New Client Paperwork

New Client Paperwork
Patient Name*

First NameMiddle NameLast Name
Patient DOB:*

MonthDayYear
Date
Email*
example@example.com
Phone Number:*
Please enter a valid phone number that our office can reach you at via phone call or text message from our secure phone system.
Do you give our office permission to call or text the phone number you listed?*

YesNo, if selected you will not receive reminder texts for your appointments.
Emergency Contact Name:*

First NameLast Name
Emergency Phone Number:*
Relationship*
Provider you are scheduled with...*
Date of 1st Appointment*

MonthDayYear
Date
Enter Pharmacy Information*

Demographic Information

If you already completed the New Client INTAKE Request Form, you can select 'Yes' and skip this page.
Have you already completed our New Client Intake Request Form before scheduling your appointment or receiving this form?*

YesNoI'm not sure.
Patient Gender:
Cell Phone Number*
Please enter a valid phone number.
Social Security #:*
Address (Mailing)*

Street Address

CityState

Zip Code
Do you have insurance?*

YesNo, I will be SELF PAY
Primary Insurance: *
If you do not see your insurance, please select Other.
OTHER Insurance Name:
Member ID/Policy# (Primary)*
Please enter your Member ID/Policy# as shown on your insurance card.
Policy Holder (Primary)*

SelfOther
Relationship to client:*
Policy Holder Name:*

First NameLast Name
Policy Holder DOB:*

MonthDayYear
Date
Policy Holder SSN#: (if applicable):
Do you have secondary insurance?*

YesNo
Secondary Insurance:
Member ID/Policy# (Secondary)

Information

Please enter all applicable information.
Please list family members IN the household and their relationship to you.
List immediate family members NOT in the household.

Biopsychosocial History
Presenting Problems
Symptoms Checklist (Please do NOT leave blank)*
Prior Psychotherapy, Counseling, Inpatient Stays? *
If yes, please provide information below.
Family Psychiatric History?*
If yes, please provide information below.

Medical Information (continued)

Please provide the following information in regards to the client. If a child is the client, please complete the form for your child.
Are you currently on any medications?*

YesNo
Please list all medications and the dosages you are currently taking.
Primary Care Physician (PCP):
Permission to contact PCP, if needed?

Yes, permission grantedNo, permission denied
Please list below your GOALS, STRENGTHS, MOTIVATION, etc. Also, do you have family support and is your spouse (if applicable) willing to meet with the counselor in order to improve your therapy?*

Social Media Policy

Please read the following and sign.
Social Media
The use of social media and electronic communication is a convenient and often
preferred way of communicating. However, privacy and confidentiality are not
guaranteed in these forms of communication. The Clinical staff, i.e., counselors and
Nurse Practitioners from New Horizons Counseling Center do not communicate with, or contact clients through social media or networking platforms such as Twitter, Facebook, LinkedIn, Google, Instagram, Pinterest, etc. Additionally, if they discover that they have accidentally established an online relationship with you, they will cancel that relationship. This is due to the significant security risk these types of casual social contacts can create for you.

Our clinical staff may participate on various social networks for personal and
marketing purposes, but not in their professional capacity as a Counselor. If you have an online presence, there is a possibility that you may encounter them by accident. If that occurs, please discuss it with your counselor during your next session. We have researched this issue and concluded that social media communications with clients have a high potential to compromise the professional relationship. Please do not attempt to contact counselors in this way.

If you have any questions about anything in this policy, please bring them up with
your clinical staff member. As recent technology develops and the Internet changes, there may be times when New Horizons Counseling Center may need to update this policy. Clients will be notified in writing of any policy changes. The website will also be updated to reflect any changes.

"Friending"
Our clinical staff members do not accept invitations from current or former clients to participate in their online social networks, nor do they invite clients to participate in their own personal online social networks (e.g., Facebook, Twitter). The practice of adding clients as friends or contacts on these sites can compromise your
confidentiality and our respective privacy. It may also blur the boundaries of the
therapeutic relationship. If you need to contact your clinical staff member between
sessions, please email, phone or text (depending on the preference of yourself and
your clinical staff member. If you have questions about this, please bring them up
when with your clinical staff member in your next session.

Following
At times, New Horizons Counseling Center posts articles related to wellness and
psychology on our website, on the New Horizons Counseling Center web page and
may make other posts on Twitter or Instagram. We have no expectation that you as a client will follow these posts. Our primary concern is your privacy, so comments have been disabled on our website. You are welcome to use your own discretion in choosing whether to follow New Horizons Counseling Centers posts.

New Horizons Counseling Centers clinical staff do not follow current or former clients on blogs or Twitter. If there are things from your online life that you wish to share with your clinical staff member, please bring them into your session where we can view and explore them together, during the therapy hour.

Interacting
Please do not use messaging on social media or networking sites to contact your
clinical staff member. These sites are not secure, and the messages may not be read in a timely fashion. Do not use Wall postings, @replies, or other means of engaging with your clinical staff online if you have an established therapeutic relationship. Engaging with your clinical staff in these ways can compromise your privacy and may also create the possibility that the exchanges will need to be documented and archived in your client records, becoming a part of your legal, medical record.

Our clinical staff recognize that viewing clients’ online activities without their consent, and without explicit arrangement towards a specific purpose, could potentially have a negative influence on the working relationship. If there are things from your online life that you wish to share with your clinical staff, please bring them into your sessions where we can view and explore them together, during the therapy hour.

Text Messaging/SMS
Because text messaging is not a secure mode of communication, New Horizons clinical staff will not text message nor will they respond to text messages from anyone in therapy, with any clinical staff, concerning any matters other than scheduling or rescheduling appointments. So, please do not text message me unless we have made other arrangements.

Websites
New Horizons Counseling Center has a professional website that you are free to
access to obtain information about our practice. You are welcome to access and
review the information on the website and, if you have questions about it, please
discuss them with your counselor during your therapy sessions. The website includes a contact form to use if you do not have your counselor’s New Horizons email address. Please include your counselor’s name and the word ‘confidential’ in the subject field. The email will then be forwarded unread to your counsellor. For example: Attn: Counsellor Joe, Confidential.

Use Of Search Engines
Counsellors will not use web searches to gather information about you without your
permission. It is our belief that this violates your privacy rights; however, we
understand that you might choose to gather information about your counselor in this way. There is an incredible amount of information available about individuals online, much of which may be known to that person and some of which may be completely inaccurate or unknown. If you encounter any information about your counsellor through web searches, or in any other fashion for that matter, please discuss this with your counselor during a session so that you can discuss its potential impact on your treatment.

Although it is not a regular practice for our counselors to search for clients on Google or Facebook or other search engines, extremely rare exceptions may be made during times of crisis. If they have a reason to suspect that you are in danger or if it becomes necessary as part of ensuring your welfare. These are unusual situations and if counsellors ever resort to such means, they will fully document it and discuss it with you in person as early as is feasible.

Business Review Sites
You may find New Horizons Counseling Center on sites such as Yelp, Google, Yahoo
Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site.

You have a right to express yourself on any site you wish. Please note that by posting publicly about your counselor or counseling experience, you may inadvertently expose your confidential information. We urge you to take your own privacy as seriously as we take the commitment of confidentiality. You should also be aware that if you are using these sites to communicate indirectly with your counselor about your feelings about our work, there is a good possibility that they may never see it.

The therapeutic alliance is essential to the success of therapy. The relationship is so important in counseling that there must be a good fit. Not every counselor is a good fit for every client. What works for one person in therapy may not work for another. Counseling is a subjective and unique experience.

If you have a concern about a counselor, clinical staff member or a session, the best approach would be to discuss that concern in person with the counselor or clinical staff member. Discussing reactions with the counsellor or clinical staff member, whether they are positive or negative can be an important part of therapy. Even if you choose not to return to a counsellor or clinical staff member, it is important to let that individual know directly why you felt it was not a good fit. By doing so, you may provide helpful information to the person, and they may also gain a sense of closure.

Sometimes clients may not feel safe or able to speak directly to their clinical staff
member. They then have the option of contacting the New Horizons Counseling Center at admin@Newhorizons.com If there is an ethical issue or a client feels that something wrong has occurred, after all other options have been exhausted, a complaint can be filed with the counselor’s or nurse practitioner professional association or the
regulatory body that registers that counselor. The regulatory body will investigate
and act if they deem it necessary. Please note that when filing a formal complaint, it is possible that details of therapy may be revealed in the investigation. Information on our counselors’ registration numbers and register body are found on receipts and on the website.

Protecting your confidentiality means that our clinical staff member cannot tell people that you are a client. But you are welcome to tell anyone you wish who your clinical staff member is or how you feel about the treatment provided to you, in any forum of your choosing. But please do not rate or review your clinical staff members work with you on any of the above-mentioned websites while you are in still in treatment. Doing so has a significant potential to damage your ability to work together and may jeopardize your own privacy.

Location-Based Services
If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. New Horizons Counseling Center is placed as a check-in location on sites such as Foursquare, Facebook, Google, Gowalla, Loop, etc. If you have GPS tracking enabled on your device, it is possible that others may conclude that you are a therapy client due to your location.

Thank you for taking the time to review the New Horizons Counseling Center social
media Policy. If you have questions or concerns about any of these policies and
procedures or regarding our potential interactions online, please bring them to the
attention of your counsellor so that you can discuss them.

Thank you
Signature*

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Name of person signing

First NameLast Name
Today's Date:

MonthDayYear
Date

Office Billing, Insurance, and No Show/Late Cancelation Policy
I authorize:

• use of this form on all of my insurance or other payor submissions.

• the release of information to my insurance company or other payor.

• direct payment from my insurance company or payor to {provider) and/or New Horizons Counseling Center, L.L.C.

I understand:

·         It is my responsibility to pay any deductible amount, co-payment, or co-insurance amount on the day and time services are provided.

·         Reminder calls/texts are not guaranteed and are provided as a courtesy. Clients are responsible for keeping track of their appointment dates and times.

·         Appointments are expected to be cancelled at least 24 hours prior to the appointment time. If necessary, I may leave a message on the office voicemail of New Horizons Counseling Center.

·         Failure to provide appropriate notice of cancellation will result in a $60.00 failed appointment fee.

·         Delinquent accounts will be turned over for collection after 90 days unless prior payment arrangements have been made.

·         Fees for court appearances or reports written for legal purposes will not be charged to insurance companies and are my responsibility. These fees must be paid prior to the reports being released.   It is my responsibility to request a copy of court related fees.
In signing this, I consent to counseling services for myself and/or dependent and agree to the above billing policy. I also acknowledge that I have been given a copy of {Provider} “Declaration of Practices and Procedures” which includes information regarding the patient medical relationship, billing, emergency information, and limitations to confidentiality. Signature*

Powered by Jotform SignClear
Name of person signing

First NameLast Name
Today's Date:

MonthDayYear
Date

Release of Information
I, Your Name* hereby authorizeProvider Name at New Horizons Counseling Center, LLC to release information pertaining to my sessions to:
please enter PCP / Family Member Name / Others whom information can be released to
for the purpose of Case Consultation.

Information to be Release:
No limitation, any information may be released to the party above

No, I DO NOT grant release to outside parties at this time.

I understand that authorization shall remain valid until revoked by the client. I have been informed that I may revoke this authorization by written or oral communication to   Provider Name   at New Horizons Counseling Center, L.L.C. I certify that this form has been fully explained to me and that I understand its contents.

Signature Of Client*      Date

If Minor: Signature of Guardian   Date
Should be Empty:

New Client Paperwork

Demographic Information

Information

Biopsychosocial History

Medical Information

Medical Information (continued)

Social Media Policy

Office Billing, Insurance, and No Show/Late Cancelation Policy

Release of Information