SPS Intake Form for Adults

Please provide a contact phone number and indicate the number type you've provided.

I authorize Strongsville Psychological Services, Inc. to release to my insurance company information regarding treatment, diagnosis, prognosis, and referrals, but only to the extent reasonably necessary to process the insurance claim.

I agree to assign all insurance benefits to Strongsville Psychological Services, Inc, and guarantee payment of any and all charges not covered by my insurance company.

By clicking the “I Accept” box below, you are agreeing to the conditions stated above, and understand that by confirming, you are submitting your electronic consent.

I agree to guarantee payment of any and all charges.

By clicking the “I Accept” box below, you are agreeing to the conditions stated above, and understand that by confirming, you are submitting your electronic consent.

Strongsville Psychological Services will bill your insurance company.  Copays are due at the time of each appointment.  We suggest you pay toward any deductible at each appointment to avoid an excessively large balance.  After your insurance company pays, you will be billed for any remaining balance.  If your insurance company denies or pays incorrectly for any reason, it is your responsibility to contact them and correct the problem.

If you are unable to pay your balance when it is due, please call us and make arrangements to pay on a monthly basis.  If no payments are made after several months, we may be forced to send your account to our collection agency.

While we make all efforts to obtain accurate information, we cannot be held responsible if your insurance company quoted incorrectly or pays differently. It is important that you check with your insurance company to verify what your outpatient mental health benefit is, and to make sure that your counselor is an eligible provider under your plan.

FOR ANY CANCELLATIONS WITH LESS THAN 24 HOURS NOTICE, OR ANY NO-SHOWS, THERE WILL BE A $50 FEE CHARGED.

These charges are not covered by insurance.  It is the therapist’s discretion to waive this charge for exceptional circumstances.

By clicking the “I Accept” box below, you are agreeing to the conditions stated above, and understand that by confirming, you are submitting your electronic consent.

This notice describes how mental health/medical information may be used and disclosed and how you can get access to this information.  Please review it carefully.

Mental health information is confidential except in situations involving dangerousness to self and/or others, mistreatment of a minor or elder, or situations requiring emergency intervention.  Under these circumstances, relevant authorities, other treatment personnel, and/or family members can be contacted to facilitate necessary interventions.

The confidentiality rights for a client under 18 are not as complete as those for adults.  Certain information regarding physical health is protected, but parents/guardians have a right to know if their child is at risk for self-harm, harm to others, or demonstrating a serious substance abuse problem or mental illness that puts them at risk and/or requires immediate intervention.  Non-custodial parents retain a right to request a review of their child’s records.

Information identifying you and/or your diagnosis and type/dates of service are typically required by your insurance company to access your benefits.  Some companies require additional clinical data to maintain your authorization for covered services.  Any other disclosure of confidential information is made only with your written authorization which you also have a right to revoke.  You have the right to request reasonable accommodations in standard practices (for instance, to what address billing statements are sent, at what telephone number messages can be left) to further protect your privacy.

You have the right to inspect and copy your health information and amen such information.  However, psychotherapy records are by law excluded from this privilege and can be inspected or copied only if the therapist and/or SPS feel this is warranted.  The therapist/SPS may also decline a request to amend any records.  This denial can be appealed.

For a six-year period from the date this notice is signed, you have the right to receive an accounting of any disclosures made from your records.  Disclosures after the termination of psychotherapy that you do not authorize occur only under rare legal circumstances.  You have a right to have a copy of this Privacy Notice.  Any complaints requiring SPS compliance with this Notice can be directed to the therapist, the owner(s) and the U.S. Department of Health and Human Services.

SPS staff and counselors are legally mandated to maintain the privacy of your protected health information and to abide by the terms of this Notice.  You have a right to be informed of any revision of this Notice that substantially changes your protection or SPS obligation.

By clicking the “I Accept” box below, you are agreeing to the conditions stated above, and understand that by confirming, you are submitting your electronic consent.

I have read and understand this Notice, and I accept the terms stated above.

To ensure timely payment and uphold appointment commitments, Strongsville Psychological Services requires all clients to provide a valid credit card to be kept securely on file. This information will be taken at the time of intake.  Your card will only be charged under the following circumstances:

 

·         Late cancellations or missed appointments, as defined by our cancellation policy

·         Any balances (copays, insurance remainders) that are unpaid after 30 days

·         Services rendered that are not covered by your insurance plan

 

Your card information will be stored securely in accordance with HIPAA and PCI-DSS compliance standards.

By signing this agreement, you authorize Strongsville Psychological Services to charge your card as outlined above. Charges will only be made when necessary and, when possible, with advance notice. This authorization will remain in effect until you submit a written cancellation request.

By clicking the “I Accept” box below, I affirm that I have read and agree to the terms above, and authorize the use of my credit card in accordance with this agreement.

I hereby consent to engaging in Telehealth Psychotherapy with Strongsville Psychological Services as part of my mental health treatment.  I understand that Telehealth Psychotherapy will be conducted by video conferencing, telephone, email, instant messaging, and/or other data communications.

1.     The laws that protect the confidentiality of my personal information also apply to Telehealth Psychotherapy.  Other than not being in the same room together there is little or no difference in the therapy session.  I understand that the therapist will be alone in their office and the session will be private and confidential.  I also agree to be alone in a private room to preserve therapeutic confidentiality during the session.

2.     I understand the use of Doxy.me is marketed as HIPAA compliant and that all attempts to keep information confidential will be made.  I will not hold this therapist liable for any gathering or use of patient information by this platform.

3.     There is no permanent video or voice recording kept of the Telehealth Psychotherapy session.

4.     The potential risk of Telehealth services is that there could be a partial or complete failure of the equipment being used which could result in the inability to complete the therapy session.  In addition, due to the nature of the technology used, teletherapy sessions might be experienced differently than in-person meetings.

5.     I understand that there is a risk of being overheard by anyone near me if I am not in a private room while participating in teletherapy.  I am responsible for providing the necessary computer, telecommunications equipment and internet access for my teletherapy sessions, and arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.  It is the responsibility of the psychological treatment provider to do the same on their end.

6.     By signing this document, I agree that certain situations including emergencies and crises are inappropriate for Telehealth services.  If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis team in my immediate area.  I acknowledge that emergency situations include thoughts of hurting myself or others, or any life-threatening situation of any kind, including but not limited to uncontrollable emotional reactions or dysfunction as a result of abusing alcohol or drugs.  By signing this document, I acknowledge I have been told that if I feel suicidal, I am to call 9-1-1 or the National Suicide Prevention Lifeline toll-free at 1-800-273-TALK (8255) or other local emergency services.

By clicking the “I Accept” box below, you are agreeing to the conditions stated above, and understand that by confirming, you are submitting your electronic consent.