Elliott & Associates, Inc.

Today's Date

Patient's Name

First NameLast Name

Middle Name

Date of Birth

Date

Gender (insurance companies still require the male/female binary form. If you identify differently/nonbinary, please select the option that was used for your insurance coverage)

MaleFemale

Patient's Social Security Number

Patient's Relationship Status

Patient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.

Cell Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Email

example@example.com

Preferred Phone?

HomeCellWork

Can we leave messages on your home phone?

YesNo

Can we leave messages on your cell phone?

YesNo

Would you like to receive reminder texts or calls?

YesNo

Reminder Preference

Home Phone voiceCell Phone textCell Phone voiceEmail

How did you find our office

Name of referring doctor (if applicable)

Name of referring friend/family member (if applicable)

Employer name

Occupation

Emergency Contact's Name

Relationship to Patient

(Parent Spouse Other)

Emergency Contact - Home Phone

Please enter a valid phone number.

Emergency Contact- Cell Phone

Please enter a valid phone number.

I do not have insurance and I will be paying myself (people who self pay are require to have a credit card on file.)

Name of Primary Insurance Company

Identification number for primary insurance

Policy/Group number for primary insurance

Name of policyholder (primary insurance)

Date of Birth for policyholder (primary insurance)

Date

Policyholder’s Social Security (primary insurance)

Policyholder’s address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Policyholder’s Employer

Please take a photo or upload image of both sides of your insurance card. If you do not know how to do this you can bring your card to the office and we will make a photocopy.

Do you have Sessions covered by an Employee Assistance Program (EAP)

YesNo

EAP Authorization Number

Number of visits allowed

EAP Company

Name of Secondary Insurance Company

Secondary Insurance Identification #

Secondary Insurance Policy/Group #

Name of Policyholder for Secondary Insurance

First NameLast Name

Policyholder's date of birth

Date

Policyholder’s Social Security (for secondary insurance)

Policyholder’s address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please take a photo or upload image of both sides of your insurance card. If you do not know how to do this you can bring your card to the office and we will make a photocopy.

Signature*

Type name*

Date*

Date

SCHEDULING:

Appointments are available from 9:00 am to 6:00 pm Monday through Friday, with limited evenings and Saturday hours. Our administrative office staff is available on weekdays from 9:00 am to 5:00 pm to assist with scheduling appointments.

INSURANCE:

Our office bills insurance as a courtesy to the client. It is ultimately the client’s responsibility to know their policy and for payment in full for any portion of service that insurance does not cover. Please note that copays are required at the time service is rendered.

Fees:

Initial Consultation: $195

Session Fee: $170

SELF PAY:

Clients without insurance coverage will be billed at a courtesy fee of $125.00 for the initial appointment and $95.00 per session after. Self-pay clients are required to leave a credit card and charge authorization on file. This information will be stored in a secure external credit card billing system and may be updated upon request at any time.

CANCELLATION POLICY:

24-hour notice is required for appointment cancellations. Cancellations made with less than 24-hours notice and no-shows for appointments will be charged $75.00 (not billable to insurance) Monday appointments must be canceled by noon on the previous Friday.

TELEPHONE & EMERGENCY PROCEDURES:

If you need to contact your therapist between sessions, please leave a message at the answering service (419) 885-1910 and your call will be returned as soon as possible. Our therapists check their messages a few times during the daytime only, unless they are out of town. If an emergency situation arises, indicate it clearly in your message. If you need to talk to someone right away, call the National Suicide Prevention Lifeline, 24-hour emergency service at (800) 273-8255, or the Police: 911. Please do not use email or faxes for emergencies since they are not always monitored on a daily basis.

CONFIDENTIALITY:

What you say in therapy, your records, and your attendance are all protected and kept confidential. Exceptions include when your records are subpoenaed for legal reasons when reporting is required or allowed by law such as in the case of child abuse or neglect, extreme danger to self, suspected elder abuse, danger to others, or when you give written permission to release information.

HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT (HIPAA) and No Surprise Act:

Elliott & Associates, Inc. complies with all policies and procedures, occurring under the HIPAA guidelines and No Surprise Act. Please review the policies in the window below. A permanent copy of the HIPAA policies and No Surprise Act is available in our waiting room and from the Office Manager.

Signature*

Type Name*

Date*

Date

Minor Child's Date of Birth

Date

According to Ohio State Law, when a child is from a divorced family, only the custodial parent can sign to allow treatment. Are you the court-designated parent for this child?

YesNo

Custodial Parent / Guardian Signature Relationship to minor

Type Name

Date

Address for Parent or Guardian (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

At times there will be counseling interns performing services for you. These persons are trained in psychological methods and are preparing to become independently licensed. They are working under the supervision of Jacob Elliott, Ph.D. (license # 260), who are ultimately responsible for your treatment. The supervisees are functioning under the rules of the Ohio State Board of Psychology. They will be performing assessments of emotional and cognitive levels. The supervised activities also include crisis intervention and psychological treatment including individual, couple, family, group therapy, biofeedback, and Neurotherapy. Supervision is provided on a regular basis. Due to the nature of supervision, the psychology assistant will be discussing your case with the supervisor in order to provide the best quality care. At all times, Dr. Elliott is responsible for the services you receive from Elliott & Associates, Inc. If you would like to contact Dr. Elliott or any of the counseling interns you can do so by calling our office at (419) 885-1910 or by email at info@qualitytherapycenter.com. All billing for mental health services will be billed directly from Elliott & Associates.

We respect your right to confidentiality and will not reveal the confidential information that you share with us to outside individuals or agencies without your written permission. However, there are several exceptions to this policy listed below:

● We are obligated by law to report suspected child (sexual, physical, or emotional) and neglect to the proper authorities.

● We are obligated by law to report suspected elder abuse to the proper authorities.

● We are obligated to take necessary action to prevent harm to self and others, and we will take necessary action to prevent such harm from occurring.

● If you are involved in court matters, your records may be subpoenaed at any time during or after your treatment. We will make every effort to protect your confidentiality and will not release your record without the appropriate consent or a court order to do so.

Patient or Parent of Patient's Signature *

Power of Attorney for Patient (if applicable)

Type name for signature above:*

Date*

Date

Session Copays: Sessions copays will be charged on the day (or after) a scheduled session.

I Agree

Session Deductibles and Coinsurance: Session deductibles and coinsurance fees will be charged according to the insurance explanation of benefits.

I Agree

Uncovered Services: I understand I will be charged for any services not covered by my insurance.

I Agree

Late Cancellation Fees: I understand I will be charged $75.00 for cancellations that are less than 24-hour notice. Monday appointments must be canceled by noon on the Friday before.

I Agree

Returned Check Fees: If a check is returned unpaid, the amount of the check will be charged to the credit card, plus any returned check fees.

I Agree

Health Savings Account (HSA) Cards: If I have an HSA credit card. I authorize Elliott & Associates, Inc. to charge the card for all services at the time of the session or afterward. I understand that missed sessions cannot be billed to HSA credit card.

I Agree

I authorize Elliott & Associates, Inc. to bill my credit card on file with the office for services listed above.*

Type Name *

Date*

Date

Elliott & Associates, Inc.

Welcome!

Your Employment Information

Emergency Contact

HEALTH INSURANCE INFORMATION

Secondary Health Insurance

CONSENT FOR BILLING INSURANCE

Office Policies

By signing below, you acknowledge that you accepted the terms of the HIPAA, No Surprise Act, and office policies.

CONSENT FOR TREATMENT OF A MINOR

Information Regarding the Treatment of Minor Children

Disclosure Statement

Credit Card / HSA Authorization Agreement

We will call you to get your credit card information.

Patient Intake Information

Current Medications

Medical and Psychological History

Educational History

What are three therapy goals you have?

Thank you!