New Client Form

New Client Form

Thank you for choosing Momentum Counseling! Please complete this form in its entirety and let us know if you have any questions.
Patient Information
Patient Name*

FirstLast
Date of Birth*

MonthDayYear
Date
Is the patient a minor?*

NoYes
Parent or Guardian's Name*

First NameLast Name
Sex/ Gender*

MaleFemale
Social Security Number
If you identify differently, and would like to tell us, please do so.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email Address*

Payment Information
How will you pay for services?*

Self PayInsurance or Medicaid
Insurance Provider or Medicaid MCO*
Member ID or Policy Number*
Group Number
Upload Picture of Insurance Card

Cancelof
Do you have Sencondary Insurance?

NoYes
Seconday Insurance Provider*
Secondary Insurance Member ID*
Seconday Insurance Group Number
Who is financially responsible for this patient?*

SelfOther
Financially Responsible's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Relationship to Patient*
Social Security Number
Financially Responsible's Email Address
example@example.com

Consent to Treatment
I voluntarily agree to undergo mental health treatment and understand that I may end treatment at any time. I understand that my therapist or counselor cannot guarantee results (e.g., less depressed, improved marital satisfaction, etc.) of mental health services. However, there will be clearly stated reasons, goals, and objectives for continuing/discontinuing mental health treatment. This will be discussed with my mental health provider. I understand that there may be some risks in participating in mental health services. These may include, but are not limited to, addressing painful emotional experiences and/or feelings; being challenged or confronted on a particular issue; re-uniting with family members; or being inconvenienced due to costs/fees of counseling.

I am aware that I can discuss any unforeseen risks versus benefits with my mental health provider at any time. Furthermore, I understand that this “Consent to Treatment and Privacy Practices form” is not intended to be “all inclusive” of aspects of my mental health treatment. It is only intended to provide some useful information before deciding to engage in mental health treatment.

Momentum Counseling is committed to the protection of your mental health information as required by federal and state law. Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Noted exceptions are as follows:

DUTY TO WARN AND PROTECT
When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

ABUSE OF CHILDREN AND VULNERABLE ADULTS
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

PRENATAL EXPOSURE TO CONTROLLED SUBSTANCES
Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

MINORS/GUARDIANSHIP
Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.

INSURANCE PROVIDERS (when applicable)
Insurance companies and other third party payers are given information that they request regarding services to clients.
Acknowledgement*

I certify that I have read, fully understand, and agree to Momentum Counseling's Consent to Treatment and Privacy Practices.

Fee Schedule and Billing Practices
Fees for Therapy
These fees are what are charged to your insurance company and do not apply if the contracted rate is less than these amounts, which is typically the case. Additionally, these fees do not apply if a previously arranged out-of-pocket rate has been established. Out of pocket fees will be based upon the level of care needed.
- Initial (Intake) Assessment - $225.00
- 45-60 Minute Session (Individual or Family) - $185.00
Other Fees
Insurance companies do not typically cover these fees.
- Letter Writing - $35.00+, based on detail and deadline
- Disability Claims - $35.00
- Copying Records - 1st copy, no charge; additional copies, $1.00 /page, plus postage
- Court Attendance - $2000.00 (due up-front, non-refundable)
- Missed Appointment (No Call, No Show) Fee - $60.00
- Late Cancellation (Less than 24 hours) Fee - $40.00 (48 hours is appreciated)
- Phone calls lasting longer than 5 minutes are assessed at $1.00/minute
- Return Check Fee - $45.00
Billing Practices
We require payment at the time of service. If you have a deductible, co-pay, or co-insurance, payment is expected at the time of service. Balances remaining on an account 30 days from the date of service will be considered past due.

If you have insurance, please understand that this is an agreement between you and your insurance company. If you have not done so already, you should contact your insurance company to obtain a quote of your outpatient mental health benefits. Find out if your deductible or co-pay applies, and if your insurance requires an authorization for your visits, please make sure that you obtain this authorization before your first appointment.

As a service to you, Momentum Counseling may contact your insurance company to verify eligibility and obtain a benefits quote, but please understand that we are not responsible if benefits are misquoted. Also, please be aware that insurance benefits quoted by your insurance company are not a guarantee of payment and that you are ultimately responsible to know the benefits of your policy.

If your insurance company denies your visits for any reason, you will be responsible for the full fee of each of visit.

If your insurance company requires you to meet a deductible, Momentum Counseling will accept a payment of the contracted rate that has been established by your insurance company, until the deductible has been met. Actual amounts collected will be based on your Insurance Company’s current reimbursement rates. We would ask you to please be aware of the status of your deductible.
Acknowledgement*

I certify that I have read, fully understand, and agree to Momentum Counseling's Fee Schedule and Billing Practices

Card on File Policy
To streamline our billing and payment system and to provide a seamless, convenient way for patients to pay their bills, effective October 1st, 2020, Momentum Counseling will require all patients keep an active credit card on file with us. We will bill your insurance company first and upon their determination of benefits, we will only charge your credit card when they inform us of patient responsibility. Circumstances when your card would be charged include but are not limited to: missed or canceled sessions without 24 hour notice, missed copayments, deductible and coinsurance, any non-covered services and/or denial of services, as well as any current balance on your account.

Once your insurance has processed your claims, they will send an Explanation of Benefits (EOB) to both you and our office showing the amount of your total patient responsibility. You will typically receive the EOB before we do, so if you disagree with the patient responsibility balance owed, it is your responsibility to contact your insurance carrier immediately.

When we receive the EOB, we will enter all pertinent payment information into our system. At that time, any remaining balance owed by you will be charged to your credit card and a copy of the charge will be sent to you.

If the credit card we have on file for you changes, please notify us IMMEDIATELY by completing this form with the new card details. It is not uncommon for people to change or cancel their credit cards for various reasons, including when a credit card expires.

If there is a problem with your bill/claim and it is brought to our attention after your credit card payment processes, we will investigate it and if we owe you the money, we will refund it to the same card in a timely manner. We understand that there are legitimate reasons that you may not have a credit card. If this is the case, you are welcome to leave an HSA (Health Savings Account) or Flex Plan Card on File.

My Products

Card Authorization

$1.00 Quantity

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Acknowledgement*

I understand and accept the contract terms as stated above. I have been given the opportunity to read this agreement and all related documents in full and in my own time. I have also been offered the opportunity to have any matters contained therein explained or clarified, as well as the opportunity to take independent advice prior to entering into this agreement. I acknowledge that I am contractually bound by this agreement, and that I am liable for fees for services due to the services performed in accordance with this agreement. Additionally, I understand that my card information will be kept on file at the payment processor during the period of this contract.
Date*

MonthDayYear
Date
Signature

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New Client Form

Patient Information

Payment Information

Consent to Treatment

Fee Schedule and Billing Practices

Card on File Policy