Sentinel Mental Health Inc - Intake Paperwork

Sentinel Mental Health Inc.

1645 Ave D Suite C, Billings MT 59102

Sentinel Mental Health - Helena

21 North Last Chance Gulch, Helena Montana 59601

Phone - 406-272-2511

Fax - 406 - 204-0474

For use by all current clinicians - This list may not be fully accurate, for a current list please call our office.

Billings Clinicians

Suite C

Jennifer Finn - MSW, LCSW - Suite C

Kelly Williams - MSW, LCSW - Suite C

Meadow Nilles - SWLC - Suite C

Suite A

Denise Schumacher - MSW, SWLC - Suite A

Kai Peetz - MSW, SWLC - Suite A

Kyanne Wear - LCSW - Suite A

Suite K

Sharda Olson-Meyer - MSW, LCSW - Suite K

Monica VonLangen - LCSW, CTP, CSAM - Suite K

Suite I - Downstairs

Jenna Kidgell - SWLC - Suite I

Mariah Fredrickson - SWLC - Suite I

Helena Clinicians - Suite 201

Gianna Lishman - LCSW - Suite 201

David Chenault - LCSW - Suite 201

Lyndsay Smith - MSW, LCSW- Suite 201

Adrienne Bombelles - MSW, SWLC - Suite 201

Helena Clinicians - Suite 207

Lisa Benevides - LCSW - Telehealth / Suite 207

Alex Bostrom - MSW, SWLC - Suite 207

Allysha Dalzell - MSW, SWLC - Suite 207

Jordan Brown - LCSW

Montana - Telehealth

Nick Taylor - Psychiatric Nurse Practitioner, MSN, PMHNP-BC

Allison DeVault - PCLC - Telehealth
Today*

MonthDayYear
Date
Were you referred to a specific clinician?
Please select the location you are requesting.
How did you hear about us?
If referred we'd love to say thank you :-)
Name of client (If you are the parent, your info is requested later in the form)*

Patient First NamePatient Last Name
What days and times are best for you?
Very basic details of what you would like to work on with your clinician?
Do you / the client take any medications for mental health management? If so, please list.
Sentinel Mental Health Inc has a Dr. available to work with our clients to manage mental health medications. We find combining therapy with a Dr. oversight can provide very positive results. Would you like us to review these services with you?

YesNoMaybe Later
Past Medical History
Other Substance Use
Is the patient a minor?

YesNo
Is therapy Court Ordered?

YesNo
What is your current marital status? *
Please state that you AGREE to the following statement. I understand that I MAY ONLY request my minor child's summary of treatment.*

I UNDERSTAND and AGREE
Parents Name - Required*

First NameLast Name
Parent / Guardian / Responsible party for payment SS#*
If minor, Parent/Guardian Name*
Parents phone number - Required*
Please enter a valid phone number.
Do you have a court executed parenting plan?

YesNo
Picture of page in parenting plan which outlines how medical / therapy decisions are handled. If you don't have one you may skip this.

Cancelof
Are you looking for reunification services?

YesNo
I understand if I have a parent plan in place I will be required to proide details which relate to my childs therapy. I understand that unless SMH receives court ordered information restricting parental rights, SMH will provide basic session details to parents. Therefore, if there has been restrictions placed on a parent related to child participation in therapy SMH be made aware and have the proper documentation filed.

I understand and agree
Are you looking for Family Therapy / Couples

YesNo
Family Therapy / Couples requires we have signed intake (this form) and insurance / cash agreement for each participant. Please forward the link you recieved to your partner to fill out and have them note their relationship to you.

I understand
My partners name (skip if single)

First NameLast Name
Date of Birth (client)*

MonthDayYear
Date
If over 18 SS# (client)*
Sex M/F - For administrative purposes and insurance claims (client)*
Do you identify as male, female, or neither? (client)*
Relationship status (client)*
Address*

Home Address

Street Address Line 2

CityState

Zip
Mobile Phone*
Work Phone
Email*
example@example.com
Address

Parent/Guardian Address

Street Address Line 2

CityState

Zip
Emergency Contact*
Relationship*
Phone*
INSURANCE INFORMATION
Primary Insurance Company Name - IF Uninsured - List NONE *
Primary Insurance Company Name - In uninsured - Pick NONE*
TriCare and Humana REQUIRE a preauthorization from your primary physician.*

I understand that NOT getting my preauthorization will result in being charged 100% of my insurance allowable.I do not have TriCare or Humana
Front Insurance Card

Cancelof
Back Insurance Card

Cancelof
Secondary Insurance - Front

Cancelof
Secondary Insurance - Back

Cancelof
Primary Insured Person's Name
Member ID
Primary Insured Date of Birth

MonthDayYear
Date
Group/Policy # ( You may not have a group )
Is the primary insureds address the same as the patient?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Patient / Client
Insured Employer
Do you have a secondary Insurance?

YesNo
Secondary Insurance Company Name*
Phone
Secondary Insurance Company Address
Primary Insured Person's Name
Insured Date of Birth

MonthDayYear
Date
Member ID
Group/Policy #
Relationship to Patient
Insured Employer
Responsible Party Signature

Clear
Consent to Treat and use of technology
Therapist Qualifications

Licensed Clinical Social Workers (LCSW) have professional training in conducting mental health treatment. Social Workers with a Candidacy License (SWLC) have completed their Masters of Social Work schooling and have been board certified to treat clients under the supervision of a LCSW. You have the right to inquire fully about the credentials, education and experience of your therapist and have your questions answered to your satisfaction. In this practice, treatment is provided by a Licensed Clinical Social Worker who is certified in Oncology Social Work, or a Social Worker with a Candidacy License supervised by a Licensed Clinical Social Worker who is certified in Oncology. The Montana Board of Behavioral Health regulates Clinical Social Workers and therapists in the state of Montana.

What to Expect from Treatment

The therapist will work with you, your child or family to provide the most effective treatment possible. Studies of psychotherapy indicate that most clients benefit from treatment. However, treatment benefits cannot be guaranteed because the response to therapy is different for each client. Psychotherapy can involve a variety of different activities, which vary from client to client.

You are entitled to the following information: Methods and techniques of therapy, duration of therapy if known, fee structure, the right to seek a second opinion, and the right to terminate therapy at any time.

Confidentiality/ Informed Consent/ Disclosures

Legal and professional ethics require therapists to maintain complete confidentiality in the majority of cases. In these cases, the therapist cannot release any information without written permission. The following exceptions require the therapist to break confidentiality: The client presents a clear and present danger to him/herself and refuses to accept the appropriate treatment. The client communicates to the therapist threats of physical violence against an identified person or victim, or the therapist has a reasonable basis to believe there is a clear and present danger of physical violence against such a victim. The therapist has grounds to believe a child under the age of 18 has been or is at risk for being abused or neglected.

It should be noted that insurance companies reimbursing for mental health services require information about these services. Therefore, if you are using insurance to pay for you or your child's treatment, information may be released to the insurer.

The use of Technology in the creation of Notes

Many of our therapists/clinicians/provisionally licensed may use different forms of technology to improve the capture of important information in the therapeutic environment. This could be in the form of voice-to-text, or programs that take the information written from the session and help to create a concise note, or programs designed to take the dialogue from a session ie - transcription, and build a session note.

The use of any technology that creates a temporary file is eliminated once a session note is created.
Please check to signify you understand and agree with the section listed as Consent to Treat.*

I agree
Disclosure Regarding Counselor's Policy NOT to Testify
If you are involved in a divorce or custody litigation, my role as a counselor is not to make recommendations for the court concerning custody or parenting issues or to testify in court concerning opinions on issues involved in the litigation. By signing this disclosure statement, you agree not to call your clinician as a witness in any such litigation. Experience has shown that testimony by counselors in domestic cases causes damage to the clinical relationship between a counselor and client. Only court-appointed experts, investigators, or evaluators can make recommendations to the court on disputed issues concerning parental responsibilities and parenting plans. If subpoenaed by an attorney, additional fees will be assessed but not less than 100/hour to prepare, drive time, any time spent in court. You may be required to make a payment in advance to cover likely expenses. You will be provided a statement for any billed services. In checking this Disclosure Statement, you agree with this practice.
I Agree
If treatment records are requested, the therapist will provide a treatment summary only. Note request or summary requests may take up to 14 days and are $15.00 / search and .50 / page. In signing this Disclosure Statement, you agree with this practice. In the state of Montana, if the Theripist believes providing progress notes could negatively affect the client, the theripist may refuse the request or provide the note with some sections redacted.*

I agree
I cannot ensure the confidentiality of any form of communication through electronic media including text messages. You are also advised that any email sent to me via computer in a work-place environment is legally accessible by an employer. We will accept email and/or texting communication for the scheduling/cancellation of appointments, if you prefer. While we try to respond to messages in a timely manner, I cannot guarantee immediate responses. Please do not use these methods of communication in an emergency or to discuss therapeutic content. Please note that we are legally obligated to maintain records of our sessions and communication. These records include a brief synopsis along with professional observations and plans. These records and / or a summary may be subpoenaed for a variety of reasons. In signing this Disclosure Statement, you understand and agree with this practice.
I agree
I do not accept friend or contact requests from current or former clients on any social media networking site including but not limited to Facebook, LinkedIn, Instagram, etc. I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please discuss this with me.
I agree
Appointments and Financial Arrangements:Therapy sessions are generally 40-55 minutes in length depending on the age of the client and the situation. The initial appointment is a diagnostic intake session with a fee of $225.00. Subsequent therapy sessions are billed at $115 to $165 depending on the length and content of the sessions.
I agree
Telephone calls and telephone appointments:Currently telephone appointments and video appointments are covered by insurance. This was an insurance change due to COVID-19. This policy could change at any time. If you require a telephone or video appointment and your insurance discontinues coverage the appointment will billed to you at $120.00 / Session.
I agree
Outside of therapy conversations. When a therapist is required to have conversations with the client, guardian, significant other, parent or parents, doctors, lawyers etc, these conversations are not billable to your insurance company but are considered billable time. SMH bills these interactions at $10.00 / 5 minutes. This amount is subject to change.

I understand and agree
Insurance and Billing
Sentinel Mental Health Inc. maintains all client billing records and works with insurance companies. All therapy claims are electronically submitted to your insurance carrier, and then Sentinel Mental Health Inc. will send you a monthly statement. You are responsible for the deductible, co-insurance, and any non-covered services, please check with your insurance to ensure you are covered for services. Residual bills that are the patient's responsibility may not exceed $500 without prior approval from Sentinel Mental Health and have a payment plan initiated. If the bill exceeds $500 and no payment plan is arranged, Your provider reserves the right to stop services until the bill is paid. Should you have questions about your bill, please contact Sentinel Mental Health Inc. (406) 272-2511. Payment may be made by check, cash, or credit card. Clinicians may accept Venmo, if you choose to pay via Venmo it is your responsibility to make your payments private to comply with HIPAA regulations. All payments should be made to Sentinel Mental Health Inc. VENMO payments can be viewed by others and should only be made if you make your payments private.
I agree
I understand that I need to call my insurance and confirm my coverage for mental health services and ensure that my clinician is IN NETWORK.

1) Check your deductible - do you have one? How much do you have left to cover personally?

2) Do you have a co-pay? If so, you may not need to cover a deductible.

3) If you have a deductible what will your insurance cover after the deductible is met?

4) Ask if Sentinel Mental Health Inc is "In Network"

It is very important you check each of these things so that you know exactly what your personal responsibility will be regarding each of your sessions.
I will call to confirm
Client / Parent or legal gardian of *

First NameLast Name
Indicate by my signature on this form that I consent to the mental health treatment for myself or my child. I agree and consent to the conditions listed above.
Client or Parent/Guardian Signature

Clear
Therapist Signature

Clear
If you have any questions reguarding this notice or our health information privacy policies, please contact your provider. I hereby acknowledge that I have been presented with a copy of a Sentinel Mental Health employee, Notice of Privacy Practices.
Privacy Notice
This notice describes how health information about you (as a patient) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Our commitment to your privacy: Our organization is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize these laws are complicated, but we must provide you with the following important information: Use and disclosure of your health information in certain special circumstances: The following circumstances may require us to use or disclose your health information: 1. To public health authorities and health oversight agencies that are authorized by law to collect information. 2. Lawsuits and similar proceedings in response to a court or administrative order. 3. If required to do so by a law enforcement official. 4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual, or the public. 5. If you are a member of the US or foreign military forces (including veterans) and if required by the appropriate authorities. 6. To federal officials for intelligence and national security activities authorized by law. 7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. 8. For workers' compensation and similar programs. 9. You authorize the release of any medicial records, pictures or other information to medical professionals necessary to pre-certify procedures, process medical claims or for continuity of care.

Your rights regarding your health information: 1. Communication. You can request that our organizations communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. We will accommodate reasonable requestes. 2. You can request a restriction in our use or disclosure of your health information for treatment, payment or healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request, however, if we do we are bound by our agreement except when otherwise required by law, in emergencises, or when the information is necessary to treat you. 3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to your provider. 4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to a Sentinel Mental Health employee. You must provide us with a reason that supports your request for amendment. 5. Right to copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, please contact your provider. 6. Right to file a complaint. If you believe your rights have been violated, you may file a complaint with our organization or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact a Sentinel Mental Health employee. All complaints must be in writing. You will not be penalized for filing a complaint. 7. Right to provide authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

If you have any questions reguarding this notice or our health information privacy policies, please contact your provider. I hereby acknowledge that I have been presented with a copy of a Sentinel Mental Health employee, Notice of Privacy Practices.
Signature

Clear
Confirmed Appointment Policy

Appointments may be canceled, or requested to be moved out side of 24 hours. We realize that emergencies and other scheduling conflicts arise and are sometimes unavoidable. However, advance notice allows us to fulfill other patient's scheduling needs and keeps the clinic operating at its most efficient level. Please provide our office with a minimum of 24-hour notice to change or cancel a confirmed appointment. Patients who do not attend a scheduled and confirmed appointment or do not provide 24-hour notice to change a scheduled appointment will be responsible for a $100.00 charge. This charge cannot be billed to insurance and therefore must be paid by the patient by your next billing cycle. All notice of canceled appointments should be made to 406-272-2511 only, do not send messages to clinicians' private lines. Cancelations need to be made on weekdays as we work to fill open time slots during the week, not on weekends. For example, weekend or holiday texts or calls to cancel a confirmed appointment for the next weekday appointment would violate the policy. If you are not feeling well, we can easily convert an appointment from face-to-face to a telehealth appointment. Please just send the request to the number listed above. After two missed or canceled appointments, without the appropriate 24-hour notice, you may be placed on a same-day scheduling policy for your treatments, which would not allow you to schedule any appointments in advance.
Cancelations are to be called in and a message left 406-272-2511.*

I understand and agree
24 Hour policy excludes weekends and Holidays. (This means that an appointment needs to be called in or texted in on the Friday before)*

I understand and agree
Appointment reminders are not guaranteed to be sent, they are an attempt to assist you in remembering your appointment time, but it is ultimately your responsibility to make a note of your appointment.*

I understand and agree
Appointments rescheduled for the benefit of the client to avoid a late cancelation are considered confirmed at the time the change is made. These appointments may not be canceled.

I understand and agree
Emergencies, after-hours, weekend and holiday phone calls should always be made to the main office phone line. (406) 272-2511. This phone line receives calls 24/7 and messages left will be returned. Your clinician does not answer their phone on weekends and holidays.

I understand and agree
Signature of Patient (or Responsible Party)*

Clear
Date*

MonthDayYear
Date
No Surprise Billing
Sentinel Mental Health Inc (SMH) has contracts with most health insurance companies. This does not mean we are In-network with every company, it is your responsibility to confirm your status. Below is a list of the maximum amounts SMH bills insurance companies. These are the maximum amounts you may be billed for sessions.

Individuals

Intake session $225.00

1 hour - 53 min session for an individual billed to insurance at $195.00

45min - 37 min session for an individual billed to insurance at $165.00

30min - 17 min session for an individual billed to insurance at $135.00

Couples / Family Therapy

Intake session $225.00

Min Session 27 minutes - Billed to insurance at $175.00

Min Session 27 minutes w/o client Billed to insurance at $160.00

Phone sessions / Telehealth

Billed the same as individual and couple/family therapy

Phone calls / Texting Consultations - scheduled or not scheduled

If the client or the parent/guardian of our client requests a call or engages in texting the therapist, you will be billed for the time. Calls over 17 minutes MAY be billed to insurance if billable to insurance, shorter calls or texting can't be billed to insurance and become the responsibility of the client or Guardian.

Calls / Text conversations are billed at $10.00 per 5-minute increments.

Cash Rate - intake - 180

Hour / 53 min - $120

- 45 / 37 min -$115

- 30 / 17 min -$110

Utilizing the CASH rate is only available to those without insurance coverage.

Court proceedings and associated time spent in preparation.

Daily rate/therapist - $1000 - Paid as a retainer and due upon request, always paid in advance. Any unused time will be refunded.

Prep time will be billed out at $120 / hour/therapist.

If you are working with a provisional licensee you will be charged for the provisional time and the supervisor time, this can significantly increase the cost. Please ask about this if you have questions.

*Missed appointments / cancelations within 24 hours of appointment

$100 - Or your insurance allowable

All Session notes/ Summaries

$15.00 / search and $.50 / page.

Note requests should be made in writing, by email, or via certified mail. Note requests can take up to 21 days but more normally should be completed within 10 days.

Credit card payments up to - 3.5% of the balance paid - 0.35 cents/transaction.

Bounced Checks - $35.00 fee

Unpaid Balances- 60 days or older will result in a 5%apr late charge per month.

Note:

We bill your insurance for you. If we are having a difficult time, or your insurance company isn't responding to us, you will be required to cover the session fees. If you are required to cover the session fees, you will be provided evidence of the session and the fees you have paid to your insurance company, and the insurance company will reimburse you as per your agreement with them.

Your insurance company may determine that some services Sentinel Mental Health Inc. provided are not covered under your policy. This could include, but is not limited to, a limit to a number of sessions and type of sessions, phone consultations or other types of consultations that fall outside the limitations of your policy. By signing this document you agree to be responsible for fees related to services rendered.

*Notice to the office to reschedule/cancel any appointment must be provided on weekdays which are not holidays and must be outside 24 hours before the appointment. If you've received your confirmation text/email you are not outside the 24 hour window.
I understand and agree to abide by the No Surprise Billing policy for SMH.

Clear
Should be Empty:

INSURANCE INFORMATION

Consent to Treat and use of technology

Disclosure Regarding Counselor's Policy NOT to Testify

Insurance and Billing

Privacy Notice

Confirmed Appointment Policy

No Surprise Billing