Journey to Healing, PLLC

Intake and Consent

Today's Date *

Date

Name *

Patient First NamePatient Last Name

What days and times are best for you?

Date of Birth *

Date

Social Security Number # Mandatory *

Sex M/F - For administrative purposes and insurance claims*

Do you identify as a male, female, or neither? *

Relationship Status*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mobile Phone*

Work Phone*

Email*

Emergency Contact*

Phone *

Relationship*

Parent, Spouse, Friend, etc.

Insurance Information

Primary Insurance Company Name

Front Insurance Card

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Back Insurance Card

Drag and drop files here

Secondary Insurance - Front

Drag and drop files here

Secondary Insurance - Back

Drag and drop files here

Primary Insured Person's Name

Member ID

Primary Insured Date of Birth

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

Insured Employer

Do you have a secondary insurance?

YesNo

Secondary Insurance Company Name*

Phone

Insured Date of Birth

Date

Member ID

Group/Policy #

Relationship to Patient

Insured Employer

Responsible Party Signature*

Consent to Treat

Therapist Qualifications

Licensed Clinical Social Workers (LCSW) have professional training in conducting mental health treatment. 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. 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 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.

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. In signing this Disclosure Statement, you agree with this practice. 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 Therapist believes providing progress notes could negatively affect the client, the therapist 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 $250.00. 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

Insurance and Billing

Journey to Healing, PLLC maintains all client billing records and works with insurance companies. All therapy claims are electronically submitted to your insurance carrier, and then Journey to Healing 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 $300 without prior approval from Journey to Healing and have a payment plan initiated. If the bill exceeds $300 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 Journey to Healing (406) 272-6583. Payment may be made by check, cash, or credit card.*

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 Tia Robinette 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 agree to calling my insurance and verifying benefits prior to my intake appointment.*

I will call to confirm

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 Signature*

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 Journey to Healing, 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 Journey to Healing. 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 Journey to Healing. 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 Journey to Healing-Notice of Privacy Practices.

Signature*

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 service 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 406-272-6583 only. Cancellations need to be made on weekdays as we work to fill open time slots during the week, not on weekends. 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. I have read, understand, and agree to abide by the policy above:

Cancellations are to be called in and a message left with 406-272-6583.*

I understand and agree

Appointment reminders will be delivered when your scheduled appointment has been officially confirmed. Any notice to our office of a change or cancel beyond this time frame will result in a late cancelation fee being charged.*

I understand and agree

Signature of Patient (or Responsible Party)*

Date*

Date

No Surprise Billing
Journey to Healing abides by the 2022 No Surprise Billing Act.

Journey to Healing has contracts with most health insurance companies. This does not mean we are In-network with every company and it is your responsibility to confirm your status at the time of every session. Below is a list of the maximum amounts billed to insurance companies. These are the maximum amounts you may be billed for sessions.

Individual Therapy Sessions

Intake session $250.00

1 hour - 53 min session for an individual billed to insurance at $200

Telehealth Sessions

Billed the same as above for individual

Cash Rate -

-Intake -$180

-Hour / 53 min -$120

- 45 / 37 min -$115

- 30 / 17 min -$110

Utilizing the CASH rate is only availavle 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.

Missed appointments / reschedule / cancellations within 24 hour notice.

$100

All Session notes/ Summaries

$3.00 per page

All note requests or summary requests may take up to 14 days.

Credit card payments - 3% of the balance paid - 0.30 cents/transaction.

Bounced Checks - $35.00 fee

Notes

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 Journey To Healing, PLLC 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.

I understand and agree to abide by the No Surprise Billing policy of Journey To Healing, PLLC.

Date*

Date

Signature*