Forever Young Counseling
New patient intake Form
Date
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Month
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Day
Year
Date
Patient Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Birthday
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Month
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Day
Year
Date
Is this a mobile phone?
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Yes
No
Would you like text reminders?
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Yes
No
Have any other counselors or therapists worked with the patient?
Please list all providers
Has the patient ever attempted suicide?
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Yes
No
If yes, how many times and date of last attempt (or best guess at date)?
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If the patient is a minor please fill this section out
Parent/Guardian
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Insurance
If using Montana Healthy Kids or Medicaid a pic of the card will do
Will you be using insurance? If so, please take a photo of your insurance card.
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Yes
No
Primary insurance company name
Group/policy number
Insurance company phone number
Insured person's name
Insured person's social security number or ID number
Insured person's date of birth
Insured person's relationship to patient
Insured person's employer
Front of insurance card
Back of insurance card
The legal stuff that is boring but necessary
INFORMED CONSENT The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect.This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.THE THERAPEUTIC PROCESSYou have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.CONFIDENTIALITYThe session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:1. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.2. If a client threatens grave bodily harm or death to another person.3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.5. Suspected neglect of the parties named in items #3 and # 4.6. If a court of law issues a legitimate subpoena for information stated on the subpoena.7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
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I accept
I decline (if the is selected, treatment will not be provided0
Notice of Privacy – HIPAAPlease sign bottom after readingThis notice describes how health information about you as a client may be used and disclosed and how you can get access to your health information. This is required by the privacy Regulations created as a result of the Health Information Portability and Accountability Act of 1996 (HIPAA)Our commitment to your privacy: As independent providers we are dedicated to maintaining the privacy of your health information.We are required by law to maintain the confidentiality of your health information. We realize these laws can be complicated, but we provide you with the following important information:1. Use and disclosure of your health information in special circumstances: The following circumstances may require us to use or disclose your health informationo To public health authorities and health oversight agencies that are authorized by law to collect Information o Lawsuits and similar proceedings in response to a court or administrative ordero If required to do so by a law enforcement officialo When necessary to reduce or prevent a serious threat to your health and safety or health and safety ofanother individual or public. We will only make disclosures to a person or organization able to help preventthe threat.o If you are a member of the US Military or foreign military forces including veterans, and if required by theappropriate authorities.o To federal officials for intelligence and National security activities as authorized by law.o To correctional institutions or law enforcement officials if you are an inmate or under the custody of a Iawenforcement official.o For workers compensation and similar programs2. Your rights regarding your health information:o Communications. You can request that we as independent practitioners communicate with you about yourhealth and related issues in a particular manner or at a certain location. For instance, you may ask that wecontact you at home rather than at work. We will accommodate reasonable requests.o You can request a restriction in our use or disclosure of your health information for treatment, payment, orhealthcare operations. you have the right to request that we restrict our disclosure of your healthcare information to only individuals involved in your care or the payment for your care such as family members and friends. We are not required to agree to your request; however, if we do, we are bound by our agreement except when otherwise required by law In emergencies or when the Information is necessary to treat you.o You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you including patient medical records or billing records but not including psychotherapy notes. You must submit your request in writing to your therapist.o You may ask us to amend your health information if you believe it is incorrect or incomplete and as long as the information is kept by or for our practice. To request an amendment, your request must be in writing and submitted to your therapist. You must include your reason for the request supporting the amendment.o Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time.o Right to file a complaint. If you believe your rights have been violated, you may file a complaint with your therapist at 406-259-6161 or with the Secretary of the Department of Health and Human Services.o Right to provide authorization for other uses and disclosure. each therapist must obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.
I accept
I decline (if this its selected, treatment will not be offered)
I have read the office policy regarding billing, appointments, and fees. I authorize the release of any medical or other information to process my claims. I understand that insurance may or may not cover part or all of my charges. I authorize payment of my insurance and any fees that I may incur. In the unfortunate circumstances that we are forced to send your bill to collections, a 30% surcharge will be added to cover the added costs. I authorize this for myself or any minor children that I am signing for.
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I accept
I decline (if this is selected, treatment will not be provided)
Telemedicine if utilized. I understand the following with respect to telemental health:1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.2) I understand that there are risks, benefits, and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.3) I understand that there will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.6) I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, please call me at 406-200-8518 to discuss since we may have to re-schedule.7) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.Emergency ProtocolsI need to know your location in case of an emergency. You agree to inform me of the address where you are at the beginning of each session. I also need a contact person who I may contact on your behalf in a life- threatening emergency only. This person will only be contacted to go to your location or take you to the hospital in the event of an emergency.
I accept
I decline (if this its selected, treatment will not be offered)
General Notice I have a legal and ethical responsibility to make my best efforts to protect all communications that are part of our psychotherapy sessions. I have chosen to use Mentalyc’s note-taking system for psychotherapy as part of my effort to provide the best care to my clients. It provides me with an automatically generated transcript and summarization of our sessions. Mentalyc’s system is HIPAA compliant and uses up-to-date encryption methods, firewalls, and backup systems to help keep your information private and secure. You are consenting for me to record our sessions using Mentalyc’s system.Details Recordings of our sessions will be transcribed and summarised by Mentalyc’s HIPAA-compliant technology. Mentalyc doesn’t store the recordings and client personal information. I may choose to keep the summarised notes as part of your confidential medical record. Mentalyc only keeps anonymized data to help improve the tool. As with any technology, there are certain risks and benefits, which I will list here:Risks:● All technology contains a risk of confidential information being disclosed. You can ensure the security of our communications by only using trusted secure networks for psychotherapy sessions and having passwords to protect the device you use for psychotherapy. Mentalyc mitigates this risk by ensuring up-to-date technological security and storing the data with as little identifying information as possible.● Mentalyc Researchers will have access to your de-personalized transcripts (transcript content with removed names, emails, and other identifying information). ● The system may contain unknown bias in the way it generates the session summary and presents clinical information. This risk is mitigated by your therapist’s commitment to review and modify the note as needed using their clinical expertise.Benefits:● The technology allows the therapist to focus more of their attention on therapy.● Removes the need for taking notes or trying to remember information during and after the session. ● Mentalyc reduces the therapist's workload and may help with compassion fatigue.● The technology may provide additional clinical insights for the therapist which helps improve outcomes in the therapeutic process.
I accept
I decline (if this its selected, treatment will not be offered)
Signature Please provide your signature to indicate your acceptance of our office policies.
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