Counseling Intake Packet

Counseling Intake Packet
Client Name (First, MI, Last)
Today's Date

MonthDayYear
Date
Primary Address
Local Address

Same as Primary
Local Address
City
Local City
State
Local State
Zip
Local Zip
County of Legal Residence
Out of StateUnknown
Home Phone
Work Phone
Other Phone
Where may we contact you?

Primary AddressLocal AddressBilling AddressHome PhoneWork PhoneOther Phone
Where May we leave you a message?

HomeWorkOther
Client Age
DOB (MM/DD/YYYY)

MonthDayYear
Date
Gender

MaleFemale
Soc. Sec. No.
Marital Status

MarriedSingleDivorcedWidowSeparatedOther
Race & Ethnicity

W WhiteN Native Am.P - Native Hawaiian/Other Pacific IslanderMultiple RaceB - Black/African Am.A AsianM - Alaskan NativeUnknownA - Puerto RicanB - MexicanC CubanD - Other HispanicE - Not Hispanic or Latino
Parent/Guardian/Custodian if Minor (include name and address)
Emergency Contact Phone
Emergency Contact (name and address)
Relationship
Emergency Contact Phone
Primary Language
Does Client need the assistance of an interpreter?

YesNo
Interpreter?

American Sign LanguageOther
Client needs assistance with visualization of material or alternate format?

YesNo
Advance Directive?

YesNo
If yes, request a copy of the directive. If no, ask if client needs assistance in obtaining an advance directive.
Payers

MedicareMedicaid
Medicaid No.
Medicare No.
Primary Private Insurance
Insurance Plan No.
Group No.
Client Name
If client is a child: fill in name of school .Grade currently in grade.
PLEASE GIVE US A BRIEF DESCRIPTION OF THE PROBLEM OR WHY YOU WERE REFERRED HERE:
**Urgency Score** Please select one

Recent discharge from hospital - currently suicidal / homicidalClient states need to get in within the week - Pregnant, IV drug use, suicide attempt within the past 30 days, HIV positiveClient states need to get in within several weeksClient open to appointment times
Do you have any preference as to the type of therapist you would like assigned to you? (IE: Male/Female, Christian Based, Has a particular belief of value system)
IF so PLEASE INDICATE
Have you ever been hospitalized or received counseling here or at other places for emotions, mental health or substance abuse problems?

YesNo
If Yes, when?

MonthDayYear
Date
Where
What for?
If Chemical dependency problem and female, are you pregnant?

YesNo
Do you have a CDL License?

YesNo
Are you D.O.T Regulated?

YesNo
IN ORDER TO BILL INSURANCE, THE FOLLOWING MUST BE COMPLETED ON THE POLICY HOLDER
Primary Insurance
Social Security Number
Birthdate

MonthDayYear
Date
ACCESS COUNSELING SERVICES, LLC
FINANCIAL POLICY AND AGREEMENT for Mental Health and AOD Services

We are committed to providing you with the best possible care and would be happy to discuss our financial fees with you at any time.
*CO PAYMENTS OR FULL PAYMENT IF DEDUCTIBLE APPLIES, ARE DUE AT TIME OF SERVICE *WE ACCEPT CASH, CHECK, VISA, MASTERCARD AND DISCOVER
Insurance: If you have insurance, we will help you receive maximum benefits. You are responsible for providing all

insurance coverage information and establishing the primary and secondary coverage at the time of service. We will accept and file your insurance if we are a provider on your plan. Your insurance coverage is a contract between you and your mustbeatthey paidyour payspay,

you will be responsible for your deductible until it is paid. Once we file your insurance, if payment is not received within 60 days, you will need to submit the payment for the balance due or make payment arrangements with our office.

Minor Children: The parent(s) or guardian who brings a child to therapy or psychiatrist appointment is responsible for the

copay and/or deductible. It is our policy to consider an 18 year old who is still in high school a "minor". Insurance billing for

the minor is the same as the above section on Insurance.

As an Access Counseling Services, LLC client, the following fees apply for services received.

Self Pay Fees (For Office Use Only)

INTAKE with Therapist (1-hour)

PER SESSION with Therapist (1-hour)

PER SESSION with doctor (20-30 minutes)

HEALTH HISTORY with nurse (1 hour)

PER SESSION for Group (1-hour)

PER SESSION for Case Management hour)

INTENSIVE OUTPATIENT (IOP) (Day)

*If you miss or cancel (without 24 hours' notice) three consecutive appointments your case will be reviewed by your

*If you miss or cancel (without 24 hours' notice) three appointments within a calendar year your case will be reviewed by your treatment team for closure. *Referrals will be made for discharge planning. *You may reapply for reinstatement, but you will have to go through the intake process again and your commitment to treatment will be reassessed along with other established criteria to determine if you can resume services at Access Counseling Services.

I understand that all payments are made at the time of service. I also understand that my services may be reduced and/or interrupted if I am unable to pay. I understand that only payment arrangements that are approved by the Executive Director/CEO, or her designee, are valid. I understand I can contact Deanna Proctor, Executive Director/CEO and Client Rights Officer with any questions.
Client Name
Responsible Party Name
Client or Responsible Party Signature
Date

MonthDayYear
Date
ACCESS COUNSELING SERVICES, LLC CONSENT FOR TREATMENT FOR MENTAL HEALTH AND CHEMICAL DEPENDENCYSERVICES
I hereby authorize Access Counseling Services, LLC to utilize customary behavioral health treatment services, including chemical dependency, in providing care for: blanks.
These services will be provided by Access Counseling Services, LLC staff or consultants. I concur with the following: I

have received the Client Orientation Handbook which includes, but not limited to, the statement of the Notice of Privacy

Practices and Client Rights. I have accepted my initial fee agreement. I will participate in forming a plan for my child's / my

own treatment as my signature on the individual service plan will affirm. Further, I understand that while counseling and other

services provided by the agency offer reasonable expectation of benefit, there is no certainty of success. There may be

minimal risk inherent in any psychiatric, psychological, or behavioral health counseling intervention and I can expect that any

reasonable or anticipated risks will be discussed with me. I understand that it is my responsibility to inform Access Counseling

Services, LLC service providers of any problems or side effects that may develop in the course of my treatment so that they

may be addressed and do so early enough in session to allow for processing without going over my allotted time.

Access Counseling Services, LLC recognizes and affirms a person's right to refuse or withdraw consent for treatment.

In this event, efforts to develop alternative approaches in collaboration with the person served will be made to ensure that the person receives needed services. If consent for treatment is still withdrawn or revoked, efforts will be made to ensure that the

person understands the implications and consequences of not receiving treatment.

I understand that all records and reports are considered confidential and will not be released to any individual or agency without my prior written authorization. However, information may be released without my prior authorization under the

1. Upon receipt of a subpoena Duces Tecum.

2. In the event of a medical emergency.

3. If there is evidence to suggest that child abuse has occurred.

4. To validate an insurance claim and then only information sufficient to substantiate claim.

5. Release authorized in accordance with state and/or federal laws and regulations pertaining to professional

6. To qualified personnel for research, audit or program evaluation.

7. To comply with federal laws and regulations about a crime committed by a client, either at the program or

against any person who works for the program or about any threat to commit such a crime.

8. In the event of communicated harm to self or others.

9. To my therapist's supervisor or in peer review with other agency clinicians who are also bound to protect

Confidentiality of alcohol and drug abuse client records maintained by this program is protected by Federal Law and

Regulations. Violation of this by a program is a crime. (See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 for Federal Laws and

42 CFR Part b, paragraph 2.22, for Federal Regulations
Signature
Date

MonthDayYear
Date
Relationship

SelfParentGuardian
Should be Empty:

Counseling Intake Packet

Do you have any preference as to the type of therapist you would like assigned to you? (IE: Male/Female, Christian Based, Has a particular belief of value system)

IN ORDER TO BILL INSURANCE, THE FOLLOWING MUST BE COMPLETED ON THE POLICY HOLDER

ACCESS COUNSELING SERVICES, LLC

*CO PAYMENTS OR FULL PAYMENT IF DEDUCTIBLE APPLIES, ARE DUE AT TIME OF SERVICE *WE ACCEPT CASH, CHECK, VISA, MASTERCARD AND DISCOVER

ACCESS COUNSELING SERVICES, LLC CONSENT FOR TREATMENT FOR MENTAL HEALTH AND CHEMICAL DEPENDENCYSERVICES

CO PAYMENTS OR FULL PAYMENT IF DEDUCTIBLE APPLIES, ARE DUE AT TIME OF SERVICE WE ACCEPT CASH, CHECK, VISA, MASTERCARD AND DISCOVER