Client Appointment Request Form

Client Appointment Request Form
Client Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
NoYes
Name of parent or guardian

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Voicemails OKText Messages OK
Email*
example@example.com
Insurance Provider*
Insurance ID Number*
YesNoNot Sure
Co-pay amount
Insurance Card (Optional)

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Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
AnxietyAddiction/Substance AbuseAnger ManagementChild and Adolescent CounselingDepressionEducational CounselingMarriage CounselingMood DisorderStress ManagementPersonality DisorderRecent loss/ BereavementRelationship IssuesTraumaEating DisorderPost Traumatic StressEMDRFamily CounselingPrescription ServicesPsychiatric Care/ Medication ManagementVeteran ServicesOther/ additional backgroundParole ProgramGroup CounselingNYLEAP
Group Counseling Topic
Parole Officer Name
Parole Officer Email
example@example.com
Parole Officer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parolee Release of Information

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Other/ additional background:
Prescription Services/ Psychiatric Care are provided through our virtual partner agencies. To request or schedule an appointment, please complete the forms through their portals as well.

For Fulton Family Psychiatry:

https://www.fultonfamilypsychiatry.org/appointments

For Green Wellness

https://form.jotform.com/Green_Wellness/med-management-intake

For Timothy Greco, NP (Commercial plans only)

https://www.timgreconp.com
AnytimeMorningAfternoonEveningWeekend
Provider Preference*
YesNo
YesNo
Provider Gender Preference (note: male provider availability is limited and not guaranteed)*
Preferred Counseling Method*
YesNo
EnglishSpanish
How did you hear about us?*
Upload any pertinent documents that you would like your provider to review.

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MyselfParent/GuardianCare CoordinatorSchool CounselorHospital Discharge PlannerSPOAFamily Member/ FriendPrimary Care ProviderSalvation ArmyOther
Please provide your name and contact information. NOTE: To facilitate a smooth referral, please ensure the client is aware of this referral and has consented to receive counseling.
As the parent or legal guardian with the authority to consent on behalf of the minor child named above, I hereby give my consent for the minor child to seek counseling, psychotherapy, psychological assessment and/or psychiatric care from the professional staff associated with or employed by Mobile Counseling of New York LCSW, PLLC. The mental health provider responsible for the care has explained to me the proposed treatment plan, the general nature and extend of the risks involved in treatment, and alternative treatment options, if any. However, treatment will not be delayed if any emergency exits. This consent will be valid until the minor
reaches the age of 18, but can be revoked at any time through written notification.

I have read and understood this consent form and agree to allow an NYS licensed clinician through Mobile Counseling of New York LCSW, PLLC to begin therapeutic intervention(s) with the minor child:
Consent to treat a minor Signature*

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Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices.We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of
Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.
For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the
minimum amount of PHI necessary for purposes of collection.
For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI
will be disclosed only with your authorization.
Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:
• Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government
agency audits or investigations (such as the social work licensing board or the health department)
• Required by Court Order
• Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or the persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission
We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at 14 Lafayette Square, Suite 2300, Buffalo, NY 14203:
• Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that
access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.
• Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
• Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
• Right to a Copy of this Notice. You have the right to a copy of this notice.

COMPLAINTS
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at Mr. Matthew Scheuer, 716-302-4545 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate
against you for filing a complaint.

The effective date of this Notice is April 11, 2019.
Notice of Privacy Practices
Receipt and Acknowledgment of Notice
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I hereby acknowledge that I have received and have been given an opportunity to read a copy of Mobile Counseling of NY LCSW, PLLC’s Notice of Privacy
Practices. I understand that if I have any questions regarding the Notice or my
privacy rights, I can contact Mr. Matthew Scheuer, (716)302-4545.
I am signing as a personal representative of an individual.
Please describe your legal authority to act for this individual (power of attorney, healthcare surrogate, etc.).
Notice of Privacy Practices Signature*

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Date*

MonthDayYear
Date
RELEASE OF INFORMATION, ASSIGNMENT OF BENEFITS, AND FINANCIAL RESPONSIBILITY
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I hereby authorize Mobile Counseling of New York LCSW, PLLC to release by electronic means or otherwise any medical and/or billing information concerning my care, including copies of my medical records to the following:

Any person or entity responsible for payment for the medical services rendered to me at the Facility, including third
party payors, self-insurers, worker's compensation carriers and government agencies or any person or entity acting as
the agent or contractor of such party responsible for payment, in connection with obtaining payment for the medical
services rendered to me at the Hospital by employees of the Facility or any person providing services at the Facility.
Federal, State or other governmental or quasi-governmental agencies or such other parties required by law for reporting
purposes or for purposes of determining eligibility in government sponsored benefit programs.
Any person or entity participating in quality studies, utilization review or similar studies of the care rendered by the Facility and /or its physicians.
Any health professionals involved in my care for the purpose of facilitating the continuity of my medical care.
To persons authorized by the Facility in connection with the performance of supervised research in compliance with the rules and procedures of the Facility. I also understand that an authorized researcher may contact me at some future date.
I acknowledge that the above authorization has no expiration date and is valid to authorize the release of medical records and billing information at any time a valid request is received.

This includes information relative to alcohol abuse, drug abuse, psychological or psychiatric conditions and Acquired Immune Deficiency Syndrome (AIDS).

ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize my Medicare and/or medical insurance benefits to be paid directly to Mobile Counseling of New York LCSW, PLLC separately from other Facility or professional bills. I understand that I am financially responsible for non-covered services as well as any deductibles, coinsurance or amounts in excess of insurance benefits. If coverage is denied, I give my express consent to appeal to the insurance on my behalf.

FINANCIAL RESPONSIBILITY: In consideration of services rendered or to be rendered to the patient designated herein at my request for this occasion of service, I guarantee and agree to pay charges for those services rendered including any amount not paid in my insurance plan, Medicare, health service plan or health maintenance organization. Members of health maintenance organizations (and preferred provider organizations) are generally required to comply with certain
policies and procedures requiring use of participating providers and compliance with plan requirements for primary referral, emergency admission, pre-certification and utilization review. These are conditions to payment of benefits by the health
maintenance organizations (and preferred provider organizations Mobile Counseling of New York LCSW, PLLC, may not participate with your health care coverage plan and their charges may not be covered.

By signing the financial responsibility statement, the patient and guarantor(s) acknowledge and agree they are responsible for payment of billed charges rendered in any case in which payment may be denied by the health maintenance organization (or preferred provider organization) because of a failure to comply with such coverage requirements or for any other reason.

A copy of this form shall have the same force and effect as the original.

I acknowledge that I have read and understand its contents fully. The undersigned is the patient, the patient's legal representative or is authorized by the patient to execute this form and accepts its terms.
Release of Information for Billing Signature*

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Date*

MonthDayYear
Date
Appointment Preference (Appointments must be made within 7 days of discharge)

MonthDayYear
Date
Hour MinutesAM/PM Option
YesNo
Peer Name
Peer Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
NoYes
Student ID number (optional)
Are you requesting services to occur at a partner school?
You may download a paper copy here. Please complete the form and return it to your child’s school. Services will begin once insurance has been verified, and all required releases have been submitted.
BPS 89Niagara WheatfieldOlmsteadGrand Island SchoolsBPS 33BPS 3DavinciBPS 59BPS 131South Park HSBPS 81BurgardWaterfrontBPS 31iPrepRiversideBPS 72BPS 54BPS 76LafayetteSt. Mary's AcademyHoly Family SchoolTrinity Catholic SchoolBishop Ludden Jr./Sr. High SchoolMost Holy Rosary SchoolSt. Mary's SchoolSt. Rose of Lima SchoolBlessed Sacrament SchoolHoly Cross SchoolBishop Grimes Jr./Sr. High SchoolNotre Dame Jr./Sr. High SchoolNotre Dame ElementarySeton Catholic Central Junior/Senior High SchoolSt. John the Evangelist School
YesNo
Release of Information (ROI) for Educational Collaboration

Client Name: {clientName}
Date of Birth: {dateOf}

I, the undersigned parent/legal guardian of the above-named child, hereby authorize the release and exchange of confidential information between:

Agency/Provider Name: Mobile Counseling of New York LCSW, PLLC
Contact Information: 716-302-4545

AND

School Name/District: {schoolList}

Purpose of Disclosure:
To collaborate and communicate regarding the child’s care, condition, and needs for the purpose of developing and implementing an Individualized Education Plan (IEP) or other individualized support services to promote academic and emotional success in the school setting.

Information to Be Shared May Include:
Diagnostic information
Treatment summaries or recommendations
Behavioral observations and intervention strategies
Relevant educational or developmental history
Current services or supports being provided
This release is valid for one year from the date signed unless otherwise indicated below:
I understand that this authorization is voluntary and that I may revoke it at any time by providing written notice, except where information has already been shared in good faith.

Parent/Guardian Name (Printed): {nameOf}
Date: {date121}
Signature

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Welcome to Mobile Counseling of New York LCSW, PLLC

This agreement outlines the nature of therapy services, the purpose of the therapeutic relationship, ethical boundaries, and resources available to ensure your safety and well-being.

Please read carefully and feel free to discuss any questions or concerns with your
therapist.

1. Purpose of Therapy
The purpose of therapy is to support your emotional and psychological well-being by:
• Providing a safe, supportive environment to explore your thoughts, feelings, and
behaviors.
• Assisting you in identifying and working toward personal goals.
• OCering evidence-based techniques to help you overcome challenges and enhance
your quality of life.
Your therapist is committed to fostering a therapeutic relationship rooted in trust, respect,
and professional integrity.
2. Meaningful and Ethical Boundaries
Therapists follow a strict code of ethical guidelines to ensure a safe and professional
relationship. Key boundaries include:
• Confidentiality: Your privacy is a top priority, and your information will not be
shared without your written consent unless required by law.
• Professional Conduct: Therapists will always act in your best interest, providing
guidance within the scope of their expertise.
• Non-Exploitative Relationship: Your therapeutic relationship must remain
professional, free from any personal, financial, or social conflicts of interest.
• Respect: Your values, beliefs, and experiences will be honored without judgment.
If at any time you feel these boundaries are not upheld, you are encouraged to report
concerns.
To express concerns or discuss potential ethical violations, contact our office at: 716-
302-4545.
3. Respectful Relationship
A positive and respectful therapeutic relationship is built on:
• Open communication.
• A shared commitment to your therapeutic goals.
• Mutual respect for boundaries, time, and eCort.
If you have questions or need clarification on any aspect of therapy, your therapist is here to help.
In the spirit of mutual respect for time, session cancellations must be communicated at least 24 hours in advance. Requests to reschedule sessions are subject to the availability of your therapist and should also be communicated in advance. Repeated cancellations or late reschedule requests (3 or more) may lead to termination or a planned pause in services until the issue can be resolved.
4. Immediate Risk Resources
If you are experiencing an immediate risk to your safety or are considering harm to yourself,
the following resources are available for immediate assistance:
• National Suicide Prevention Lifeline: Dial 988
• Crisis Text Line: Text HOME to 741741
• Local Emergency Services: Dial 911
• Hospital Emergency Department: Visit your nearest emergency room.
• Local Crisis Services

Our practice is committed to providing a safe environment and helping you access the care you need.
Acknowledgment and Consent By signing below, you acknowledge that you understand the purpose of therapy, the ethical boundaries set forth, and the resources available. You agree to engage in treatment with respect and openness and to abide by our late cancellation/reschedule policy highlighted above.

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