Client Intake Form

Client Intake Form
Today's Date*

MonthDayYear
Date
Legal Name (as it shows on insurance card or other official documents)*

First NameLast Name
Preferred Name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*
Marital Status
Parent/Guardian Name if client is under 15 years old

First NameLast Name
Relationship
Email address*
example@example.com
Best contact phone number*
Please enter a valid phone number.
Type of phone*
Additional Phone Number
Please enter a valid phone number.
Type of phone
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For confidential messages (email address or/and phone #)
Primary Insurance
Primary Insurance Phone Number
Please enter a valid phone number.
Primary policy number/ Member Record Number
Spouse or partner's name

First NameLast Name
Spouse or partner's Phone Number
Please enter a valid phone number.
Emergency contact *

First NameLast Name
Emergency contact Phone Number*
Please enter a valid phone number.
Employer
If you are a Kaiser Employee, please let us know.
Employer Phone Number
Please enter a valid phone number.
For couple's or family counseling: A person supporting the client in counseling needs to fill out our Collateral Agreement for Participation. We need their information to send them the form.

For Couple's counseling, each individual needs to fill out their own Intake Form.
Name of person supporting you in counseling (Couple's or family counseling)

First NameLast Name
Email for Collateral Agreement to be sent to
example@example.com
Allergies
Current prescription drugs, herbs or homeopathy
What brought you here, and what would you like to accomplish? *
How did you hear about us? *

Informed Consent and Agreement to Therapy and Payment
1. INSURANCE BENEFITS AND BILLING: If I use health insurance benefits, I understand that a quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s insurance contract at time of service. I authorize Counseling Services ofPortland (CSP) to furnish my insurance company with any/all information requested or necessary concerning my present claim. I authorize payment of benefits from my insurance provider to CSP or my contracted provider at CSP. PLEASE INITIAL*
Please Initial
2. APPOINTMENT FEE: I agree to pay CSP the amount owed for my session, unless otherwise noted, at time of service, for my payment or copayment. (Note: If you need a reduced fee, please ask your counselor to go over the “Reduced Fee Worksheet” to help make your therapy affordable for you.) PLEASE INITIAL *
Please Initial
3. EMERGENCY CALLS: I understand that I will be charged for emergency telephone consultations at the prorated hourly office visit rate. PLEASE INITIAL *
Please Initial
4. EXTENDED SESSIONS: I understand that I will be charged at the prorated hourly rate for extended sessions that are more than an hour long. PLEASE INITIAL*
Please Initial
5. OVERPAYMENT: I agree to return any money owed to CSP received from my insurance company and owed to CSP. I understand that any money paid in excess of my fees will be returned to me by CSP. PLEASE INITIAL*
Please Initial
6. LATE CANCELATION: I understand that I am responsible for paying fees incurred from late cancellations with fewer than 24 hours notice and for no-show appointments. I understand that my insurance will not cover missed appointments. I understand that I am responsible for a late cancellation fee of $130, which is not covered by insurance. Exceptions to this policy are cases where sudden illness or legitimate emergencies occur and if you are an OHP Medicaid client. I authorize my credit card on file to be charged at the time of the canceled session. (Note: Your Health Savings Account card will not pay for Late Cancel or No Show fees. In this case, we will need cash, a check, or additional credit card information.) PLEASE INITIAL or put NA if you have OHP.*
Please Initial
7. INSURANCE LIABILITY OF PAYMENT: If I use health insurance benefits for my visits, I understand that my health insurance company will only pay for services that it determines to be “reasonable and necessary.” Every effort will be made by CSP to collect payments from my health insurance company for my visits. If my health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under my plan, my insurer will deny payment for that service and I will be responsible for payment. PLEASE INITIAL*
Please Initial
8. BENEFICIARY AGREEMENT: I understand that, for the reasons stated above, my health insurance company may deny payment for services. If my health insurance company denies payment, I agree to be personally and fully responsible for payment. I also understand that if my health insurance company does make payment for services, I will be responsible for any co-payment, coinsurance, deductible, no show fees or any other fees that apply. PLEASE INITIAL*
Please Initial
9. SECONDARY INSURANCE BILLING: I understand that if I have Secondary Insurance, CSP WILL NOT bill my Secondary Insurance company if it is Out of Network. I am therefore responsible for any payments owed to my counselor that are not covered by my Primary insurance. I will be issued a superbill or statement upon request to submit with my EOBs to my secondary insurance for reimbursement if there is any. PLEASE INITIAL*
Please Initial
10. OUT OF NETWORK INSURANCE: I understand that if I have Out of Network insurance, CSP WILL NOT bill my insurance company. I am therefore responsible for any payments owed to my counselor. I will be issued a Good Faith Estimate to understand my financial obligation and I request an updated one from my counselor at any time. I will be issued a superbill or statement upon request to submit to my Out of Network insurance if the need arises. PLEASE INITIAL*
Please Initial
11. PAYMENT PLAN: My credit or debit card will be charged for each session fee or insurance copayment at the time of service. I understand that my credit/debit information will be kept secure, confidential, and encrypted in CSP’s HIPAA-compliant electronic medical system. PLEASE INITIAL*
Please Initial
12. TELE-HEALTH CONSENT: Telehealth involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving client care. The information may be used for diagnosis, follow-up care and/or education, and may include any of the following: Client records, Live two-way audio and video and Output data from computer or medical devices and sound and video files. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of client identification and information and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption. I understand I have the following rights under this agreement if I choose to use Tele-health (Virtual visits), I have a right to confidentiality with Telehealth under the same laws that protect the confidentiality of my medical records for in-person visits. Any information disclosed by me during the course of my virtual visit, therefore, is generally confidential. If at any time I feel that virtual visits are not working for me, I can speak freely to my counselor to see how to accommodate my need for in-person visits as long as that is available to me through my counselor or another counselor at CSP. I understand that if CSP is not able to accommodate me, I would be given referrals to resources that may be able to accommodate me for in-person visits, with no guarantee to when the availability would be. PLEASE INITIAL*
Please Initial
By signing below, you consent to seeing one of our Independent Contract therapists at Counseling Services of Portland. Client or Parent/Guardian Signature*

Clear
Name of signer*

First NameLast Name
Should be Empty:

Client Intake Form

Informed Consent and Agreement to Therapy and Payment