First Steps

1
Existing Clients* This field is required.If you've met with someone at Emerald within the last 6 months, please call 270.534.5128 to reschedule an appointment or send us a chat via emeraldtherapycenter.com
I understand
2
Today's Date
Date
Month
Day
Year
3
New or Existing Client?* This field is required.
4
Client's Name* This field is required.
First Name
Last Name
5
Birth Date* This field is required.
Month
Day
Year
6
Gender* This field is required.
Female
Please Select
Male
Female
Choose Not To Disclose
7
Client's Phone Number* This field is required.This is for appointment reminders via text.
Area Code
Phone Number
8
Please Confirm Client's Phone Number* This field is required.This is for appointment reminders via text.
Area Code
Phone Number
9
Email* This field is required.Please list an email address to send appointment reminders.
example@example.com
10
Address* This field is required.Please use the address listed on the insurance card (if applicable)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Social Security Number* This field is required.This is required to verify benefits for certain insurance carriers. Please skip if you plan to pay as a self-pay client.
12
Our Promise: Mental Health Services Cannot Wait.* This field is required.One of our representatives will reach out within 24 business hours to schedule an initial appointment. If unsuccessful, please call 270.534.5128 option #2 or use our live chat on emeraldtherapycenter.com to connect with us ASAP.
I understand
13
How did you hear about Emerald?* This field is required.
Internet
Friend / Family
Social Media
Physician Referral
Other
14
Do you have a parent or legal guardian?* This field is required.
Yes
No
15
Guardian's Name* This field is required.
First Name
Last Name
16
Guardian's Phone Number* This field is required.
Area Code
Phone Number
17
Is there a specific provider you'd like to see?Emerald Team Members Bios can be found at https://emeraldtherapycenter.com/staff-paducah-therapy/
18
Emergency Contact* This field is required.
First Name
Last Name
19
Emergency Contact's 's Phone Number* This field is required.
Area Code
Phone Number
20
What services can Emerald provide for you?* This field is required.
Counseling
Medication Management
Assessments
Case Management (Medicaid Only)
Addiction Treatment
All of the above
21
Where would you like to be seen?* This field is required.
Paducah- Village Square Location
Paducah - Livingwell Location
Murray - Swann Warehouse
Mayfield
Telehealth
22
Telehealth services require a strong internet connection. If your internet connection is limited, we can provide services via a phone call. What works best for you?* This field is required.
Video
Phone
23
In a few words, what can we help you with?* This field is required.
24
What can we help you with?
Anxiety
ADHD
Depression
Grief
Couples Counseling
Addiction Treatment
Anger Management
Parenting Classes
MRT- Re-entry
Gender Issues
Eating Disorders
Faith-Based Counseling
Autism Spectrum Disorder
Behavioral Issues
25
Notice of Privacy Practices * This field is required.EMERALD THERAPY CENTER, LLC NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice describes the privacy practices of Emerald Therapy Center, LLC, (ETC) and all business associates with whom we may share your protected health and medical information. We provide the Notice of Privacy Practices to every patient we have a direct treatment relationship with after January 7, 2020 effective date. This Notice is also available to any member of the public and is posted within our reception area. Every effort will be made to obtain a signed Receipt of Notice of Privacy Practices from each patient that will be kept on file. If the patient refuses to sign the form, it will be noted that the Notice was given but the patient refused to or could not sign the Receipt. We understand that your medical or PHI (“protected health information”) is confidential and we are committed to maintaining its privacy. Federal law requires that we provide you with this Notice of our legal duties and privacy practices with respect to your PHI. We are required to abide by the terms of this Notice when we use or disclose your PHI and are also required by law to notify you if you are affected by a breach of your secured PHI. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION OR PHI ABOUT YOU Treatment Purposes. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. In addition, we may contact individuals through telephone, mail and email with appointment reminders and may utilize facsimile transmissions for specific authorizations and prescription refills through pharmacies. We may also disclose your PHI to other providers involved in your treatment. Payment Purposes. We may use and disclose PHI to obtain payment for the treatment services provided. For example, we send PHI to Medicare, Medicaid, your health insurer, HMO, or other company or program that is to pay for your health care so they can determine if they should pay the claim. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection. Health Care Operations. We may also disclose PHI to other health care providers when such PHI is required for them to treat you, receive payment for services they render to you, or conduct certain health care operations, such as quality assessment and improvement activities, and peer review. We may share your PHI with third parties that perform various business activities such as an outside billing company, appointment reminder service or electronic practice management vendor provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. Disclosure to Family, Close Friends and Other Caregivers. In an emergency situation, we may disclose PHI to those involved in a patient’s care when the patient approves or, when the patient is not present or not able to approve, when such disclosure is deemed appropriate in the professional judgment of the practice or such as necessary. When the patient is not present, we determine whether the law requires the disclosure of the patient’s PHI, and if so, disclose only the information directly relevant to the person’s involvement with the patient’s health care. Disclosures Required by Law. As a behavioral health provider, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. However, we may also use or disclose PHI about you without your prior authorization, subject to certain requirements and as required by law. Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If PHI is disclosed for this reason, it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat. We may disclose PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect. Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority. Health Oversight Activities. We may use and disclose your PHI to state agencies and federal government authorities when required and as authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control. We may use and disclose your PHI in order to assist others in determining your eligibility for public benefit programs and to coordinate delivery of those programs. Judicial and Administrative Proceedings. We may use and disclose your PHI in judicial and administrative proceedings such as pursuant to a subpoena, court order, administrative order or similar process. Efforts may be made to contact you prior to a disclosure of your PHI to the party seeking the information. Law Enforcement. We may use or disclose PHI to law enforcement to locate someone who is missing, to identify a crime victim, to report a death, to report criminal activity at our offices, or in an emergency. Specialized Government Functions. We may review requests from US military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Dept of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm. Work-Related Injuries. We may use or disclose PHI to an employer to evaluate work-related injuries. Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm or to provide treatment in an emergency situation. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency. Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA. Uses and Disclosures Required by Law – DO NOT APPLY TO PRACTICE. We may disclose information as required by law for the following purposes although generally these do not apply to (ETC): marketing and research studies; fundraising; coroner or medical examiner and funeral directors for death certificate; disclosures to facilitate organ, eye and tissue donations. USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION For any purpose other than the ones described above, we will only use or disclose your PHI when you give us your written authorization. For instance, we will obtain your written authorization before we send your PHI to your employer or health plan sponsor, for underwriting and related purposes for a life insurance company or to the attorney representing the other party in litigation in which you are involved. Highly Confidential Information. Federal and Kentucky law requires special privacy protections for highly confidential information about you. Highly Confidential Information consists of PHI related to: psychotherapy notes; mental health and developmental disabilities services; alcohol and drug abuse services; HIV/AIDS testing, diagnosis or treatment; venereal disease(s); genetic testing; child abuse and neglect; domestic abuse of an adult with a disability; or sexual assault. In order for us to disclose your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written authorization. YOUR RIGHTS REGARDING YOUR PHI Right to Receive an Accounting of Disclosures. You have the right to request an accounting of disclosures that we have made of your PHI for purposes other than treatment, payment, and health care operations, or release made pursuant to your authorization. If you request an accounting more than once during a twelve (12) month period, we will charge you $25. A request for disclosures must be made in writing to the Privacy Officer. Right to Inspect and Copy Your PHI. You have a right to inspect or get a copy of your medical record file and billing records maintained by us. In some circumstances, we may deny you access to a portion of your records. If you desire access to your records, submit your request in writing to the Privacy Officer. A reasonable fee, not to exceed limits allowed under Kentucky law, will be charged for the copying and mailing. Right to Amend Your Records. You have the right to request that we amend PHI maintained in your medical record file or billing records. If you desire to amend your records, please submit your request in writing to the Privacy Officer. We are not required to agree with your request to amend. Right to Request Restriction of Disclosures. You may submit a request in writing to the Privacy Officer to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction. Right to Receive Confidential Communications. We accommodate all reasonable requests to keep communications confidential and to allow you to receive your PHI by alternative means of communication or at alternative locations. A request for confidential communications must be in writing, must specify an alternative address or other method of contact and must provide information about how payment will be handled. The request should be submitted to the Privacy Officer. We will determine the reasonableness based on the administrative difficulty of complying with the request. We will reject a request due to administrative difficulty if no independently verifiable method of communication (such as a mailing address or published telephone number) is provided for communications; or if the requestor has not provided information as to how payment will be handled. Authorization. We obtain written authorization from a patient or a patient’s representative for the use or disclosure of PHI for reasons other than treatment, payment or health care operations. We will not, however, get an authorization for the use or disclosure of PHI specifically allowed under the Privacy Rule in the absence of an authorization. We do not condition treatment of a patient on the signing of an authorization, except disclosure necessary to determine payment of claim (excluding authorization for use or disclosure of psychotherapy notes); or provision of health care solely for the purpose of creating PHI for disclosure to a third party (pre-employment or life insurance exams). A specific written authorization is required to disclose or release mental health treatment notes, alcoholism treatment, drug abuse treatment or HIV/Acquired Immune Deficiency Syndrome (AIDS) information. Right to Revoke Your Authorization. You have the right to revoke your written authorization, except to the extent that we have taken action in reliance upon it, by submitting your request in writing to the Privacy Officer. Effective Date and Changes to this Notice. This Notice is effective January 1, 2020. We reserve the right to revise this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new Notice. Any new Notice will be posted in the reception area of Emerald Therapy Center, LLC. Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of the breach, including what happened and what you can do to protect yourself. Right to a Copy of this Notice. You have the right to a copy of this Notice which may be obtained by contacting the Privacy Officer. For Further Information or Complaints. If you have questions, are concerned that your privacy rights have been violated, or disagree with a decision made about access to your PHI, you may contact our Privacy Officer who serves as the contact person for all issues related to the Privacy Rule. Complaints must be addressed to the attention of the Privacy Officer at Emerald Therapy Center LLC; 5050B Village Square Drive Paducah Ky, 42001. telephone (270) 534-5128. Written complaints may also be filed with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington, D.C. 20201. Complaints must name the practice, describe the acts or omissions that are the subject of the complaint, and must be filed within 180 days of the time you became aware or should have become aware of the violation. We will not retaliate or take any adverse action against you if you file a complaint.
I understand
26
Do you confirm that you have read and consent to Emerald's Notice of Privacy Practices disclosure?* This field is required.
Yes
27
Signature* This field is required.
Clear
28
Guardian Signature (if under age 18)* This field is required.
Clear
29
Date* This field is required.
Date
Year
Month
Day
30
Telehealth Consent* This field is required.TELEHEALTH CONSENT Emerald Therapy Center, LLC I agree to participate in a telemedicine evaluation and/or ongoing treatment performed by a W2 employee, or independently contracted provider who assumes sole responsibility and liability for treatment. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. [Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small]. I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person. I understand that medical records of telemedicine services will be kept at Emerald Therapy Center. I understand that some or all of my medical information may be used for teaching or educational purposes. I agree to have my telemedicine medical records reviewed for the purposes of evaluation (data collection, analysis and presentation in verbal or written format at scientific meetings). I understand that any presentation will not identify me by name or other identifiable markers.
I understand
31
Do you confirm that you have read and consent to Emerald's Telehealth Consent disclosure?* This field is required.
Yes
32
Do you want us to share your private healthcare information with anyone?* This field is required.This is only provided upon request.
Yes
No
33
Signature* This field is required.
Clear
34
Guardian Signature (if under age 18)* This field is required.
Clear
35
Date* This field is required.
Date
Year
Month
Day
36
Consent for Release and Use of Confidential Information and Receipt of Notice of Privacy Practices* This field is required.EMERALD THERAPY CENTER, LLC Consent for Release and Use of Confidential Information and Receipt of Notice of Privacy Practices I, _____________________, (name of patient or legal or personal representative), hereby give my consent to Emerald Therapy Center, LLC to use or disclose for the purpose of carrying out treatment, payment or healthcare operations, some basic information contained in the patient record of _________________________. (Patient’s Name) I understand that by law and professional ethics, what is shared in psychotherapy remains confidential unless permission has been given to share it, or except as the law or my managed care company requires. I consent to the release of basic identifying information and the amount of the unpaid balance to a collection service or an attorney for purposes of collecting a debt if this becomes necessary. I understand and consent to the release of information about my condition and care (including access to my chart) to the managed care company for their review for purposes of payment or quality assessment. If seeing a therapist as opposed to a Psychiatrist, I understand that some insurance companies require the therapist be supervised by a Psychiatrist. I understand that I may be seen by a graduate level intern or non-licensed counselor under the supervision of a Licensed Clinical Social Worker, Licensed Clinical Counselor or Psychiatrist. I understand the supervision will involve a review of the treatment plan and confidential discussion of my progress. I understand and consent to the release of information about my condition and care (including access to my chart) to all the providers, both doctors and therapists, of (ETC). I understand that they provide on-call coverage for each other as well as for continuity of care should I see multiple providers within (ETC). I acknowledge receipt of Emerald Therapy Center’s Notice of Privacy Practices and consent to the uses and disclosures therein.I understand that Emerald Therapy Center, LLC reserves the right to change the privacy practices described and that a copy of any Revised Notice will be made available to me at my next visit. I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent by giving written notice of my desire to do so to my provider. I also understand that I will not be able to revoke this consent in cases where the provider has relied on it to disclose my health information.
I understand
37
Do you confirm that you have read and consent to Emerald's Consent for Release and Use of Confidential Information and Receipt of Notice of Privacy Practices disclosure?* This field is required.
Yes
38
Signature* This field is required.
Clear
39
Guardian Signature (if under age 18)* This field is required.
Clear
40
Date* This field is required.
Date
Year
Month
Day
41
Patient Rights & Responsibilities* This field is required.Patients have the right to be treated with personal dignity and respect. Patients have the right to care that is considerate and respects members’ personal values and belief system. Patients have the right to personal privacy and confidentiality of information. Patients have the right to receive information about managed care companies’ services, practitioners, clinical guidelines, and patient rights and responsibilities. Patients have the right to reasonable access to care, regardless of race, religion, gender, sexual orientation, ethnicity, age, or disability. Patients have the right to participate in an informed way in the decision-making process regarding their treatment planning. Patients have the right to discuss with their providers the medically necessary treatment options for their condition regardless of cost or benefit coverage. Patients have the right of members’ families to participate in treatment planning, as well as the right of members over 12 years old to participate in such planning. Patients have the right to individualized treatment, including: Adequate and humane services regardless of the source(s) of financial support, Provision of services within the least restrictive environment possible, An individualized treatment or program plan, Periodic review of the treatment or program plan, and An adequate number of competent, qualified, and experienced professional clinical staff to supervise and carry out the treatment or program plan. Patients have the right to participate in the consideration of ethical issues that arise in the provision of care and services, including: Resolving conflict, Withholding resuscitative services, Forgoing or withdrawing life-sustaining treatment, and Participating in investigational studies or clinical trials. Patients have the right to designate a surrogate decision-maker if the member is incapable of understanding a proposed treatment or procedure or is unable to communicate his/her wishes regarding care. Patients and their families have the right to be informed of their rights in a language they understand. Patients have the right to voice complaints or appeals about their managed care company or the care provider. Patients have the right to make recommendations regarding managed care company rights and responsibilities policies. Patients have the right to be informed of rules and regulations concerning patients’ conduct. Patients have the responsibility to give their provider and managed care company information needed in order to receive care. Patients have the responsibility to follow their agreed-upon treatment plan and instructions for care. Patients have the responsibility to participate, to the degree possible, in understanding their behavioral health problems and developing with the provider mutually agreed-upon treatment goals. By signing below, I acknowledge that I have been given an opportunity to review the Patient Rights and Responsibilities Statement. I acknowledge that I am entitled to have my own personal copy of the Patient Rights and Responsibilities Statement and that Emerald Therapy Center, LLC has made available a copy of this document. s
I understand
42
Do you confirm that you have read and consent to Emerald's* This field is required.
Yes
43
Signature* This field is required.
Clear
44
Guardian Signature (if under age 18)* This field is required.
Clear
45
Date* This field is required.
Date
Year
Month
Day
46
Protected Health Information Consent* This field is required.I consent for Emerald Therapy Center, LLC and those representing this group to share my private health care information with the following individuals and/or entities. Emerald is permitted to send and receive information to and from the entities below if needed:
I consent to share information with the following individuals:
Do not share my information.
I may provide consent at a later date and time.
47
Court Appearance* This field is required.Will you need an Emerald clinician to testify on your behalf?
Yes, I will need an Emerald clinician to appear in court.
No, I will not need an Emerald clinician to appear in court.
I may require an Emerald clinician to appear in court.
48
Consent for Court Appearance Terms and Conditions* This field is required.Subpoenas: Emerald clinicians may be requested to appear in court to discuss work on your case. Please note that Emerald clinicians do not automatically appear at your hearing. Should you request a clinician's presence at your hearing as either a fact witness or an expert witness, your attorney will need to issue a subpoena to the clinician. As a professional, Emerald clinicians expect to be compensated for the time. Billing for a clinician’s time considers many factors, such as potential therapy practice income loss for clients that must be rescheduled during the time the clinician is in court, travel time to get to court, updates & reports to the court, and courtroom waiting time. Emerald clinicians require a minimum of 14 days’ notice to clear a clinician's scheduled to attend the hearing. Charges for preparation time before a hearing: To provide a clinician's best testimony for your hearing, Emerald clinicians do charge appropriately for a clinician's time spent preparing for your case, such as compiling notes, reviewing documents, reports & correspondence, etc. To be adequately prepared, Emerald clinicians set aside a minimum of two hours to review the work completed on your case before the hearing. You will be charged for at least 2 hours of preparation work in addition to a clinician's time spent waiting in court to testify as Emerald clinicians observe the hearing and a clinician's time testifying. Travel Costs: Emerald clinicians provide work all over the region and are willing to travel to provide testimony. Emerald clinicians have offices in Murray, Mayfield, and Paducah and do not charge mileage if Emerald clinicians are within the local area. If Emerald clinicians are required to travel outside of the home office of the clinician's city limits to attend a hearing, Emerald clinicians will be compensated at a rate of 58 cents/mile in addition to $20/hour for every hour spent driving. This amount will be deducted from your deposit sent 14 days before the hearing. Custody Evaluation Testimony Fees: Emerald clinicians strive to write reports that allow detailed explanations of a clinician's work and clear-cut recommendations about what Emerald clinicians believe are the appropriate recommendations for your children. Once a clinician’s report is submitted to the Court and the attorneys, a clinician’s work as a custody evaluator ends. Should you decide to subpoena an emerald clinician to testify at your hearing, a clinician’s role then changes to that of an expert witness. You will be charged for a clinician’s testimony. Emerald requires a $1000 deposit to be submitted a minimum of 14 days before the clinician is called to testify. To be prepared for your hearing, Emerald clinicians require 2 hours of preparation time before the hearing to review a clinician's notes, details about the case, and a clinician’s report. Parent Coordination Testimony Fees: If Emerald clinicians must attend a hearing for a parent coordination case, Emerald requires a $1000 retainer to be sent 14 days before the hearing. If the parties need to be billed 50/50 for the retainer, please let our billing department know that ahead of time. This fee is not included in a regular parent coordination pricing agreement. If Emerald clinicians are subpoenaed to court and are waiting or observing the hearing, a clinician's rate is $180/hour. If Emerald clinicians are called to provide testimony, you will be billed at $180/hour. Remaining credit and balances owed after the conclusion of a hearing: If a balance is owed after a hearing, the parties will be issued a bill within 14 days notifying them of the balance owed, and that payment is required within 30 days. Cancellation of a hearing: Your deposit before the court date must be received before 14 days of when your hearing is scheduled to be held. Occasionally, the parties will reach an agreement through their attorneys and will decide to cancel their court hearing. If your hearing is canceled in less than 72 hours of the scheduled date, you will only receive 50% of your deposit back. Please note that as a professional who was subpoenaed to be at your hearing, Emerald clinicians were required to cancel therapy clients, groups, and other meetings that Emerald clinicians generate income from to be available to you for your case. On such short notice, Emerald clinicians often cannot fill those appointment slots reserved for you, so Emerald clinicians expect to be compensated for the time allocated for your case. If the clinician has already spent the two hours preparing for your case when it is canceled, your refund will be 50% minus the 2 hours of preparation time Emerald clinicians spent on the case already. ***If your hearing is canceled in more than 72 hours; Emerald will be happy to issue you the total amount of your deposit. The signature of this document indicates your understanding and acceptance of both financial and timely requirements for Emerald clinicians to represent a client via a court appearance. If an Emerald clinician is subpoenaed to represent a case in court. The above policy is activated regardless of the financial capabilities of the client.
I understand
49
Primary Care Physician
First Name
Last Name
50
Primary Care Phone Number
Area Code
Phone Number
51
Primary Care Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
52
Current Therapist / Counselor
First Name
Last Name
53
Therapist's Phone Number
Area Code
Phone Number
54
Current Therapist / Counselor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
55
Signature* This field is required.
Clear
56
Guardian Signature (if under age 18)* This field is required.
Clear
57
Date* This field is required.
Date
Year
Month
Day
58
Financial Policy Terms and Conditions* This field is required.Emerald requires all clients who are not Medicaid recipients to maintain an active credit/debit card on file at all times. We will ask for this information over the phone at the time of scheduling, and your information will be kept confidential and secure within our electronic medical record system. By signing below, you authorize Emerald Therapy Center, LLC to store and charge your credit/debit account for all balances due for services rendered, including late/cancellation fees, and patient responsibilities not covered by insurance that you may incur during treatment. Emerald will process all credit cards within 24 hours after each appointment has occurred. This authorization will remain in effect until you cancel this authorization in writing or verbally, and you may do so at any time. If you request to cancel this authorization, you are providing Emerald permission to use the card on file at the time of your request to pay all outstanding balances before the card is removed. If your payment is declined at the time your card is processed, your services may be subject to termination. My signature indicates that I have read and accept these disclosures. PAYMENT POLICIES We accept cash, personal checks, debit cards, MasterCard, Visa, American Express and Discover. Payment of copays and deductibles are due at the time of service. Emerald Therapy Center, LLC schedules appointments by a block of time for each patient. If you are unable to attend your scheduled appointment, we reserve the right to charge a $50 fee for any late notice cancellations or missed appointments. Late notice cancellations include cancellations within 24 hours of appointment. Your insurance will generally not cover this charge. If you have any questions regarding this policy, please discuss it with our front office staff. As insurance is a contract between you and your insurance carrier, you are ultimately responsible for the payment of all charges. You must provide proof of insurance at the time of your initial visit and are responsible for providing this office with changes in insurance coverage. Failure to do so may result in denial of your claim. As a matter of courtesy to our patients, we will submit charges to your insurance company. Any amount that your insurance company will not be paying such as a co-pay or deductible is due from you at the time service is rendered. If your insurance company has not paid within sixty days or denies coverage, the balance will be billed to you for immediate payment. If you do not have insurance, payment in full is required at the time of service. If there are any problems with meeting your financial obligations, please speak with our front office staff. Some managed care companies require the patient to get PRIOR approval and an authorization for their visit. If you fail to get necessary prior approval for your visit, payment in full is required at the time of service. If a patient’s bill remains unpaid, Emerald Therapy Center, LLc reserves the right to provide your name, basic identifying information, and the amount of the unpaid balance to collection services or an attorney. ASSIGNMENT OF BENEFITS Insurance Authorization/Release: By signature below, I hereby authorize Emerald Therapy Center, LLC to release any and all information necessary concerning my diagnosis and treatment for the purpose of securing payment from my insurance company; to pursue rightful collection of monies owed by my insurance company for services rendered until the company’s responsibility has been satisfied or all appeal efforts have been exhausted and thereby authorize payment of the insurance benefits directly to Emerald Therapy Center, LLC for any and all services rendered. Medicare Authorization/Release: By signature below, I request that payment of authorized Medicare benefits be made on my behalf to Emerald Therapy Center, LLC for any and all services rendered to me by their providers. I hereby authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services.
I understand
59
I authorize Emerald to store my credit or debit card within my confidential medical record and process the card within 24 hours after each appointment.* This field is required.
Yes
60
I understand that if I do not provide 24 hours notice for canceling an appointment in the future, I may be charged a cancellation fee as described in the Financial Policy Terms and Conditions.* This field is required.
Yes
61
Do you confirm that you have read Emerald's Credit/Debit Card Policy as described in the Financial Policy Terms and Conditions?* This field is required.
Yes
62
Signature* This field is required.My signature confirms that I agree to Emerald's Credit/Debit Card Policy as described in the Financial Policy Terms and Conditions
Clear
63
Fee for Services* This field is required. Fee for Services ALL ASSESSMENTS ARE $500.00 DUI 20 Hour Education $500.00 Intensive Treatment (1 Year) $2140.00 All Assessments Assessment (up to 3 sessions) $650.00 (Sessions needed after the assessment will be filed to client’s insurance). Self-Pay Client – Session needed after assessment $100.00 Private Pay Individual Outpatient Intake $112.50 Individual Outpatient per Session $100.00 Group Outpatient Session (other than IOP) $50.00 Couples Counseling per Person $65.00 Intensive Outpatient Group Sessions (IOP) $100.00 By signing below, I acknowledge that I have been advised of the above-stated fees.
Clear
64
Guardian Signature (if under age 18)* This field is required.
Clear
65
Date* This field is required.
Date
Year
Month
Day
66
Picture Identification* This field is required.Please upload a Drivers License or other form of identification.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
67
Insurance Information* This field is required.
I will upload a copy of my card
I will manually enter my insurance information
There's no need. I'm paying self-pay.
68
Insurance Carrier:      *
Policy Holder's Name:   First Name *     Last Name *
Policy Number:    *
Group Number:    *
Group Name:    *
SSN:    000-00-000 *
69
Insurance CardPlease upload a copy of your insurance card front and back (if applicable).
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
Should be Empty: