.HPPGA New Client Intake Packet

Healing Psychotherapy Practices of Georgia, LLC

3750 Palladian Village Dr., Suite 320 Marietta, GA 30066 Tel: 770) 792-0079

Confidential Client Information and Agreement

Todays Date*

Date

Name*

First NameLast Name

Date of Birth*

Date

Age*

Home Phone*

Work Phone

Other Phone

OK to leave messages at which number

Home Address*

City*

State*

Zip*

Drivers License State

EmailAddress*

example@example.com

Can we send you our monthly e-newsletter? (please check one)

YES thanks

NO thanks

Legal Guardian for (minor client). If this does not apply, mark N/A*

Guardians date of birth

Date

Age

Employer

Occupation

Spouse's / Partner's Name

Date of Birth

Date

Partner's Employer

Partner's Occupation

Person to Contact in Case of Emergency*

Relationship*

Emergency Contact Home Number*

Work Phone

Other Phone

Primary Care Physician (PCP)

PCP Phone

Who May We Thank For Referring You*

POLICIES AND PROCEDURES

The following are our policies and procedures. Please read them carefully and ask any questions you may have before signing this agreement.

Initial next to each number below.

1. Phone calls: Calls are returned Tuesday through Friday, we attempt to return calls in a timely manner. Please leave your phone number with your message. If you need to speak with your therapist or office staff prior to your next appointment, please call our office during regular business hours.*

2 Emergencies: If you have an emergency that cannot wait for a call back please call 911 or go to your nearest Hospital Emergency Room*

3 Cancellation policy: If you are not able to attend a scheduled appointment we ask that you cancel 24 hours prior to that scheduled appointment If you fail to cancel a scheduled appointment 24 hours prior we cannot use this time for another client who may need the support Therefore you will be assessed a fee for the missed appointment*

4. Billing: The following billing policies apply: a. Fees for sessions are due at the time of service. We accept cash, check, money order, and credit cards. There will be an additional $10 fee for bounced checks. b. We require that you place a credit card on file, for collection of any outstanding debts.*

c. A fee of $100 will be charged for no show/no calls or appointments not cancelled 24 hours prior to scheduled appointment time. Please note this may vary for clients using insurance and depends on the contract that we have with the insurance provider. If there is a credit card on file, this will be used to collect the monies owed.

d. By listing your credit card on our Credit Card Authorization Form, or any other official financial form provided by our office, you are giving us permission to store your card information in our electronic medical/billing record systems. The credit card that you place on file is the card that we will use to collect on ALL outstanding monies owed. By providing your credit card information, you are giving us permission to store your credit card number in our electronic medical/billing record systems. When collecting on monies owed, your credit card number may be manually typed into our electronic billing system.

e. If we are unable to collect on monies owed, be advised that uncollected fees may be turned over to the office's collection agency. Only necessary information will be released to them. Please be assured that we will make every effort to work with you before this happens.

f. In the event of a chargeback from the client, we will provide the requesting bank, credit card agency, and/or organization with necessary paperwork to show proof of charges owed and services rendered. If our valid charges are denied in this process, we reserve the right to turn your account over to a collection agency to recoup funds for services rendered.

POLICY FOR COMPLETION OF FORMS

An administrative fee is charged for the completion of all documents/questionnaires presented by patients for completion by providers. (Please see Fee Schedule below These documents include but are not limited to disability insurance benefit forms, Family and Medical Leave Act (FMLA) forms, school forms, and medical reports. These fees are due prior to the completion of the

Our priority is providing treatment to our patients, therefore we process form requests within 7 to 10 business days, depending on the number of form requests already filed.

Completing Forms and writing letters

up to 3 pages - $65.00

Beyond 3 pages - $130.00

CONFIDENTIALITY

Contents of all therapy sessions are considered to be confidential. Exceptions are as follows:

Suicide/Homicide

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.

Legal

To respond to a subpoena from a court.

**Information that may be requested in any of the above limits includes: type of services, dates/ times of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries.

Client Signature*

CONSENT TO TREATMENT

By signing this Client Information and Confidentiality, and Consent Form as the Client or Guardian of said Client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am agreeing to receive a mental health assessment and treatment or for my minor dependent to receive these services. I understand that I may stop treatment at any time that I choose.

Client Signature Clients ParentGuardian if under 18*

Date*

Date

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

I understand that at my request I have the right to view or have a copy of the privacy practices of Healing Psychotherapy Practices of Georgia, LLC. This will outline how my protected health information can be used and shared and what I can do if I have problems or questions while receiving services from Healing Psychotherapy Practices of Georgia, LLC.*

Yes, I acknowledge.

Signature*

Print Name*

Date*

Date

TELE-MENTAL HEALTH INFORMED CONSENT

I, (client first and last name) hereby consent to participate in counseling sessions via tele-mental health with a licensed clinician who works for Healing Psychotherapy Practices of Georgia, LLC. I understand that tele-mental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.*

First NameLast Name

I understand the following with respect to tele-mental health:

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.
I understand that there are risks and consequences associated with tele-mental health, including but not limited to, disruption of session transmission due to technology failures, interruption and/or breaches of confidentiality if participants are not in a secure and confidential area while having their session, and/or limited ability for the clinician to respond to emergencies.
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.
I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to tele-mental health, unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; legal proceedings where a judge court orders records
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 tele-mental health services are not appropriate and a higher level of care is required.
I understand that during a tele-mental 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 five minutes, your therapist will call you at the number
I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

EMERGENCY PROTOCOLS

I need to know your location in case of an emergency. You agree to inform me of this information each session.
I have read the information provided above and asked any questions I might have had. I agree that the information contained in this form and all of my questions have been answered to my satisfaction and I agree with it.

Signature of client/legal guardian*

Date*

Date