Intake Form

Brighter Pathways, LLC INTAKE FORM
Thank you for choosing Brighter Pathways, LLC. Your journey to GREAT starts here! We strive to be one of the best group of providers in the area It is our desire to give you the greatest experiences to help you live your best life and keep it going! In order to get you loaded and ready to begin services, Please complete your intake information below.

Your appoinment must occur within 14 days of the date of this form or you will need to complete a new one.

If you have been away for services for more than 6 months consecutively, you will be put on INACTIVE status will need to complete a new form when you resume.

If you require assistance, please call our office at (803) 708-7990 x 1
- How did you hear about us?*
- Name*
  
  First NameMILast NameSuffix
- D.O.B.
  
  MonthDayYear
  Date
- Legal Gender*
  
  MaleFemale
- Who is intake for?*
  
  Adult(Self)Child( under the age of 18)Other
- Address*
- Suite, Apt, Etc.
- City*
- State*
- Zip Code*
- Daytime Phone*
- Email Address*
  example@example.com
- Marital Status*
- Emergency Contact*
- Telephone number*
- Relationship to you?
- Is there anyone else you'd like to give permission to discuss your care or records with? * If yes, please be sure to complete a release of information. You can always revoke consent(see Revoke form) or add a permission(See ROI form). This could be PCP, Other healthcare provider, employer, Attorney/Lawyers, Schools, Family, etc...*
  
  YesNo
- Do you have medical Insurance? *Please check with office to ensure we are provider's in your network or if you have out-of-network benefits. Please also note payment, if required, is expected at the time services are rendered. * Some groups are not covered under insurance.*
  
  Yes(To keep cost affordable to you, Please list all the insurances you have(Primary, Secondary) below.No( Uninsured clients may be able to obtain more affordable services under our Sister Company, Bridgeway Wellness Center, LLC. Ask our staff if you are interested in more information regarding rates and/or to sign up.Using EAP (Employee Assistance Program Sessions First)
- Primary Insurance/ EAP Name*
- Take Photo of your card or Authorization #*
- Take Photo of back of card #*
- EAP Authorization Code
- Insured Name*
- Insured Birthdate*
- Relation to the Insured
- Is there another insurance we should bill to? (If yes, Please fill in info below.)*
  
  YesNo
- Secondary Other Insurance Name:
- Take Photo of Other Insurance(front)
- Take Photo of Other Insurance(back)
- Insured Birthdate
- Relation to the Insured
- Current Problem *?
  
  DepressionAnxietyGrief/LossRelationship/FamilyAngerBehavioral IssuesTraumaSubstance AbuseOther
- Describe your symptoms and/or the issue you have been having. *
  
  0/50
- How long has this been going on?*
  
  Less than a month1-6 months7-12 monthsmore than a yearOther
- How often do you experience the problem?*
  
  DailySeveral days per weekEvery now and thenOccasionallySeveral times per monthOther
- Which services are you in need of?
  
  Assessment OnlyIndividual TherapyFamily TherapyOtherEmployee Assistance Program(EAP)Group TherapyOther
- What areas of your life/functioning is this affecting? (Check all that apply.)*
  
  Home LifeDaily responsibilities( cooking, grooming, money management, etc)WorkRelationships(Family, Friends, getting along with others)SchoolEmotionsOther
- Have you had previous mental health treatment/Diagnosis before?
  
  YesNo
- If yes, what was your diagnosis?
- Are you prescribed Medication?*
  
  YesNo
- Do you have allergic/adverse reactions to anything?*
  
  YesNo
- Do you have any specific preferences you'd like us to try to meet? ** Not Guaranteed**
- What are your main goal(s)?*
- Rights and Risk of Therapy: You are urged to be fully involved in your care. You can terminate therapy at any time you wish. You have the right to divulge only what you want to be included in your records. You are urged to open an honest. Your care may involve emotionally provoking subjects and scenarios. You are urged to challenge and push yourself towards change and healing. Therapists are warned against dual relationships. Gift giving is discouraged, please refrain when possible.*
  
  I have read and understand the terms
- Confidentiality: We will not share your personal information or information about your treatment unless in the following situations: You provide permission, which you can revoke at any time. Your records are subpoenaed by the courts/attorney You threaten harm to yourself or someone else. Information is provided to indicate abuse/neglect of children and vulnerable adults. You decide to take legal action against me or the practice. Even if the patient is a minor, confidentiality is still held to the highest regard. Discretion will be made for serious/life-threatening events to break confidentiality. All efforts will be made to maintain your confidentiality when possible.*
  
  I have read and Understand the terms
- Appointments All office visits are by appointment, scheduled with your regular Therapist. You are urged to be on time, most sessions will last 45 to 60 minutes. If you are more than 15 minutes late, your appointment may be cancelled. Most of the time you will receive an appointment reminder. Please confirm. Note you cannot text us back but are welcome to call or email to notify us. You are required to cancel your appointment at least 24 hours in advance to avoid cancellation fee. Insurance companies will not pay for no-show/cancellation charges. After1 month of inactivity, your case will be considered for closure. Your therapist will contact you to attempt to re-engage you at least once and will close your case automatically if you do not respond or reengage. Once closed, you are more than welcome to re-enter therapy when you are ready, provided your therapist is currently accepting new clients during that time.*
  
  I have read and understand the terms
- ELECTRIC MEDICAL RECORD(EHR) To enhance our practice operations and make services better for you, we will be using Therapy Appointment(PsychSelect) to manage our records. We will send you an invitation to establish your patient portal. This will allow you to send secure messages with your provider, upload documents securely, and other helpful features as they come available. Please establish your*
  
  I have read and understand the terms
- Fees: The client portion of fees is expected at the time of service. To maximize time, we will REQUIRE a card on file. You are responsible for any unpaid portions after insurance. If we are in your insurance network, we have agreed not to charge you more than their agreed allowable amount. If we are not in the network, you will be charged our full fee(listed below)Accounts become delinquent after (30) days. Accounts more than 90 days in arrears will be terminated; unless a payment plan has been agreed to. I agree to discuss any changes to my financial situation. We accept Visa, MasterCard, & American Express. The card must be in your name or permission form sign by responsible party for you to use their card. Fees: The client portion of fees is expected at the time of service. You are responsible for any unpaid portions after insurance. Accounts become delinquent after (30) days. Accounts more than 90 days in arrears will be terminated. I agree to discuss any changes to my financial situation.*
  
  I have viewed the fee schedule, read and understand terms
- Card on File Requirement. If you are using your insurance benefits, Brighter Pathways, LLC, requires the patient portion of the first session be paid by credit card – Visa,Master Card, or HSA. This is due to the high incidence of unreported deductibles and the fact that insurance may not cover certain services such as Marriage Counseling, Family Counseling, Hypnotherapy, and sessions lasting longer than 45 or 60 minutes. By paying via credit card, you acknowledge that this credit card information will be automatically kept on file via PCI-compliant encrypted code with the following credit card processor: International Bancard. Health Savings Account cards may also be kept on file as the primary form of payment, but must still have a back-up credit card on file in case HSA funds are depleted. You further agree and understand that if insurance does not pay the contracted rate for services, any remaining balance due that is the legal patient responsibility will be charged to this Health Savings Card or Credit Card on file. This amount typically includes co-pays, co-insurance, and deductibles that have not yet been met or were quoted incorrectly by the insurance company.Brighter Pathways, LLC will provide you access to the TherapyAppointment patient portal where you can view your account, request statements, or pay your outstanding charges. Clicking on the payment line will allow you to view or print the receipt. By signing my name below, I authorize Brighter Pathways, LLC to keep my credit card on file and to charge my credit card an amount not to exceed $150.00; unless agreed upon. I have the right to request my credit card to be removed via written or verbal request but recognize a payment must be made before the start of each session before services will be rendered. THIS AUTHORIZATION EXPIRES 6 MONTHS FROM THE DATE OF YOUR FINAL THERAPY SESSION.*
  
  I have read and agree to the terms of this agreement.
- Current Fee Schedules/Services offered:
  - Initial interview: $155.00
  - Individual Therapy Sessions
    
    (30minutes) $40.00
    
    (45minutes) $95.00
    
    (60minutes): $115
  - Family Therapy Sessions: $110.00
  - Couples Session $60.00
  - Cancellation/No show: $60 (not billable to insurance) We will bill YOU if your appointment is not cancelled at least 24 hours in advance: $60.00
    
    If medicaid is your primary insurance, please note, we cannot bill you for a missed appointment. We do, reserve the right to terminate services with you for 2 missed appointments not cancelled within 24 hours of appointment.**
  - Crisis Session: $40.00/15minutes
  - Specialty groups: Price vary per group
  - Returned check fee: $25.00
  - Medical records:
    
    If Printed: $15 up to 50 pages(front and back), .03/page afterwards.
    
    Faxed/emailed:$10.00
    
    US Mail: $30.00
  - Court Appearances: $80.00/Hour
  - Completing documents: $30.00 each form and up to the discretion of the clinician.
    
    This service may be paid for and submitted via the website.
- Handling of Crisis/Emergency Situations: In a crisis situation after hours, between 8p and 8am, you have the option of reaching a counselor on call. The on-call counselor may or may not be your primary counselor but is here to help you through your crisis. You may call 803-708-7990, Ext 2 In a crisis situation after hours, if a counselor cannot be reached, these are call/text options 988 Suicide and Crisis Lifeline, the 24 hour Mental Health Crisis 1-800-273-TALK (8255), 1-800-SUICIDE (1-800- 784-2433) Line, 988, or go to your local Emergency Room for immediate assistance. Please note there is a charge for crisis calls. It may or may not be covered under your insurance. You understand you are responsible for any balances unpaid by your insurance/payor.*
  
  I have read and understand terms
- Assignments of Benefits: I assign directly to Brighter Pathways, LLC all insurance benefits, if, any, otherwise payable to me for services rendered. I understand I am financially responsible for all charges not paid by my insurance as well as collection fees or interest that may be added if the account should be placed with an outside collection agency. I authorize the use of my signature on all insurance submissions. The above name facility may use my healthcare information and my disclose such information to the named insurance company or companies and their agents for the purpose of obtaining payment for services and determining benefits or the benefits payable for related services. This consent will expire 1 year after I have been discharged or inactive from brighter Pathways, LLC.*
  
  I have read and understand terms
- Informed Consent for Telemental Health Services
  The following information is provided to make therapy more accessible through telemental. This section covers your rights, risks and benefits associated with receiving services, our policies, and your agreement to utilized telemental health whenever necessary while under our care.
  
  Please read this document carefully and note any questions you would like to
  discuss.
  - Client’s Rights
    You have the right to decide to end our psychotherapy work at any time without prejudice. If you
    wish, I will provide you with the names of other qualified therapists.
    
    You have the right to ask any questions about procedures used during therapy. If you wish, I will
    explain my usual method of psychotherapy practices with you.
    
    You have the right to refuse the use of any therapeutic technique. I will inform you if I intend to
    use any unusual procedures and explain any risks involved.
    
    You have the right to learn about alternative methods of treatment. I will discuss these with you
    during our work together.
    
    Telemental health services are not appropriate for all clients. Generally, those who are
    experiencing suicidal ideation or altered mental status may not be appropriate.
    
    Should telementalhealth services not be a good fit for you, call our office at (803) 708-7990 x 1 and we will assist you in finding alternative options.
  - Benefits and Risks
    
    Telemental health refers to psychotherapy services that occur via phone, email, or synchronous videoconferencing. All of our interactions will fall under this term. When using technology there is always the
    risk of security issues, as well as technical issues (phone not charged, computer or software notworking, etc.). You will develop an individualized plan for how best to address technical issues that may
    arise and will take steps to facilitate the security of interactions with your therapist. In addition to the identified risks, there are several benefits that come from using technology. For instance, it allows
    therapists to connect with people who may otherwise not be able to access services, there is an
    opportunity for more flexibility in scheduling, and convenience in being able to connect from a space of
    your choosing.
    
    In order to protect your confidentiality and to facilitate the security of your information asmuch as possible, here is a list of recommendations:
    
    Engage in sessions in a private location where you cannot be heard by others
    
    Use a private phone
    
    Do not record any sessions
    
    Password protect any technology you will be interacting with your therapist on
    
    Always log out or hang up once sessions are complete
    
    To avoid others knowing we have connected, your therapist may be contacting you from a blocked number or will be sending you a link for the waiting room to the session.
  You acknowledge and agree Brighter Pathways,LLC is not held liable for any Breach of confidentiality that occurs as a result of client's failure to complete sessions in a secure place or close out information on all or any device used to conduct the session.
  
  Emergency Management Plan
  Brighter Pathways, LLC still provides Crisis intervention services after hours. If you have a true crisis, you may call 803-708-7990 x2. In the event of an emergency, it is imperative you are aware of resources in your area. As a precaution, please identify two (2) nearby
  emergency hospitals below in case the on call Counselor is unable to assist you.
  
  Contacting Your Therapist
  Calling or secure messaging through the portal are the main forms of contact that will be used outside of the consultation and sessions. Please note if you do use email, that email is not secure, so communication should be limited to scheduling questions, providing resources. If you cannot reach your main Therapist or encounter an issue. You can Message Angel G. Johnson, through the portal or email brighterpathwaysllc@gmail.com.
  
  You will still receive a text message reminder the day before the scheduled session. If you need to cancel an appointment, we Reqire it be done 24 hours in advance. If something comes up you cannot prevent, please cancel/reschedule as soon and early as possible.
  
  Due to COVID-19,telehealth( phone or video) services, at this time will be covered by my insurance provider, therefore this form serves as an agreement the session fees will be paid in full at the time of service, claims will be billed to your insurance provider, and you agree to pay for any charges your insurance does not cover. I understand there may be a time where telemental health will not be covered and I may have to explore other options.
- I have read the above and I agree to terms*
- My or my representative's signature below indicates I have read/reviewed the policies for both outpatient services/ telemental health services and agree to receive services with Brighter Pathways, LLC.*
- Valid ID of Client/ Responsible Party*
- Printed Name*
- Date*
  
  MonthDayYear
  Date
- Relationship to signer:
  
  SelfParentOther
- 6156 , Ste 105 Columbia, SC 29212 Phone: 803-708-7990 Fax: 803-636-2637
  
  Website: www.brighterpathways-sc.com Email:brighterpathwaysllc@gmail.com
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Brighter Pathways, LLC INTAKE FORM