Adult Intake Form

Adult Intake Form

Personal Information and Presenting Problem
Client Full Name:*
InsuranceFacebookSchoolPsychiatristWebsitePrimary Care PhysicianOther
Marital Status:*
Age:*
Employment/Student Status:*
School or Employer:*
Please describe your reasons for seeking therapy:*
Have you ever been in therapy before or hospitalized for psychiatric issues? If yes, please describe:*

Registration Information

Provider: Balance Counseling LLC / Ashley Gilbert LMSW
Client Full Legal Name:*
Date of Birth:*

MonthDayYear
Date
Gender:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Ok to discuss scheduling via email?*
Ok to send receipts via email?*
Emergency Contact Information
Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:*

Insurance Information

Copy of both sides of the insurance card(s) needed at intake.
Primary Insurance Name #1:
Policy Number:
Group Number:
Policy Holder:
SS #:
SelfSpouseDependent
Insured Date of Birth:

MonthDayYear
Date
Employer:
Primary Insurance Name #2:
Policy Number:
Group Number:
Policy Holder:
SS #:
SelfSpouseDependent
Insured Date of Birth:

MonthDayYear
Date
Employer:
ALL COPAYS AND BALANCES ARE DUE IN FULL AT THE TIME OF YOUR APPOINTMENT

Important Signatures
Client Full Legal Name:*
Date of Birth:*

MonthDayYear
Date
INSURANCE BILLING
I authorize Balance Counseling LLC (hereandafter called Medical Practice) to release any medical information to our billing company[Mid Michigan Medical Management] for paper & electronic billing of your insurance company. I authorize my insurance company to assign benefits to the Medical Practice. I understand that I am responsible for payment of services rendered by the Medical Practice regardless of reimbursement for these services by the insurance company and that any inaccuracy of information on this form may result in nonpayment by my insurance company. I agree to notify the Medical Practice immediately whenever I have changes in my health plan coverage.

ACCOUNT RESPONSIBILITY
I am responsible for payment to Medical Practice for all services rendered, due at the time of the visit. I also understand that if I suspend or terminate my care and treatment, any outstanding balance will be immediately due and payable. If I default on any payment obligations as called for in this agreement, the Medical Practice reserves the right to forward my information to collections, and an additional 30% may be assessed to my account to cover the costs of this action. There will be no obligation to provide continuing services to any client who names the Medical Practice as a creditor in any bankruptcy filing.

INFORMED CONSENT & NOTICE OF PRIVACY PRACTICES
I am consenting to treatment and have received and understand the contents of the Policies, including the Notice of Privacy Practices (HIPAA).
*My signature below indicates that I have been provided a copy of, and that I fully understand & agree to all of the terms and conditions of the Policies. If I have questions, the information has been explained and/or summarized for me.
Client Signature*
Date*

MonthDayYear
Date

Private Pay and Legal Fees Agreement

Initial Intake Session*	$165.00 per hour
Counseling Session (45-60 Minutes)*	$125.00 per hour
Insurance Requests (Short-term Disability, FMLA, etc.)	$125.00 per hour
In School Meetings (IEP, Behavior Planning, etc.)	$100.00 per hour
Phone Communication with Lawyer	$125.00 per hour
Email Communication with Lawyer	$125.00 per hour
Lawyer Requested Documents including assessments, recommendations, and written statements	$200.00 per hour
Court Appearance	$250.00 per hour, plus drive time per hour

* These services may be available for some clients on a sliding scale based on economic necessity.

By signing this document, I am acknowledging that requests for any of the above services will be paid in fill within one month of the invoice date. If not paid in full, I will not continue to receive these services until paid. In lieu of insurance, I agree to pay the flat rate fee of $_____ per session.
Client Signature:*
Date:*

MonthDayYear

Important Notice to All Patients

It is your responsibility to know your individual insurance policy. Many insurance policies have exclusions, and most have deductibles and co-payments/co-insurance. Some insurance policies may not cover our services.

It is important for you to check with your insurance carrier to determine if the provider you are seeing is listed as an "in-network" provider. If they are not listed as an "in-network" provider, you may have a higher deductible and/or co-pay.

Regardless of insurance coverage, you are responsible for all bills not covered by your insurance policy.

Insurance does not normally cover additional services such as phone or email communication to lawyers, legal documents, or court appearances. You will be responsible for full payment for these services.
Client Signature:*
Date:*

MonthDayYear

Insurance Information
Provider Name/Group: Balance Counseling LLC

Address/City/State: 925 Grand Rapids St. Middleville, MI 49333

Phone: 616-987-0860
1. Call the toll free number on the back of your insurance card.
2. Ask for "Outpatient Mental Health Benefits" or "Behavioral Health Benefits"
3. If coming for Substance Abuse Treatment, you need to know specifically if it is a covered benefit and if it requires authorization.
4. When asked for the provider's name, tell them: Ashley L Gilbert LMSW
5. You may be asked for the "NPI Number" (the National Provider Identification Number)
  1. Give them the following NPI: Type 1 - 1033594031, Type 2 - 1598313314
  2. Possibly Tax id #: **-***8766
6. Ask for the following information and record it here:
Is this provider In-Network:   Yes   No
Deductible: In-Network:   Deductible   Out-of-Network:   Deductible
Amount Met for In-Network:   Amount   Amount Met for Out-of-Network:   Amount
Co-pay: In-Network:   Co-pay   Out-of-Network:   Co-pay
Maximum out of pocket/stop loss amount per year:   Amount
Maximum number of sessions per year:   Amount
Is authorization required:   Yes   No
If yes, how is that obtained?
Additional information given to you:
Claims Mailing Address:   Street Address   Address Line 2   City   State   Zip
Name of person you spoke with:   Name
Date:   Date   Time:   Time

Intern Disclosure
I understand that Balance Counseling LLC supports education and is teaching and learning organizations. I am aware that students may be sitting in on sessions and/or reviewing case charts/files. Students at this organization are under agreement of all confidentiality policies and agree not to disclose any patient, chart, or file information to third parties or persons. You have the right to refuse or accept student participation.*

AcceptRefuse
Client Signature:*
Date:*

MonthDayYear
Email, Telehealth, and Phone Communication
Some patients prefer to communicate about appointment times or other administrative issues via email. Although information stored on my computer is encrypted (Hushmail service), email transmitted through regular services is not encrypted. This means that a third party may be able to access information in an email and read it, since it is transmitted over the internet. In addition, once the email is received by you, someone may be able to access your email account and read it. This may include your employer if you use a work-related email address. I discourage sending any clinical or other sensitive information via email. Please use the telephone for anything urgent or time-sensitive, as I cannot guarantee that I will see an emergency email. I will respond to voicemail and text messages within 24 hours, not including holidays or weekends.

Please be aware that there will be no one other than myself on telehealth calls, but that you may have others around you which is then not a confidential call. Please also be aware that the face-to-face videos are not saved, but due to it being over the internet and phone line, a third party may be able to view the video. The platform I use is HIPPA compliant (Therapy Notes service).

Also, please be aware that phone messages are stored on a confidential voicemail. However, if you choose to utilize text messages, it is important to note that messages to this clinician's phone are password protected but are not on a secure line (iPlume service).

Please initial the options that meet your needs. You can change this at any time by communicating to me in writing.

I understand the risks of unencrypted email and do hereby give permission of Balance Counseling LLC to contact me or to reply to me via unencrypted email. I have been informed of Balance Counseling LLC HIPPA and Privacy Policy. I understand that all written communications, including text messages and emails, will become part of my clinical record. Either party can terminate telehealth at any time. This will not impact the ability for in-person sessions.
Client Signature:*
Date:*

MonthDayYear
Initials I do not wish to receive any treatment-related information via text message
Initials I understand the risks of telemedicine, text messages, emails and do hereby give permission for Balance Counseling LLC to contact me or to reply to me via unencrypted text messages. Please provide your preferred phone number: Area Code Phone Number

Adult Disclosure Statement
As you consider beginning counseling at Balance Counseling LLC, it is important that you know how we view the counseling process and what you can expect from our work. Please read and sign this statement. If you have any questions, let us discuss these in our first session together.

Following an initial assessment process with you, we will try to create a trusting environment where you feel safe to share thoughts, ideas and feelings. It is the goal of the therapist to develop a counseling plan around your interests. During this process we will listen carefully to understand the meaning you have made of events and relationships in your life. The main focus however will be on what is happening in your life now.

The benefits of counseling can be increased understanding, self-confidence, and accomplishment of goals. There may also be some risks involved. You may experience painful memories/ feelings that may result in different behaviors. We will work with those of your choice to resolve any problems that may arise. Most find that the benefits of counseling outweigh the risks.

You may choose to have leave counseling at any time, however, it is best if this decision is discussed with our counselor and planned in a mutual way. Alternatives or in addition to your individual counseling may be parent groups, reading material, family counseling, or support groups may be recommended.

It is the policy of Balance Counseling, LLC. to keep all client information confidential. This includes information known to your therapist, or shared in supervision, or information in your medical records. If you wish information to be shared with other health providers and/or insurance companies, a signed release from you will be required.

Frequency and duration of sessions vary and are mutually decided upon. By signing this form, you are giving us permission to bill your insurance company and share records as required to bill insurance. You are responsible for any fees that are not covered by your insurance. If you have questions about our fees, please talk to your therapist or our business manager.
Client Signature:*
Date:*

MonthDayYear

Patient Health Questionnaire and General Anxiety Disorder

Over the last 2 weeks, how often have you been bothered by any of the following problems? Please type the number in the corresponding column.

PHQ-9*

Rows	Not at all (0)	Several days (1)	Over half the days (2)	Nearly every day (3)
1. Little interest or pleasure in doing things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling or staying asleep, or sleeping too much.
4. Feeling tired or having little energy.
5. Poor appetite or overeating.
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down.
7. Trouble concentrating on things, such as reading the newspaper or watching television.
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead, or of hurting yourself in some way.

PHQ-9 Total Score
Not difficult at allSomewhat difficultVery difficultExtremely difficult
Over the last 2 weeks, how often have you been bothered by any of the following problems? Please type the number in the corresponding column.

GAD-7*

Rows	Not at all (0)	Several days (1)	Over half the days (2)	Nearly every day (3)
1. Feeling nervous, anxious, or on edge.
2. Not being able to stop or control worrying.
3. Worrying too much about different things.
4. Trouble relaxing.
5. Being so restless that it's hard to sit still.
6. Becoming easily annoyed or irritable.
7. Feeling afraid as if something awful might happen.

GAD-7 Total Score
Not difficult at allSomewhat difficultVery difficultExtremely difficult
Should be Empty:

Rows	None	Mild	Moderate	Severe
Physical Problems
Anxiety
Depressed Mood
Eating Problems
Sleeping Problems
Agitation
Aggressive Behavior
Conflict with others
Alcohol/Drug Issues

Rows	Use	Frequency of use (days per week)	Amount per use
Alcohol
Marijuana
Cocaine
Amphetamines
Narcotics
Prescription Pills
Other

Adult Intake Form

Registration Information

Emergency Contact Information

Insurance Information

Important Signatures

Private Pay and Legal Fees Agreement

Insurance Information

Authorization for Release and Consent for Disclosure or Request for Medical Information or Records

Intern Disclosure

Email, Telehealth, and Phone Communication

Adult Disclosure Statement