New Patient Registration Form

Name*

First NameLast Name

E-mail*

example@example.com

Contact Number:*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Patient Name*

First NameLast Name

Patient Date of Birth*

MMDDYYYY

Concerns to be Addressed in Counseling?*

Who Referred You to Our Practice?*

Insurance Holder Name*

First NameLast Name

Insurance Holder Date of Birth*

MMDDYYYY

Insurance Company*

Insurance ID #*

If you don't know your number, type XXX

Social Security Number of Policy Holder*

This is required in order to submit an insurance claim

Practice Policies and Agreements

· Thank you for your interest in psychotherapy with Dr. Berman. We believe that it is important to discuss financial arrangements up front so that our relationship with you is direct and avoids any misunderstandings.

· Our fee for the initial diagnostic interview is $175.00. The standard fee for individual or family therapy is $150.00. These services are less than 55 minutes in length. Please free to ask about these fees, or fees for other services. You are responsible for any charges not covered by insurance.

· We require 48 hours notice if you wish to cancel or change an appointment. Failure to provide this notice will result in our billing you $75.00 for the missed session. If we do not see or hear from you for 30 days or more, we will assume that you have withdrawn from counseling.

· I consent to Lifespan Counseling Associates using and disclosing my protected health information to carry out treatment, payment, or health care operations for myself or my child. If this treatment is for a minor, I am a parent or guardian who is legally permitted to authorize treatment. I understand and have been provided with a Notice of Privacy Practices, which provides a more complete description of how my protected health information may be used or disclosed. I understand that I have the right to review the notice prior to signing this consent. I understand that Lifespan Counseling Associates reserves the right to change their notice and information practices and that I may obtain a copy of the revised notice by requesting a copy from the office staff. I have the right to revoke this consent by notifying Lifespan Counseling Associates in writing, except to the extent that Lifespan Counseling Associates has taken action in reliance on my consent.

· I understand that my records are protected under the applicable state law governing health care information that related to mental health services and under federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records 42 CRF Part 2, and can not be disclosed without my written consent unless otherwise provided for in state or federal regulations. Exceptions to written consent to disclosure include situations in which serious harm is imminent to the client or others, where there is suspected abuse, where the client shares information in the presence of others, or under court order. There are also limits to children’s rights to confidentiality.

Informed Consent for Telehealth Services

· There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.

· Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s).

· We agree to use the video-conferencing platform selected for our virtual sessions. I use a HIPAA compliant website. You can learn more about it here

· You need to use a webcam or smartphone during the session. At appointment time, log onto Doxy.Me/DrDeneBerman. Please write this down for future use.

· It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.

· It is important to use a secure internet connection rather than public/free Wi-Fi. It is important to be on time.

· We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.

· In the event of an emergency, call 911. In Montgomery County, you can also contact Crisis Care: 24 hours a day / 7 days a week, call Samaritan Behavioral Health at 937-224-4646. In Greene County, call the TCN Crisis Hotline at (937) 376-8701. There is a Suicide and Crisis Lifeline that you can access by dialing 988.

· If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions.

· You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.

· As your psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate, in which case I will recommend an alternative form of treatment.

By typing my name below, I agree and consent to using typed signatures, and acknowledge that my typed signature has the full effect of a physical signature.

By typing your name here, you agree to the Practice Policies and Informed Consent for Telehealth stated above. *

Counseling Request