-making process. I understand these person(s) may be given health or payment information about me.

  • ADDITIONAL INFORMATION

  • Symptom Assessment
    So we can better serve you, please give us an accurate account of what your symptoms are. If you have any questions or concerns, we invite you to discuss with your therapist.

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  • Personal and Family History

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  • TEXT REMINDERS

    For your convenience, Healing Grace now offers appointment text reminders.  This electronic communication will only relate to scheduling and will not, under any circumstances relate to therapy itself.  These are automated text reminders sent out from our HIPPA compliant scheduling software not from your therapist.  You are not able to cancel replying to this text message.  All cancellations must be done by phone directly to your therapist.  Please be aware this is considered an unsecure form of communication and there is a potential chance that a third party may be able to intercept these messages. 

     

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  • CREDIT CARD AUTHORIZATION

    Healing Grace requires keeping a credit card on file for testing.  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 expect a credit card authorization form emailed to you at the time of scheduling. *  

  • CANCELLATION POLICY

    Psychological Testing 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 provider's extension. If you cancel or no show after the 24-hour period, (and do not use an alternative option below) you will be charged a missed flat rate fee of $100.00 for the 1-hour Clinical Interview Appointment and 1-hour Feedback Session Appointment, and a missed flat rate fee of $300 for the 3-hour Testing Block Appointment, regardless of what you were quoted as expected cost. The missed fee is your responsibility and cannot be billed to your insurance company.

    You can avoid a cancellation/missed session fee by considering one of the following options:


    ⦁ Have a Telehealth session instead - this is where your mental health provider offers services 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, however within good reason, can be approved by a supervisor. Please note: Internet, a computer or mobile device, an integrated or external microphone and camera are required for video conferencing. Please note: Dr. Nadin Rizk is licensed in the state of Missouri which means you must be in the state of Missouri to be elligible for telehealth services. *Please note the 3-hour Testing Block Appointment cannot be conducted over telehealth*

  • 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.

  • 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.

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  • 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.

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  • Financial Agreement

  • 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.

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  • INVOLVEMENT OF CARE

    I hereby request the following person(s) to be allowed to participate in my care and/or payment decision-making process.  I understand these person(s) may be given health or payment information about me.

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