Youth Intake Form

**CCS will NOT list personal cell phone numbers and emails of youth/minors as a primary form of contact.**

*CCS will follow legal custody parenting agreement. If both parents share custody and medical decision making, then both parents must agree to treatment. *CCS may also ask legal guardians for proof of documentation.

**CCS Provider will be assigned to the youth/family based on parent's primary language.

*CCS has an online "Patient Portal" and to access your portal, an e-mail address is required. Please note that parents who are seeking services at CCS and/or have other children seeking services at CCS, a different e-mail address is required for each portal.

I, {1Parentguardian}, parent/guardian of {clientsFull} (youth name) (date of birth: {dateOf}), certify that the information stated above is true and accurate to the best of my knowledge. I hereby authorize Compass Counseling Services, LLC (CCS), to bill me, my health insurance company, and or my representative for all services that I receive. I further authorize my health insurance company or its representative to make direct payment of benefits to CCS or its providers under the terms and conditions of my health care contract. It is my responsibility to understand my coverage, including co-pays, co-insurance, and deductibles. This also includes understanding what services are covered or not. It is also my responsibility to let CCS know if there is a change in my insurance or coverage.

I understand that I am ultimately responsible for payment of all services. I agree that parents, guardians, or personal representatives are responsible for all fees and services rendered for treatment of a minor/child. I will be held liable for any care provided to me, or to the client for whom I am legally responsible for, even when not covered by the insurance company. I agree to all payments, including co-pays, co-insurances, specimen collection, and deductibles. I understand that filing a claim with my insurance company does not relieve me from my responsibility for the payment of all charges.

In addition, I authorize the appropriate staff at CCS to fill out any and all necessary paperwork or electronic claims required by my insurance carrier or managed care company, including but not limited to: treatment plans, insurance claim forms and termination of care information. I affirm that I have read, understand, and agree to the authorizations stated above.

This is an authorization for Compass Counseling Services, LLC (CCS) to release, obtain, and/or exchange protected mental health information with your primary care physician/medical doctor for the purposes of coordinating medical care and treatment. By signing this form, confidential psychological and psychiatric information can be released to and/or discussed with the provider/agency listed below unless noted by exclusions or limitations. This form is signed voluntarily and may be revoked at any time. All disclosures made pursuant to this form are valid as long as they were made before the date of revocation.

3. Type of Information to be Disclosed: 

This authorization does not represent a complete medical records access request. For a primary care physician/doctor to access the full record, a separate authorization will need to be completed.

I certify that my health information is being disclosed at my request or at the request of my personal representative. I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is not dependent on my signing this authorization. By signing below, I acknowledge that I have read and understand this document and that I have voluntarily given CCS/my provider authorization to disclose my records. I understand that I may revoke this authorization at any time by providing a written notice to my provider. However, the revocation will not have an effect on any actions taken prior to the date my revocation is received. I understand that my information may be redisclosed by the authorized person/organization receiving the information, and at that point, the information may no longer be protected under the terms of this agreement. I am also aware that utilizing my health and or my mental health records for legal purposes are left up to the interpretation by legal representatives and may or may not be beneficial to my legal case. This

authorization will expire one year following the date signed unless revoked in writing.

My signature below represents that I understand this form is valid for one year from date of signature and may be revoked by me (or my legal representative) at any time in writing to CCS. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services or eligibility for benefits. Additionally, I understand that a separate Authorization is needed if I want to give someone full access to my health record.

This page is an Acknowledgment of Receipt of the Client Handbook which outlines expectations, policies, and practices regarding CCS services. The Client Handbook provided for you is to review and keep. The Client Handbook includes but is not limited to: client/patient rights and responsibilities, process of treatment services, risks and benefits of mental health treatment, privacy policies, treatment options and medical necessity, urine drug screening (UDS) policy, fees and service costs, minors and custody issues, health and safety, emergency and crisis resources. Please complete and sign this Acknowledgement page to confirm that you have received a copy of the Client Handbook prior to the start of treatment. 

Your initials below indicate your understanding and agreement to these policies and practices written below and the Client Handbook.

Please write your initials on the lines to show your agreement and understanding: