New Client Registration Form

New Client Registration Form

This packet contains all the forms that must be completed before your first appointment is scheduled. All information is confidential and protected by HIPAA
Client Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Social Security Number
Gender *
Preferred Language
Address *

Street Address

Street Address Line 2

City State

Zip Code
Cellphone Number *
E-mail
example@example.com
Emergency Contact Name *

First Name Last Name
Relationship to Client
Emergency Contact's Phone Number *
Please enter a valid phone number.
Demographics

This information is voluntary and we appreciate you providing as much information as possible as it helps JFS continue to provide services.
Ethnicity
Race
Sexual Orientation
Marital Status
Estimated Annual Household Income
Number of People in Household
Are You Head of Household?
Are You A Veteran?
Are You Disabled?
Religion
Insurance Information
Medical Insurance Name
Medical Insurance Name ID
Family Doctor Name
Family Doctor Phone Number
Other Mental Health Treatment(s)
If Yes with Whom and When:
Do You Have an Advanced Health Care Directive?
Medication Currently Being Taken:
State Client's Reasons for Service:
How Did You Learn About JFS?
Signature *

Clear

Consent to Treatment
I consent and agree voluntarily to receive services from Jewish Family Service of the Desert (JFS). These services may include, but are not limited to, diagnostic assessments, individual, group, and/ or family therapy and consultations and referrals to other behavioral health professionals
Please initial each item below to acknowledge you have read and understood the terms.
I understand that by consenting to treatment, personal health information may be exchanged in a limited way for treatment, payment and healthcare operations purposes, only. *
I understand that I have the right to terminate treatment at any time. I also understand that I have the right to refuse to implement any recommendations, psychological interventions, or any treatment procedures. *
I understand that I am expected to benefit from treatment, but there is no implied or expressed guarantee that I will. *
I understand that JFS is an outpatient clinic and uses an after-hours answering service when the office is closed at night, holidays and weekends. I understand that in the event of a psychiatric emergency, I will be directed by the answering service to call 911. *
Office Based Services
You have requested to receive counseling services in the JFS Palm Springs office, and we are proud to be able to offer these services. In making this request and in signing below, you agree to abide by all JFS safety protocols. Further, you agree to do the following:
- Bring an appropriate mask/face shield to each counseling session and/or to drop off completed paperwork;
- Adhere to all posted safety precautions, including 6’ social distancing, frequent use of sanitation items, and not entering the office if you, a person accompanying you, or anyone with whom you spent the 24 hours immediately prior to your appointment are showing any signs or symptoms of exposure to COVID-19. A list of these symptoms will be posted;
- Abide by the decisions of JFS staff related to access to the JFS office;
- Provide truthful and accurate information related to health and safety questions; and
- To stay home if you or a person accompanying you feels ill. Note: You can complete your session via telecare if you have completed a consent to receive telecare services and notice is provided within two (2) hours of your scheduled session start time.
By initializing below, you agree to be provided with in-person counseling sessions at the JFS Palm Springs office, and you agree to abide by all stated and/or posted guidelines.
Initials *

Consent to Participate in Telecare Counseling Sessions
1.    PURPOSE. The purpose of this form is to obtain your consent to participate in telecare counseling with a Jewish Family Service of the Desert (JFS) Licensed Therapist.

2.    NATURE OF TELECARE COUNSELING. Telecare involves the use of audio, video, or other electronic communications to interact with you, consult with your Therapist, and/or review your medical information for the purpose of diagnosis, therapy, follow-up, and/or education. During your telecare counseling, details of your medical history and personal health information may be discussed.

3.    RISKS, BENEFITS. The benefits of telecare include having access to a Licensed Clinician for therapy without having to travel outside of your home or local health care community.

4.    A potential risk of telecare is that, in rare circumstances, security protocols could fail causing a breach of patient privacy. You may decline telecare services if you so wish.

5.    PROTECTED HEALTH INFORMATION AND RECORDS. All laws concerning patient access to medical records and copies of medical records apply to telecare. Dissemination of any patient identifiable images or information from the session or other entities shall not occur without your consent.

6.    CONFIDENTIALITY. To the best of the therapist’s and agency’s ability, all existing confidentiality protections under federal HIPAA and California law apply.

7.    RIGHTS. You may withhold or withdraw your consent to telecare at any time before and/or during the session without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

My health care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered.
I Agree to Telecare Sessions *

Yes No, I decline
I have selected the option above correctly *

Payment Policy and Fee Agreement
Please initial each item below to acknowledge you have read and understood the terms.
I understand payment is due at the time of each date of service (DOS) and can be made by cash, check or credit card. *
I authorize JFS Desert to charge the credit card that I have provided; I understand that JFS will charge the card for each service completed and will email a receipt for the transaction. I will not receive a notification prior to the charge unless the amount agreed below changes. *
I understand JFS also accepts reimbursement from many third party payers, including Medicare and Medi-Cal. JFS may assist me in the completion of the necessary insurance forms to facilitate collection of benefits. However, I understand that I am ultimately responsible for all charges not covered by my insurance. *
I understand that I must notify JFS when I change insurance plans or HMO providers as this change can modify or interrupt my mental health benefits. Failure to do so may result in requiring me to assume responsibility for payment of my counseling until a new authorization for treatment is approved. *
I understand I may be charged $25.00when an appointment is cancelled with less than 24 hours advance notice, or when I have failed to keep the appointment. *
I understand and agree that 2 or more late cancellations or “no shows” within three (3) months may be cause to discontinue services. See “Cancellation & Late Cancellation Policy Reminder Notice” on this form. *
I understand that if I have a deductible that has not been reached or if my insurance deems JFS to be an “out of network provider,” JFS will offer me the following options, one of which I accept *
I have read, understand and agree to the JFS fee policy, and I agree to paywhatever amount my insurance responsibility is, including but not limited tothe copay. I agree to allow JFS tocollect copays at the date of service or anytime thereafter. *

Client Acknowledgement of JFS Counseling, Cancellation and Late Cancellation Policy
Our goal is to provide quality counseling in a timely manner. In order to do so we have a 24-hour cancellation policy. The policy enables us to better utilize available appointments for our clients in need of therapy.

Cancellation of an Appointment

We recognize that schedules sometimes change. If you must cancel your appointment, we require that you please call at least 24 hours before your appointment. Appointments are in high demand. Your early cancellation gives others the possibility of meeting with their therapist. During evenings, weekends, and/or holidays, you can call our main number, (760) 325-4088, and leave a message with the answering service or email us at appointments@jfsdesert.org

Late Cancellations

Cancellations made less than 24 hours before an appointment are considered a late cancellation. A fee of $25 may be charged if applicable. Excessive late cancellations may be cause to discontinue services.

No-Show Policy

A client is considered a “no-show” if they do not call or email the office to cancel the session, nor arrive for the session. No-shows are inconvenient for both clients who need to schedule appointments and office staff and therapists who work hard to prepare for your visit. The late cancellation fee of $25 may apply. After two (2) “no-shows” within three (3) months, services may be discontinued at the agency’s discretion.

Counseling Policy

On your first visit to JFS your clinician will review the counseling process and begin to collect data, which will aid in the development of your treatment plan; this plan will be reviewed with you upon completion.
I have read, understand and agree to the JFS Counseling, Cancellation, and Late Cancellation Policy. *

Insurance/Medicare and/or Medi-CAL Authorization Statement for Claims Submission
I request that payment of authorized Insurance, Medicare, and/or Medi-Cal benefits be made on my behalf to Jewish Family Service of The Desert (JFS) for any services furnished to me by the physician or supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. I understand my signature requests that payment be made and authorize release of medical information necessary to pay the claim. If other health insurance coverage is indicated in Item 9 of the HCFA-1500 claim form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown.

In Medicare and/or Medi-Cal assigned cases, the physician or supplier agrees to accept the charge determination of the carrier as the full charge, and the patient is responsible for the deductible, co-insurance, and non-covered services. Co-insurance and deductible are based upon the charge determination of the Medicare and/or Medi-Cal carrier.
I have read, understand and agree to the JFS Insurance/Medicare and/or Medi-CAL Authorization Statement for Claims Submissions above. *

New Client Registration Form

Consent to Treatment

Office Based Services

Consent to Participate in Telecare Counseling Sessions

Payment Policy and Fee Agreement

Client Acknowledgement of JFS Counseling, Cancellation and Late Cancellation Policy

Insurance/Medicare and/or Medi-CAL Authorization Statement for Claims Submission

Authorization to Disclose and/or Obtain Information

Notice of Privacy Practices Summary Notice