JOURNEY THERAPY AT THE BARN CLIENT INTAKE FORMS

Amy Roth MS, NCC, LPC-MH

1500 S. Sycamore Ave, Ste 200, Sioux Falls, SD 57110

605.838.8545
Client Information
Name*

First NameMiddle InitialLast Name
Date*

MonthDayYear
Date
Home Phone Number*
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (optional)
example@example.com
Client's Date of Birth*

MonthDayYear
Date
Client's Age
Client's Gender
Preferred Method of Contact:*
Do you give your consent to communicate via text message?*
Name of Spouse/Guardian
Spouse/Guardian Phone Number
Address

Address

Street Address Line 2

CityState

Zip Code
Person responsible for payment (please print name)*
Social Security #*
Signature of person responsible for payment (must be signed for services the begin)*

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Emergency Information

In case of emergency, contact:
Name*

First NameLast Name
Relationship
Phone Number*
Work Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician
PCP Phone
Address

Address

Street Address Line 2

CityState

Zip code
Psychiatrist Name (if applicable)
Psychiatrist Phone
Address

Address

Street Address Line 2

CityState

Zip code
Other physician(s)
Other Physician Phone Number
Please enter a valid phone number.

Client Information

(Continued)
What Medications are you currently taking? (prescribed and OTC)
Please list any allergies you have.
Employment Information

(If client is a child, use parent's employment)
Employer Name
Employer Phone
Employer Name (Spouse, if married)
Employer Phone (Spouse, if married)
Please enter a valid phone number.
Primary Insurance (Avera, BCBS, Sanford)*
Secondary Insurance (if applicable)
Primary Insurance Phone Number
Please enter a valid phone number.
Secondary Insurance Phone Number (if applicable)
Please enter a valid phone number.
Primary Insurance Contract/ID#*
Secondary Insurance Contract/ID# (if applicable)
Primary Insurance Group/Acct#
Secondary Insurance Group/Acct# (if applicable)
Primary Insurance Subscriber*
Secondary Insurance Subscriber (if applicable)
Primary Insurance Subscriber DOB*

MonthDayYear
Date
Secondary Insurance Subscriber DOB (if applicable)

MonthDayYear
Date
Primary Insurance Client's relationship to subscriber*
Secondary Insurance Client's relationship to subscriber (if applicable)
Primary Insurance Copay/Deductible amount (if known)
Secondary Insurance Copay/Deductible amount (if known)
Referral Source
How did you hear about our clinic (from whom)?
HIPPA Acknowledgement

PLEASE READ CAREFULLY
HIPAA Acknowledgment Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. As stated in our notice, the terms of the notice may change. If we change our notice, you may obtain a revised copy by looking on our website or using the above contact information.
Wireless Communications

PLEASE READ AND RESPOND CAREFULLY
I hereby agree to email or text reminders being sent to me for my appointments and messages left on my phone regarding appointments.*

DECLINEACCEPT
I hereby agree that by providing my contact information of email address and/or phone number, I am granting my consent and understanding that when commuting via email, voicemail, text, or instant message these messages may be printed and placed in my file.*

DECLINEACCEPT

Consent to Treatment and Recipient's Rights

PLEASE READ CAREFULLY
By signing below, I the undersigned, hereby attest that I have voluntarily entered into treatment, or give my consent of the minor or person under my legal guardianship mentioned above, at (with) (Amy Roth) Journey Therapy at The Barn, LLC, hereby referred to as the Center. Further, I consent to have treatment provided by a psychiatrist, psychologist, social worker, counselor, or intern in collaboration with his/her supervisor. The rights, risks, and benefits associated with the treatment have been explained to me. I understand that the therapy may be discontinued at any time by either party. The clinic encourages that this decision be discussed with the treating psychotherapist. This will help facilitate a more appropriate plan for discharge.

Recipient's Rights: I certify that I have received the Recipientss' Rights information and certify that I have read and understand its content. I understand that as a recipient of services, I may get more information from the Recipient's Rights Advisor.

Nonvoluntarily Discharged from Treatment: A client may be terminated from the Center nonvoluntarily, if; (A) the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the clinic, and/or (B) the client refuses to comply with stipulated program rules, refuses to comply with treatment recommendations, or does not make payment or payment arrangements in a timely manner. The client will be notified of the nonvoluntary discharge by letter. The client may appeal this decision with the Clinic Director or request to reapply for services at a later date.

Client Notice of Confidentiality: The confidentiality of patient records maintained by the Center is protected by federal and/or state law and regulations. Generally, the Center may not say to a person outside the Center that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless: (1) the patient consents in writing, (2) the disclosure is allowed by a court order, or (3) the disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation.

Violation of federal and/or state law and regulations by a treatment facility or provider is a crime. Suspected violations may be reported to appropriate authorities. Federal and/or state law and regulations do not protect any information about a crime committed by a patient either at the Center, against any person who works for the program, or about any threat to commit such a crime. Federal law and regulations do not protect any information about suspected child (or vulnerable adult) abuse or neglect, or adult abuse form being reported under federal and/or state law to appropriate state or local authorities. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. It is the Center's duty to warn any potential victim when a significant threat of harm has been made. In the event of a client's death, the spouse or parents of a deceased client have a right to access their child's or spouse's records. Professional misconduct by a healthcare professional must be reported by other healthcare professionals, in which related client records may be released to substantiate disciplinary concerns. Parents or legal guardians of non emancipated minor clients have the right to access the client's records. When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about the client, not clinical information.

My signature below indicates that I have been given a copy of my rights regarding confidentiality. I permit a copy of this authorization to be used in place of the original. Client data of clinical outcomes may be used for program evaluation purposes, but individual results will not be disclosed to outside sources.
I consent to treatment and agree to abide by the above-stated policies and agreements with Amy Roth MS, NCC, LPC-MH. **Signature of Client/Legal Guardian***

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Date

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Date
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Date

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Date

Amy Roth MS, NCC, LPC-MH

1500 S Sycamore Ave. Ste 200, Sioux Falls, SD 57110 605.838.8545
ACKNOWLEDGEMENTS OF RECEIPT OF PRIVACY PRACTICE

By signing this form, you acknowledge receipt of the Notice of Privacy Practices that I have given to you. My Notice of Privacy Practices provides information about how I may use and disclose your protected health information. I encourage you to read it in full.

My Notice of Privacy Practices is subject to change. The most recent version will always be at my website at www.journeysupport.net in the Forms section. If I change my notice, you may obtain a copy of the revised notice from me by contacting me at the phone number above. If you have any questions about my Notice of Privacy Practices, please contact me at the address and/or phone number above.

I acknowledge receipt of the Notice of Privacy Practices of Journey Therapy at The Barn, LLC, Amy Roth MS, NCC, LPC-MH.
Signature of patient/parent/conservator/guardian*

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Date

MonthDayYear
Signature of patient/parent/conservator/guardian

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Amy Roth MS, NCC, LPC-MH

1500 S Sycamore Ave. Ste 200, Sioux Falls, SD 57110 605.838.8545
Client Rights

As a recipient of services at our facility, we would like to inform you of your rights as a patient. The information contained here explains your rights and the process of complaining if you believe your rights have been violated.

YOUR RIGHTS AS A PATIENT
1. Complaints. We will investigate your complaints.
2. Suggestions. You are invited to suggest changes in any aspect of the services we provide.
3. Civil rights. Your civil rights are protected by federal and state laws.
4. Cultural/spiritual/gender orientation. If these services are not available, we will help you in the referral process.
5. Treatment. You have the right to take part in the formulating of your treatment plan.
6. Denial of services. You may refuse services offered to you and be informed of any potential consequences.
7. Record restrictions. You may request restrictions on the use of your protected health information; however, we are not required to agree with the request.
8. Availability of records. You have the right to obtain a copy and/or inspect your protected health information; however, we may deny access to certain records. If so we will discuss this cediscion with you.
9. Amendment of records. You have the right to request an amendment in your records; however, this request could be denied. If denied, your request will be kept in the records.
10. Medical/legal advice. You may discuss your treatment with your doctor or attorney.
11. Disclosures. You have the right to receive an accounting of disclosures of your protected health information that you have not authorized.
YOUR RIGHTS TO RECEIVE INFORMATION
1. Medications use in your treatment. No medications will be prescribed by this therapist.
2. Costs of services. Wei will inform you of how much you will pay.
3. Termination of services. You will be informed as to what behaviors or violations could lead to termination of services at our clinic.
4. Confidentiality. You will be informed of the limits of confidentiality and how your protected health information will be used.
5. Policy changes.
OUR ETHICAL OBLIGATIONS
1. We dedicate ourselves to serving the best interest of each client.
2. We will not discriminate between clients or professionals based on age, race, creed, disabilities, handicaps preferences, or other personal concerns.
3. We maintain an objective and professional relationship with each client.
4. We respect the rights and views of other mental health professionals.
5. We will appropriately end services or refer clients to other programs when appropriate.
6. We will evaluate our personalities limitations, strengths, biases, and effectiveness on an ongoing basis for the purpose of self-improvement. We will continually attain further education and training.
7. We respect various institutional managerial policies bue will help to improve such policies if the best interest of the client is served.
PATIENT'S RESPONSIBILITIES
1. You are responsible for our financial obligations to the clinic as outlined in the Payment Contract for Services.
2. You are responsible for following the policies of the clinic.
3. You are responsible to treat staff and fellow patients in a respectful, cordial manner in which their rights are not violated.
4. You are responsible to provide accurate information about yourself.
WHAT TO DO IF YOU BELIEVE YOUR RIGHTS HAVE BEEN VIOLATED

If you believe that your patient rights have been violated, contact our Recipient's Rights Adviser or Clinic Director.
Signature indicating acknowledgement of Client Rights

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Amy Roth MS, NCC, LPC-MH

1500 S. Sycamore Ave, Ste 200, Sioux Falls, SD 57110

Client Information

Emergency Information

Client Information

Employment Information

HIPPA Acknowledgement

Wireless Communications

Consent to Treatment and Recipient's Rights

Amy Roth MS, NCC, LPC-MH

Amy Roth MS, NCC, LPC-MH