Intake Packet

PARENT / LEGAL GUARDIANSHIP

Legal guardian must sign consent for treatment and all releases.
Has the info for the client's guardian changed in the last 12 months?*

YesNo
Is the client under the guardianship of a non-parental adult?*

YesNo, the child is under the guardianship of a parent or parents
Is the client in foster care?*

YesNo
Please complete the following information in regards to the client's case:
DHS Case Worker*

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Guardian ad litem first name
Guardian ad litem last name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Documentation that defines current placement or guardianship*

Cancelof
Are there additional adults that hold parental rights?*

YesNo
Name

First NameLast Name
Relationship to client
Name

First NameLast Name
Relationship to client
Please complete the following information in regards to non-parental guardian(s)
Guardian 1
Guardian 1 First Name*
Guardian 1 Last Name*
Relationship to Client:*
Phone Number:*
Please enter a valid phone number.
Date of Birth:*

MonthDayYear
Date
Guardian 2
Guardian 2 First Name
Guardian 2 Last Name
Relationship to Client:
Phone:
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Documentation that defines current guardianship*

Cancelof

PARENT / LEGAL GUARDIANSHIP

Legal guardian must sign consent for treatment and all releases.
Is the client a dependent adult?*

YesNo
Guardian 1
Guardian 1 First Name*
Guardian 1 Last Name*
Relationship to Client*
Phone Number:*
Please enter a valid phone number.
Date of Birth:*

MonthDayYear
Date
Please upload documentation outlining guardianship of dependent adult.*

Cancelof
Guardian 2
Guardian 2 First Name
Guardian 2 Last Name
Relationship to Client
Phone Number:
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date

GUARANTOR

The financially responsible party whom assumes responsibility of all bills related to the client.
Has the info for the client's guarantor changed in the last 12 months?*

YesNo
Guarantor has the same information as:*

Guardian 1Guardian 2Neither
Guarantor First Name*
Guarantor Last Name*
Relationship with client:*
Phone:*
Please enter a valid phone number.
SSN:*
Date of Birth*

MonthDayYear
Date
Address is same as Client's primary address

Yes
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

EMERGENCY CONTACT

Contacted ONLY if there is a medical or mental health emergency. Person to reach if a minor’s parent/guardian cannot be contacted.
Has the emergency contact information changed in the last 12 months?*

YesNo
Emergency Contact Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Relationship:*

Other Information
Who referred you? (we do accept self referrals)
Is the client CURRENTLY under a committal, incarcerated, or in an inpatient program?*

YesNo
Committal / incarceration / program began on Date* and is expected to end on Date*
Please list location(s) and any further information.*
Has the client RECENTLY been committed, incarcerated, or in an inpatient program?*

YesNo
Committal / incarceration / program began on Date* and ended on Date*
Please list location(s) and any further information.*
Do you use any nicotine products?*

YesNo
Why type(s) of nicotine products do you use? *
At what frequency do you use these products?*
As part of our Chapter 24 State Accreditation, we are required to provide you with these nicotine cessation programs. These are voluntary programs to be utilized at your own discretion.

Iowa Quitline Quit Assist

SmokeFree.gov

INSURANCE

Please be advised that while we can verify insurance eligibility, and network status, at the time of the referral, we are unable to verify your specific plan benefits and out of pocket costs with your insurance carrier. It is your responsibility to verify your own benefits and out of pocket costs with your insurance carrier for the services being rendered. To do so, please call the number on the back of your insurance card prior to your first session.
Has your insurance or payment information changed in the last 12 months?*

YesNo
I will NOT be using insurance and will be paying privately

Yes
Our Private pay rates are as follows:

PRIMARY
Company:*
Member ID:*
Group #:*
Policy Holder:*
Policy Holder DOB:*

MonthDayYear
Date
Your Relationship to the Subscriber*
Please select Insurance Type*
NOTICE TO COMMERCIAL POLICY HOLDERS

Please note that insurance policies administered by your employer are managed and updated directly by them. Your employer reserves the right to make changes to your policy without notifying your provider. However, they are obligated to inform you, the employee, of any updates or modifications, including:
- Addition or removal of providers from their network
- Addition or removal of services or specialties
- Addition or removal of plan exclusions, such as coverage for specific diagnoses
Please direct any inquiries regarding these changes to your employer. Please be sure and contact our Administrative Department regarding changes to your health plan.
Address is same as Client's primary address

Yes
Policy Holder Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insurance Card (front)*

Cancelof
Primary Insurance Card (back)*

Cancelof
Do you have a secondary insurance?*

YesNo
SECONDARY
Company:*
Member ID:*
Group #:*
Policy Holder:*
Policy Holder DOB:*

MonthDayYear
Date
Please select Insurance Type*
NOTICE TO COMMERCIAL POLICY HOLDERS

Please note that insurance policies administered by your employer are managed and updated directly by them. Your employer reserves the right to make changes to your policy without notifying your provider. However, they are obligated to inform you, the employee, of any updates or modifications, including:
- Addition or removal of providers from their network
- Addition or removal of services or specialties
- Addition or removal of plan exclusions, such as coverage for specific diagnoses
Please direct any inquiries regarding these changes to your employer. Please be sure and contact our Administrative Department regarding changes to your health plan.
Address is same as Client's primary address

Yes
Policy Holder Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance Card (front)

Cancelof
Secondary Insurance Card (back)

Cancelof
Insurance Disclosure:
Please be advised that while we can verify insurance eligibility, and network status, at the time of the referral, we are unable to verify your specific plan benefits and out of pocket costs with your insurance carrier. It is your responsibility to verify your own benefits and out of pocket costs with your insurance carrier for the services being rendered. To do so, please call the number on the back of your insurance card prior to your first session.
I have read and understand the above insurance disclosure in its entirety. I understand there may be out of pocket costs associated with the services rendered.*

I agree

Release of Information
I would like to complete a ROI for a Primary Care Provider*

YesI Decline

Release of Information for Primary Care Provider: Declined
By signing this form I agree that Heart and Solutions, LLC has provided me the opportunity to release my protected health information to support my care through collaboration with my primary care provider.

I am respectfully declining that request at this time.

I understand that Heart and Solutions can only disclose information to any person or organization with written consent from the client or client’s legal guardian.
A copy of this signed document, including service information, will be emailed to the email address you have provided.
Client / Parent / Legal Guardian / Authorized Representative Signature*

Clear
Name of Signer*

First NameLast Name
Relationship / Role (if applicable)
Date*

MonthDayYear
Date
*Jotform acts as a witness signature for this document.

Release of Information
If the client is homeschooled or not yet enrolled in school, please decline this Release of Information.
I would like to complete a Release of Information for a school*

YesI Decline

Release of Information for School: Declined
By signing this form I agree that Heart and Solutions, LLC has provided me the opportunity to release my child's protected health information to support their care through collaboration with their school.

I am respectfully declining that request at this time.

I understand that Heart and Solutions can only disclose information to any person or organization with written consent from the client or client’s legal guardian.
A copy of this signed document, including service information, will be emailed to the email address you have provided.
Client / Parent / Legal Guardian / Authorized Representative Signature*

Clear
Name of Signer*

First NameLast Name
Relationship / Role (if applicable)
Date*

MonthDayYear
Date
*Jotform acts as a witness signature for this document.

Release of Information
Additional ROI forms may be completed for anyone else you wish to provide information to.

Often that might include: spouse or parent(s) of clients 18+ for billing purposes, other medical professionals such as psychiatrists, step parents, grandparents, other caregivers (anyone providing minors transportation to or from sessions), significant others who may be joining sessions, foster parents/siblings, case workers, attorneys, etc.
I would like to complete an additional Release of Information*

YesI Decline

Consent to Treatment
This document was last updated on 10/19/2022

Welcome to Heart and Solutions, LLC: A Strength Based Counseling Agency. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will represent an agreement between us. We can discuss any questions you have when you sign or at any time in the future.
Psychological and Behavioral Services
Therapy and BHIS counseling are built on a relationship between people that works, in part, because of clearly defined rights and responsibilities of each person. As a client in therapy or BHIS counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. This agency and your provider have corresponding responsibilities to you as well. These rights and responsibilities are described in the following sections.

Therapy and BHIS counseling has both benefits and risks. During the therapy or BHIS process, you may experience uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness. The process of therapy or BHIS often requires discussing the unpleasant aspects of your life, and these feelings can occur as a result. Even though there are risks, therapy or BHIS has been shown to have benefits for many individuals who undertake it. Therapy or BHIS can lead to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. There are no guarantees about the specific outcomes. Therapy and BHIS require a very active effort on your part. In order to be most successful, you need to work on things we discuss outside of the therapy or BHIS sessions.

The first 2-4 sessions will involve a comprehensive evaluation of your specific needs. At the end of the evaluation, your therapist will be able to offer initial impressions of what your work might include. Then you will discuss treatment goals and create a treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with your therapist. If you have questions about procedures, please discuss them with your therapist as they arise. If your doubts persist, we will help you set up a meeting with another mental health professional upon request.
Appointments
Therapy appointments will generally be 54-60 minutes in duration, once per week at a time we agree on. Some sessions may be more or less frequent as needed based on your individual needs. Therapy appointments may be scheduled for 38-45 minutes based on insurance coverage, school schedule, or developmental abilities of the client. Behavioral Health Intervention sessions are one hour of individual session and one hour of family session per week. If more than two children in the same household participate in BHIS services, they may have less family time per child.

The time scheduled for your appointments is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide us with 24 hours notice. If it is possible, your therapist will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. Heart and Solutions team members reserve the right to end a session, phone call, or services if they feel unsafe in any way.

Unless otherwise prohibited by law, you are allowed to cancel your appointment with less than 24-hour notice (“late cancel”) or miss your appointment (“no show”) only once before Heart and Solutions reserves the right to charge a fee of $20.00 for subsequent “late cancels” and “no shows”. This fee will be billed to the patient. This fee is not covered by insurance, and must be paid prior to your next appointment.

If you do not attend your scheduled session and provide no notice three times within a three month period, you will be placed on standby status. Standby status means that you will only be able to schedule with your provider for a session to occur within 24 hours. If you are on standby status and you “no-show” or late cancel, you will be discharged and referred to another provider for services. You may contact us to resume services after three months. You are able to return to good standing by completing three consecutive sessions while on standby status. If you return to good standing and “no-show” or late cancel three more times within a three month period, you will be discharged and referred to another provider services. You will be eligible to return to services at Heart and Solutions in January of the following year.
Additional Professional Fees
- Letter writing fee to you or to any outside entity on your behalf: $35.00 per letter
- Record Request Fee to you or to any outside entity on your behalf: $35.00 fee (regardless of amount of records being requested) - See separate fees for court related documentation requests/subpoenas
- Returned Ceck Fee: $25.00
- Appearance in court after being subpoenaed: $200.00 per hour
- Preparation time for subpoena (including phone calls with attorney): $200.00 per hour
- Travel time to court if subpoenaed: $200.00 per hour
If you anticipate becoming involved in a court case, we recommend that you discuss this fully with your provider before you waive your right to confidentiality. If your case requires your provider’s participation, you will be expected to pay for the professional time required even if another party compels your provider to testify. It is important to note that insurance companies will not pay for these kinds of services, and so the responsibility is yours.
Insurance and Patient Responsibility
If you have a health insurance policy, it may provide some coverage for mental health treatment. Our billing service will assist you in filing claims. You are responsible for obtaining information about your covered benefits. This includes determining if we are in or out of network, copays, patient responsibility, prior authorizations, deductibles, and all other plan details or limits to coverage. You are responsible for notifying us if/when your coverage changes. Please direct any inquiries about your coverage to your insurance company.

Patient responsibility invoices are mailed to you and are due monthly. You may pay your balance by calling our billing department at 1-800-531-4236 ext 701 and making a debit/credit card payment over the phone. You can also mail checks to PO Box 233 Grundy Center, IA 50638. We discourage mailing cash payments. Co payments and private pay balances are due at the time of service. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment, as well as to refer you to services with another provider.

If we are not a participating provider for your insurance plan, you will be considered a private pay client. You may request a receipt for your payments, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, we will refer you to another agency.

By signing our informed consent form, you agree that you have disclosed all of your insurance coverages and that if you have Medicare as your primary coverage, you have disclosed this. By signing this agreement, you agree that if you have not disclosed Medicare as your primary insurance coverage and your claims are denied because you have this coverage, you are responsible for payment in full.

Unless otherwise prohibited by law, in the event that you fail to pay the charges of Heart and Solutions, Heart and Solutions will pursue legal remedy for the full invoice of charges and you shall be liable for all costs incurred by Heart and Solutions as a result of these collection efforts, including, but not limited to, attorney fees and collection agency costs, whether or not litigation is initiated. Heart and Solutions is not responsible for the confidentiality of text messages, voice calls, emails, or voicemails sent to the intended recipient utilizing the contact information provided.
Alternative Funding Sources
Coverage from alternative funding sources such as grants, regional funding, crime victims, wrap-around services, etc. are not considered guaranteed payment and do not negate client financial responsibility.
Private Pay
Our Private Pay rates are the same as our insurance rates, however a cash-discount is offered for bills paid within 90 days of the invoice. Heart and Solutions can not offer private pay cash discounted rates to clients who are paying for services due to deductible or patient responsibility from insurance. If payment is not made within 90 days of service, you will be responsible for the full amount and we reserve the right to end services and refer you to another agency.
Bankruptcy
Please be advised that if you file for bankruptcy and include any outstanding balance with Heart and Solutions, you will be discharged from our services. This means that upon the discharge of your bankruptcy, you will not be eligible to return to or receive services from Heart and Solutions in the future.

Heart and Solutions is fully committed to working with you to address any outstanding balances and to set up manageable payment arrangements.
Consent to Transport
Heart and Solutions employees may request your permission to transport clients for various purposes. This will always be done with your consent and knowledge unless the provider must transport the client for emergency purposes. Heart and Solutions requires all employees to hold a current and valid driver’s license and car insurance. Heart and Solutions is not liable for any accidents that occur while transporting clients.
Contacting your Provider
Heart and Solutions’ providers may not be immediately available by telephone, are not crisis intervention workers, and are not on call outside of work hours. You are welcome to leave a message on their confidential voicemail and your call will be returned at their earliest convenience. If you feel you cannot wait for them to return your call or if you feel unable to keep yourself safe, 1) Call 911 and ask to speak to the mental health worker on call, 2) Go to your local hospital Emergency Room. Your provider will make every attempt to inform you in advance of planned absences, and will provide you with the name and phone number of the mental health professional covering their practice when applicable. Heart and Solutions team members do not engage with their clients on social media.

Consent to Treatment
Notice of Privacy Practices and Patient Rights

This notice involves your privacy rights and describes how information about you may be disclosed, as well as how you can obtain access to this information. Please review it carefully
I. Confidentiality
Heart and Solutions and its providers will not confirm or deny knowledge of you as a client without your written consent. If you see your provider outside of the session, your provider will not acknowledge you unless you acknowledge them first. If you have a dual relationship with your provider or with another Heart and Solutions team member, please disclose this as soon as possible to your provider so that accommodations can be made.
II. Limits of Confidentiality
Heart and Solutions may use or disclose records or other information about you without your consent or authorization in the following circumstances.

Emergency: If you are involved in a serious or life-threatening emergency and we cannot ask your permission, we will share information if we believe it will be helpful to you or others.

Debt Collections: If you refuse to pay your bill, we reserve the right to utilize an attorney or collection agency to obtain payment.

Consultation with Our Attorney: We reserve the right to consult with our attorney at any time. Our attorney is held to standards of confidentiality and is legally required to maintain confidentiality.

Child and Dependent Adult Abuse Reporting: If we have reason to suspect that a child or a dependent adult is abused, exploited, or neglected, we are required by law to report the matter within 24 hours to the Iowa Department of Human Services.

Court Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and we will not release information unless you provide written authorization or a judge issues a court order. If we receive a subpoena for records or testimony, we will notify you so that you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, we are required to place these records in a sealed envelope and provide them to the Clerk of Court. If you, as a minor or adult, become a party in a civil commitment hearing, we may be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, and/or a law enforcement officer.

Threat to Health or Safety: If your provider is engaged in their professional duties and you communicate to them a specific and immediate threat to cause serious bodily injury or death, to an identified or identifiable person, and they believe you have the intent and ability to carry out that threat immediately or imminently, your provider is legally required to take steps to protect third parties. These precautions may include:
1. Warning the potential victim(s) or the parent or guardian of the potential victim(s) if under 18.
2. Notifying a law enforcement officer, and/or
3. Seeking your hospitalization
We will also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. Heart and Solutions team members reserve the right to end a session if they feel unsafe in any way. Additionally, by signing this document, you agree that if any member of your session does not conduct themselves in a respectful manner to any team member, confidentiality rights are waived and the police will be contacted. Should a client or any of their support members verbally abuse a member of the Heart and Solutions team or act physically or verbally aggressive toward anyone in a Heart and Solutions office or session, they will be asked to leave the premises. If they refuse to leave the premises, confidentiality is waived and the police will be contacted. Should a team member be physically injured by another person in session, in the office or while performing their work duties, we reserve the right to file appropriate legal and or civil charges.

Insurance: You should also be aware that most insurance companies require you to authorize your provider to provide them with a clinical diagnosis. Sometimes providers have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record. This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it after they receive it. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit if you request it in writing. By signing this Agreement, you give Heart and Solutions, LLC permission to provide requested information to your carrier if you plan to utilize insurance coverage for payment.

Supervision: All Heart and Solutions Behavioral Health Intervention Service Providers have their Bachelor's degree in a Human Services related field or their Bachelor's degree in another field with at least two years of Human Service experience. All Heart and Solutions therapists are Master's level clinicians who are licensed to practice in the state of Iowa. Temporarily Licensed Mental Health Counselors, Temporarily Licensed Marriage and Family Counselors, and Licensed Master's Level Social Workers require ongoing supervision in order to reach full licensure status. This supervision is provided by a qualified supervisor within the agency or a contracted third party supervisor. To ensure quality client care and services, client diagnoses, assessments, and notes may be shared and discussed with this supervisor. The supervisor is ethically responsible to maintain client confidentiality in the same manner as any Heart and Solutions team member.

Parents and Minors: While privacy in counseling services is crucial to successful progress, parental involvement can also be essential. It is Heart and Solutions’ policy not to provide treatment to a child under age 13 unless s/he agrees that we can share any clinically necessary information with a parent. For children 14 and older, we request an agreement between the client and the parents allowing us to share general information about treatment progress and attendance, as well as a treatment summary upon completion of the counseling services. All other communication will require the child’s agreement, unless we believe there is a safety concern (see also above section on Confidentiality for exceptions), in which case we will make every effort to notify the child of our intention to disclose information ahead of time. In this situation, we will make every effort to handle any objections that are raised, but will be required to break confidentiality even if objections persist. We will not release any information to parents or guardians if it will jeopardize the physical or mental well being or safety of the client. We reserve the right to deny access to records and clinical information to parents and guardians of minors if sharing the information is not in the best interest of the client.

Release of Information to Primary Care Doctor and School: If you have signed a release for us to share information with your primary care doctor and/or school, a letter will be faxed or mailed to these providers in an effort to collaborate and provide a more holistic approach to your treatment.

Communication Methods: Heart and Solutions team members may utilize cellular phone services such as, but not limited to: Verizon, AT&T, TMobile and US Cellular. Heart and Solutions team members may utilize an internet or wifi based service such as Google Voice for phone calls and text messages. Heart and Solutions team members additionally utilize Google Suites for Gmail communication. Heart and Solutions is not responsible for the confidentiality of text messages, voice calls, emails, or voicemails sent to the intended recipient utilizing the contact information provided.

Professional Records: Heart and Solutions providers are required to keep appropriate records of the services that we provide. Your records are maintained utilizing an electronic system called Valant. In signing this agreement, you consent to your service records being housed in Valant. We keep records noting that you were here, your reasons for seeking counseling services, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records we receive from other providers, copies of records we send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Due to the fact that these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your provider or have them forwarded to another mental health professional to discuss the contents. If we refuse your request for access to your records, you have a right to have the decision reviewed by another mental health professional, which we will discuss with you upon your request.

Heart and Solutions clients, and guardians of clients, have access to all non-restricted client records and documentation authored by Heart and Solutions, LLC. Restricted client records include but are not limited to any and all second hand information such as documents from other agencies and collaborative services involving third parties. Records will also be considered restricted if access to them will cause harm or risk of harm to the physical or mental well being of the client.

Collaborating agencies must request documentation in writing and provide appropriate releases of information. Heart and Solutions will release requested information only when a completed release is on file and the client has been notified and has given consent.
III. Patient Rights and Provider Duties
You have the right to considerate, safe, and respectful care without discrimination of race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of the counseling process and about your provider’s specific training and experience. You have the right to expect that your provider will not have social or sexual relationships with clients or with former clients and will uphold the ethical codes of the American Counseling Association, the American Association for Marriage and Family Therapy, and the National Association of Social Workers.

Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of your protected health information. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care. If you ask us to disclose information to another party, you may request that we limit the information we disclose.

Right to Receive Confidential Communication by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communication of Protected Health Information by alternative means and at alternative locations (for example, you may not want a family member to know that you are in treatment). Upon your request, we will send your bills to another address. You may also request that we contact you only at work, or that we do not leave voicemail messages. To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.

Right to a Copy of this Notice: Once completed, this packet in its intirety will be emailed to you at the emal address provided. You have the right to a paper copy of this notice. You may ask your provider to give you a copy of this notice at any time. Heart and Solutions, LLC reserves the right to change policies and/or to change this notice, and to make the changed notice effective for medical information already accrued as well as any information received in the future. The notice will contain the effective date. A new copy will be given to you or posted in the waiting room. We will also have copies of the current notice available via request.

Complaints and Grievances: If you believe your privacy rights have been violated or you have a concern with the quality of your treatment, you may file a complaint. To do this, please complete this form: https://heartandsolutions.net/client-forms/grievances/. You may also send a written complaint to the U.S. Department of Health and Human Services.

Compliments and Suggestions: We welcome and appreciate your compliments and suggestions! Please complete this form: https://heartandsolutions.net/client-forms/suggestions/ or contact us at 800-531-4236 or by email at help@heartandsolutions.net.

Consent to Treatment
Acknowledgement of: Consent to Treatment, Privacy Practices, Patient Rights, and Financial Responsibility
Client First Name*
Client Last Name*
Client Date of Birth*

MonthDayYear
Date
My signature below indicates that I have read, understand, and agree to the terms of the Heart and Solutions Consent to Treatment including privacy practices, patient rights, and patient financial responsibility. By signing this document, I am providing consent to be treated by Heart and Solution for outpatient therapy and/or Behavioral Health Intervention Services. I understand that insurance billing is provided as a courtesy and that I am financially responsible to Heart and Solutions, LLC for all charges resulting from my treatment. It is my responsibility to notify Heart and Solutions, LLC of any changes in my health care coverage. While Heart and Solutions, LLC verifies my insurance eligibility, exact benefits cannot be determined until the insurance plan receives the claim. I agree to accept financial responsibility for all services received by me or by my dependents. I authorize direct payment from my health insurance plan to Heart and Solutions, LLC for all services provided to me or my dependent. This is a direct assignment of my rights and benefits under this policy. A photocopy of this assignment shall be considered as effective and valid as the original. We have discussed the privacy practices, and I understand that I may request a copy at any time in the future. I consent to accept these policies as a condition of receiving mental health services.
Please read and initial the following statements:
I agree that I have no other insurance coverage other than what was disclosed during my intake.*
I am aware that if I have Medicare as a primary insurance, Heart and Solutions will not be able to bill my secondary insurance provider unless it is Medicaid fee for service or the Amerigroup Managed Care Organization. If Heart and Solutions is unable to bill by insurance for this reason, I will be financially responsible for the entirety of my services.*
Name of Patient or Personal Representative

First NameLast Name
Representative's Authority (if applicable)
Date*

MonthDayYear
Date
A copy of this signed document, including service information, will be emailed to the email address you have provided.
Signature*

Clear

Consent to Treatment - Couples

Signature Page
Client First Name*
Client Last Name*
Client Date of Birth*

MonthDayYear
Date
Partner First Name*
Partner Last Name*
Partner Date of Birth*

MonthDayYear
Date
Acknowledgement of: Consent to Treatment, Privacy Practices, Patient Rights, and Financial Responsibility
My signature below indicates that I have read, understand, and agree to the terms of the Heart and Solutions Consent to Treatment including privacy practices, patient rights, and patient financial responsibility. By signing this document, I am providing consent to be treated by Heart and Solution for outpatient therapy and/or Behavioral Health Intervention Services. I understand that insurance billing is provided as a courtesy and that I am financially responsible to Heart and Solutions, LLC for all charges resulting from my treatment. It is my responsibility to notify Heart and Solutions, LLC of any changes in my health care coverage. While Heart and Solutions, LLC verifies my insurance eligibility, exact benefits cannot be determined until the insurance plan receives the claim. I agree to accept financial responsibility for all services received by me or by my dependents. I authorize direct payment from my health insurance plan to Heart and Solutions, LLC for all services provided to me or my dependent. This is a direct assignment of my rights and benefits under this policy. A photocopy of this assignment shall be considered as effective and valid as the original. We have discussed the privacy practices, and I understand that I may request a copy at any time in the future. I consent to accept these policies as a condition of receiving mental health services.
Please read and initial the following statements:
I agree that I have no other insurance coverage other than what was disclosed during my intake.*
I am aware that if I have Medicare as a primary insurance, Heart and Solutions will not be able to bill my secondary insurance provider unless it is Medicaid fee for service or the Amerigroup Managed Care Organization. If Heart and Solutions is unable to bill by insurance for this reason, I will be financially responsible for the entirety of my services.*
I understand that the person who signs as the insured is the insurance policy that we will use to bill the sessions and that if they want to change this to the other partner, they must complete a new consent form.*
I understand that the client in Couples Therapy is the relationship, not an individual. No information shared with the therapist is confidential from the partner.*
A copy of this signed document, including service information, will be emailed to the email address you have provided.
I wish to haveamount printed copy(s) of these consent agreements
Name of Insured*

First NameLast Name
Name of Partner*

First NameLast Name
Signature of Insured

Clear
Signature of Partner

Clear
Date*

MonthDayYear
Date

Appointment Reminders
Would you like to receive text /call/or email reminders for upcoming appointments?*

YESNO
I authorize Heart and Solutions to send me text messages and or to call my phone number and leave a message to remind me of my counseling appointment. I understand that these reminders will only state the name of the provider, the date and time of your appointment and will not disclose the nature of your appointment. Reminders will be sent out through an automated system the day before a scheduled appointment. The appointment must be scheduled at least 48 hours in advance for reminders to be sent out. I understand that Heart and Solutions is not responsible for the confidentiality of the appointment reminder once it is distributed to your voicemail or to your mobile phone. I agree that I have authorization to request reminders to the telephone number listed below. I understand that it is my responsibility to inform Heart and Solutions if my telephone number changes and I would like to continue to receive reminders.
Client First Name*
Client Last Name*
Client Date of Birth*

MonthDayYear
Date
At this time our system is only able to send reminders via text OR phone call to a single phone number.
I would like to receive a reminder via*

Phone CallText MessageNeither
You may choose to set up both a phone reminder AND an email reminder at the same time.
I would like to receive an email reminder*

YesNo
Phone Number (if calling)
Phone Number (if texting)
Email address
A copy of this signed document, including service information, will be emailed to the email address you have provided.
Signature*

Clear
Date*

MonthDayYear
Date

Please verify that you are human*
Should be Empty:

	Standard Rates	Discounted Rates (Paid in full within 90 days)
Intake / Assessment (90791)	$154.00	$130.00
30 Minute Session (90832)	$100.00	$95.00
45 Minute Session (90834)	$100.00	$95.00
60 Minute Session (90837)	$150.00	$120.00
Family Session (90846/90847)	$150.00	$125.00
Unscheduled Crisis Session - 30 Minutes to 75 Minutes or session lasting between 60 and 75 minutes due to a crisis - (90839)	$156.00	$156.00
Unscheduled additional session time up to 30 minutes added on to any session (90840)	$75.00	$75.00

	Standard Rates	Discounted Rates (Paid in full within 90 days)
Intake / Assessment (90791)	$154.00	$130.00
Individual BHIS Session (H2019 HA)	$25 per 15 min ($100/hr)	$23 per 15 min ($92/hr)
Family BHIS Session (H2019 HR)	$25 per 15 min ($100/hr)	$23 per 15 min ($92/hr)

Heart and Solutions Intake Packet

In order to complete this form in its entirety, you will need the following information for the person seeking services: Social security number, insurance details and insurance subscriber information.

Upon completion of this form someone from Heart and Solutions will be in touch within 10 business days.

CLIENT DEMOGRAPHICS

Services

PARENT / LEGAL GUARDIANSHIP

Please complete the following information in regards to the client's case:

Please complete the following information in regards to non-parental guardian(s)

Guardian 1

Guardian 2

PARENT / LEGAL GUARDIANSHIP

Guardian 1

Guardian 2

GUARANTOR

EMERGENCY CONTACT

Other Information

INSURANCE

PRIMARY

SECONDARY

Insurance Disclosure:

Release of Information: Guarantor

Release of Information: Billing

Release of Information

Release of Information for Primary Care Provider: Declined

Release of Information for Primary Care Provider

Release of Information

Release of Information for School: Declined

Release of Information for School

Release of Information

General Release of Information

Vanderbilt Assessment Scale - Parent

In the past 6 months, has your child shown symptoms of...

In the past 6 months, reflect on your child's performance...

Consent to Treatment

Psychological and Behavioral Services

Appointments

Additional Professional Fees

Insurance and Patient Responsibility

Alternative Funding Sources

Private Pay

Bankruptcy

Consent to Transport

Contacting your Provider

Consent to Treatment

Notice of Privacy Practices and Patient Rights

I. Confidentiality

II. Limits of Confidentiality

III. Patient Rights and Provider Duties

Consent to Treatment

Acknowledgement of: Consent to Treatment, Privacy Practices, Patient Rights, and Financial Responsibility

Please read and initial the following statements:

Consent to Treatment - Couples

Acknowledgement of: Consent to Treatment, Privacy Practices, Patient Rights, and Financial Responsibility

Please read and initial the following statements:

Appointment Reminders