HICKS GROUP WELLNESS CENTER E-FORM

Your Date Of Birth *

Month Day Year

Name of Health Plan/Member ID# *

Best Phone Number To Reach You *

Area Code Phone Number

Email *

I consent to have counseling sessions using an encrypted (HIPPA Compliant), internet-based audio/video/email and telephone service for the purposes of counseling sessions conducted over distance or face to face. I understand Hicks Group Wellness Center, its owner, licensed associates, and interns can only provide counseling in the states which they are licensed to practice. Should I be located outside of these boundaries, counseling services cannot be provided, and this consent is null and void.• I acknowledge this form of communication has advantages and disadvantages. The disadvantages are, but not limited to: WIFI speed, accessibility, ambient noise, dropped signal and or call, and temporary interrupted or paused video audio/visual feed.• I accept responsibility for maintaining a secure connection, and the need to monitor issues related to confidentiality on my side. I will inform my counselor/therapist of any limitations via telephone and/or at the beginning of session regarding the integrity of my environment.• I acknowledge that should any of the above conditions occur, alternative methods of communication will be initiated by therapist which include: email, phone call, or video session.• I understand that the rules regarding mandated reporting and reporting harm to self or others remain the same as residential sessions as per ACA ethical standards and legal protocol.• I agree that in cases of emergency life threatening emergencies that I will call 911 *

YES

I Consent for Aunjuli Hicks, LPC LLC/Hicks Group: Wellness Center to use my Health Plan and Understand: *

I MUST be knowledgeable of my health insurance benefits. Payment/co-payment for services are due at the time services are rendered Deductibles are the clients/patients responsibility in knowledge and in payments. Clients must maintain their own payment records. I am fully responsible for late fees, cancellations, No-Shows, and reports or assessments. I fully responsible for coming to my appointments. Reminders are a courtesy and will follow the policies explained to me.

I decline the offer by Hicks Group Wellness Center and Dr. Hicks to use my health plan. I will be fully financially responsible and will pay for all services including therapy sessions, cancellations, No Shows, Late Fees, assessments, and letters as needed. *

Yes I agree I must maintain their own payment records. I fully responsible for coming to my appointments. Reminders are a courtesy and will follow the policies explained to me.

I authorize and request Aunjuli Hicks LPC LLC/Hicks Group Wellness Center to obtain payments to be made to Aunjuli Hicks LPC. I have read and fully understand the Fee for Service Financial Form as outlined above. In event that it is necessary to turn my account over to collections I will also be responsible for any and all costs of collections. I understand that this authorization shall apply to all services provided to me, my dependents, or any other person for which I have assumed responsibility by signing below, from this date forward. LLC/Hicks Group Wellness Center for all services furnished to me.Claims Authorization – I hereby authorize any treating therapist to furnish any and all records, medical history, services rendered ortreatment given me or any dependent for purposes of review, investigation or evaluation of any claim submitted to my health insurancecarrier(s).I also authorize my insurance carrier(s) to disclose to a hospital or health care service plan, self-insurer, or other insurer anymedical information obtained if such disclosure is necessary to allow the processing of any claim. If my coverage is under a groupcontract held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure to them forpurposes of utilization review or audit. This authorization shall become effective immediately upon execution and shall remain in effectfor the duration of any claim or term of coverage with my insurer(s) including a reasonable time thereafter, until its final consummation.This authorization is binding upon me, my dependents, heirs, executors and administrators.Individual, group, family counseling to address issues important to their relationship must agree to do so with a willingnessto disclose and discuss, as part of the counseling process, issues that can be extremely private,embarrassing and perhaps damaging, if disclosed outside the safety and boundaries ofthe counselingrelationship. This willingness to risk participation in such intimate therapeutic discussion must beprotected and respected. Therefore, the below signatures affirm the participants’ agreement not torequest, subpoena or attempt to acquire the progress/clinical case notes from their couple/familycounselor for purposes related to any subsequent actions of divorce, child custody, etc. in whichthere is an adversarial legal action between the participants/clients. *

Yes

Please upload your photo ID for Identification purposes *

Electronic Signature *

HICKS GROUP WELLNESS CENTER CONSENT E-FORM