MSPHD Full Intake Form

Demographic Page
Client Full Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Primary Phone Number*
Please enter a valid phone number.
Can Counselor send a text message and/or leave a voice message at this number?*
Client Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Email Address
example@example.com
Is there a Custody agreement? (if client is under 14 years of age)
Client Preferred Gender Pronouns (E.g. He/His, She/Her, They/Them, Ze/Hir)
Emergency Contact Name
Emergency Contact Relationship to Client
Emergency Contact Phone Number
Please enter a valid phone number.
Insurance Provider / Company (Select "N/A" if not applicable)
Insurance Member Identification (ID) Number
Insurance Group Number
Member Service Phone Number (found on the back of the card, either call "Provider Services" or "Behavioral Mental Health" phone number)
Please enter a valid phone number.
Subscriber (What name is the insurance policy under?)
Client's Relationship to Policy Holder (e.g. child, spouse, self)
Policy Holder / Subscriber's Birthdate

MonthDayYear
Date
Policy Holder / Subscriber's Phone Number
Please enter a valid phone number.
Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Consent Documents

Consent to Treatment, Therapy Agreement, HIPPA Policy Agreement, and Consent for Telehealth
Do you have the legal authority to consent to treatment?*
Client Name*

First NameLast Name
Name and Relationship to Client (if other than the client, themselves)
Therapy Agreement & Consent to Treatment

I authorize, as either an individual over the age of 14 or the caregiver/guardian with legal rights, Michael Stephens, PHD, LPC of Michael Stephens PhD LPC Counseling Services PC to treat the above named client. The type and extent of the services to be provided will be determined following an initial assessment and thorough discussion with this provider. The goal of the assessment process is to determine the best course of treatment for the above-named client. Typically, treatment is provided over the course of several weeks.

I understand that my signature is an indication of agreement to the intentions recorded in this document. By signing this consent, I authorize Michael Stephens PhD LPC Counseling Services PC and its affiliates to bill insurance for provided treatment services and to maintain my record electronically. I understand that certain personal health information pertaining to treatment may be released to the county and my insurance company for the purpose of medical billing practices.

I understand that information shared with clinicians at this practice is confidential and no information will be released without my consent except as required or permitted by law for billing and payment purposes. I further understand that there are specific and limited exceptions to this confidentiality which include the following:
1. When there is risk of imminent danger to the Client or to another person, the clinician is ethnically bound to take necessary steps to prevent such danger.
2. When there is a suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse, the clinician is legally bound to take steps to protect the child or elder and to inform the proper authorities
3. When a valid court order is issued for medical records, the clinician, and CCWS may be bound by law to comply
4. When my clinician is in need of a clinician consultation or supervision appointment in order to process their clinical perspective and to aide them in ethical decision-making.
What Is Expected From You As A Client

It is expected for you to be on time for your sessions and that you will give a twenty-four hour notice to your counselor in the event that you need to cancel an appointment. When your counselor does not receive this notice you will be charged $30 for the missed session OR the cost of your copay / coinsurance for that session (this can be discussed with your clinician based on financial need). Decisions to charge this fee is left up to the discretion of the clinician and frequency of the concern.

If you cancel or fail to show up for more than two appointments, Michael Stephens, PHD, LPC retains the option of closing your case and providing you names of appropriate referrals upon request.

If your counselor’s assessment is that you need a higher level of care, Michael Stephens, PHD, LPC may give you referral options and require this service to be completed before continuing to schedule you for clinical services. This is something that can be processed with your counselor, but safety will be the determining factor in this decision.

Session fees are determined by insurance or financial ability. Payment for sessions should be made each time you arrive for your appointment OR before you leave from your appointment. When special circumstances make payment difficult please discuss this with your counselor as soon as possible to explore a "hardship agreement". Sessions are generally 53-60 minutes unless otherwise arranged.

Your Rights As A Client

You have the right to ask questions about any interventions used during counseling; if you wish, your counselor will explain the approach or methods used.

You have the right to decide not to receive therapeutic assistance from your current clinician. If you wish your counselor will provide names of other qualified professionals whose services you might prefer -- either within the therapy group or outside depending on your request.

You have the right to terminate your counseling services at any time without any moral, legal, or financial obligation other than those that already occurred.

One of your most important rights is to confidentiality. As explained previously, there are certain limitations to this right. You will be informed of any instance of safety or abuse reporting if they are to occur. In cases where you are being seen as a family or couple, counselor cannot guarantee confidentiality between members but this agreement will be reviewed with all parties involved in efforts to prioritize this confidentiality.

Limitations of the Therapy Contract

Your counselor is not a physician and cannot prescribe medication or give advice about physical health problems. In most cases, Counselor will refer you to resources or providers who can do appropriate screening and recommendations for your medical needs for topics that pertain to matters outside of counseling services. Nevertheless, depending on the nature of the presenting problem, the counselor might require the client to consult with a physician before proceeding with or during counseling.

Your counselor cannot guarantee that each persons' goal in counseling will be met completely. Seeking to resolve issues between spouses, family members, and other persons can lead to discomfort, as well as relationship changes that may not be originally intended.

This is an outpatient setting. We do not offer around the clock coverage or crisis intervention. You may leave your counselor a voicemail or an email and they will get back to you within 24-48 hours depending on the calls severity. It is recommended in the event of a crisis or in the need of immediate assistance, please call 911 OR visit your local emergency room OR call/text the Westmoreland County Crisis line at 1-800-836-6010 or Allegheny County Crisis line at 1-888-796-8226.

By policy, Michael Stephens, LPC, PhD, of Michael Stephens PhD LPC Counseling Services PC is unable to write or evaluate disability claims or provide support animal letters, as these are not areas of specialization for the clinicians at this practice.
HIPPA Privacy Policy and Procedure Agreement

Initial Data / Billing Information

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule provides consumers with important privacy rights and protections with respect to their health information, including important controls over how their health information is used and disclosed by health plans and health care providers. Ensuring strong privacy protections is critical to maintaining individuals’ trust in their health care providers and willingness to obtain needed health care services, and these protections are especially important where very sensitive information is concerned, such as mental health information. At the same time, the Privacy Rule recognizes circumstances arise where health information may need to be shared to ensure the patient receives the best treatment and for other important purposes, such as for the health and safety of the patient or others. The Rule is carefully balanced to allow uses and disclosures of information—including mental health information—for treatment and these other purposes with appropriate protections. (For more information got to: HHS.gov).

Privacy in Outpatient Services

The details of therapy sessions are kept confidential and will not be shared either orally or in writing unless the parent/guardian and client (14 years of age and older) have provided written authorization to release information to a specific agency. You may be given copies of all releases to obtain and release information to and from other agencies and persons that you and your child sign. Exceptions may also be made when staff are subpoenaed to court to testify regarding the case. We assure families that only the minimum amount of information will be shared that is necessary.

However, there are situations when your therapist could break confidentiality as required by law. Information may be released without authorization if the court orders it is deemed necessary to assist emergency personnel (such as the police, ambulance). Confidentiality will not be held if any individual tells a therapist about thoughts or intentions to harm him/herself or another. Also, all employees in the mental health field are mandated reporters of child abuse and are required to report any knowledge or suspicion or claim of abuse to CHILDLINE (1-800-932-0313). If any of

the above issues arise (suspected reported child abuse, threats or acts of serious physical harm/suicidality or legal issues), therapist may also inform the County Mental Health Office in the county in which you reside. If the therapist needs to break confidentiality, you will be informed in advance in most instances.

Information obtained from individual family members 14 and over during individual therapy sessions with the therapy team will not be shared with other family members unless an element of danger is present or the individual grants permission.

Consent for Phone Messages

Under the HIPAA guidelines, in order to protect the client's privacy, this Agency needs written permission in regards to leaving voicemail/messages regarding your care or the care of your child. If this Agency's representative needs to get in touch with you, and you are unavailable, it may be necessary for our staff to leave a voice mail for you to return our call. Under the new laws, we are unable to discuss the reason for our telephone call, we may only leave our name and return number. By signing this form, you release this Agency from liability, by leaving a message on the following phones.
Informed Consent for Telehealth Appointments

Benefits and Risks of Telehealth Appointments / Video Conferencing

Telehealth or Video Conferencing refers to services being conducted remotely using telecommunication technologies, such as video conferencing or telephone.

One of the benefits of Telehealth is that Counselor and client can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or counselor in not able to conduct services in an office setting. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of Telehealth, there are some differences between in-person counseling sessions and Telehealth appointments, as well as some risks.

For example:
- Risks of Confidentiality: Because telehealth sessions take place outside of the Counselor’s private office, there is potential for other people to overhear sessions if you are not in a private office during the session. To remedy this risk, it is important for you to make sure you find a private meeting space to ensure confidentiality and it is a space that the session can remain uninterrupted.
- Issues Related to Technology: There are many ways that technology issues might impact the quality of services for Telehealth. For example, technology may stop working during a session, other people might be able to get access to our private conversations, or stored data could be accessed by unauthorized people/companies. Michael Stephens PhD LPC Counseling Services PC will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks and having passwords to protect the device you use for Telehealth sessions).
- Crisis Management and Intervention: Typically, Michael Stephens, PHD, LPC will not conduct sessions during a crisis situation requiring high levels of support and intervention. For times of major crisis requiring high levels of support one can call the Westmoreland County Crisis Line (1-800-836-6010) or Allegheny Crisis Line (1-888-796-8226) or call 911. If you are needing in-person assistance you can also visit your local hospital for evaluation.
- Efficacy: Most research shows that Telehealth is about as effective as in-person psychotherapy. However, some Counselors believe that something is lost by not being in the same room. For example, there is a debate about a Counselor’s ability to fully understand non-verbal information when working remotely.
Electronic Communication

Counselor will conduct Telehealth sessions through the secure telemedicine service called Doxy.me. You will need to use your computer or cell phone to attend this session. Doxy.me does not charge its participants a fee to attend their sessions electronically through their service. However, you are solely responsible for any costs that are accrued by your service carrier while using Doxy.me. In the event that this site is down or not working, Counselor will try and utilize other telehealth softwares (including Zoom or Google Meets) or you can wish to reschedule your appointment for another date/time.

Emergency Contact Information / Contacting Them In Emergencies

Assessing and evaluating threats and other emergencies can be more difficult when conducting Telehealth than in traditional in-person therapy. To address some of these difficulties, you will be asked to identify an emergency contact person who is near your location and who will contacted in the event of a crisis or emergency to assist in addressing the situation. You will be asked to sign a separate authorization form and release of information permitting contact to your emergency contact person as needed during such a crisis or emergency.

If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, call 911, Westmoreland County Crisis Line (1-800-836-6010), or go to your nearest emergency room. Call Michael Stephens, PhD, LPC back after you have called or obtained emergency services.

If the session is interrupted and you are not having an emergency, disconnect from the session and wait two (2) minutes and then re-contact via the Telehealth platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then call me at (412) 877-8011.

If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time

Session Fees and Services

Copay rates and coinsurance can differ depending on whether you are attending services in-person or through telehealth software. It is your responsibilities to know these rate differences and be prepared to pay them at the time of services. Additionally, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. Your provider will do his due diligence to check eligibility and coverage but it is expected that you have reviewed your benefits OR call your insurance company to assure that these services are covered (or whether there is a copay or deductible amount different). If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session.
By signing this form, I know that I am illustrating that I have read and understand the above and/or have been thoroughly explained these facts by clinician. I consent to the evaluation and treatment offered by Michael Stephens, PhD, LPC of Michael Stephens PhD LPC Counseling Services PC. I understand that I may stop treatment at any time and/or to receive these services from another provider.
Signature of Client*

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Today's Date*

MonthDayYear
Date
Signature of Spouse / Parent / Caregiver (*** ONLY NEEDED FOR A CLIENT UNDER 14 OR FAMILY / COUPLES SESSIONS)

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Date

MonthDayYear
Date
Signature of Spouse / Parent / Caregiver (*** ONLY NEEDED FOR A CLIENT UNDER 14 OR FAMILY / COUPLES SESSIONS)

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Date

MonthDayYear
Date

Card on File Consent Form
Client Name

First NameLast Name
Name of Person Filling out Form (If other than client)

First NameLast Name
Relationship to Client (if other than the client, themselves)
I authorize, as either an individual over the age of 14 or the caregiver/guardian with legal rights, Michael Stephens, PHD, LPC of Michael Stephens PHD LPC Counseling Services PC to charge my credit, debit, or health savings account card for professional services within 24 hours of my scheduled appointment. If I do not cancel before 24 hours or show for my appointment, I recognize that Michael Stephens PHD LPC Services PC will charge my card $30.00 OR the cost of your copay / coinsurance for that session as aligned to this Cancelation / No Show Policy I signed off on in the Consent to Treatment and Therapy Agreement.

I verify that the credit card information I have provided to my therapist is accurate to the best of my knowledge. If this information is incorrect, fraudulent, or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or fee that is accrued from this transaction. I also understand by signing this form that if no payment has been made by me, my balance may go to collections if another alternative payment is not made within thirty days.

Signing this form will authorize Michael Stephens, PHD, LPC to contact you to get your card information to be kept on file.

Information requested will be: Card Type (E.g. HSA, VISA, etc), Name on the Card, Card Number, Date of Expiration, and CVC (3-4 digits on the back of the card), and billing zip code.

This form will be kept locked in Counselors personal files and not be put online or in our billing system.
Card Type: ____________

Name: ______________________________________________________

Number: ______________________________________________________

Date: ____ / ____

Code: ___________

Zip: ___________
Signature

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Date

MonthDayYear
Date
Should be Empty:

Demographic Page

Consent Documents

Release of Information (ROI) for Insurance

Release of Information (ROI) for Emergency Contact

Release of Information (ROI) for Miscellaneous Party

Card on File Consent Form