Alba Wellness Intake

Alba Wellness Intake
Name *

First Name Last Name
Name of client if a minor *

First Name Last Name
Birth Date of Client *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email
example@example.com
Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
Can we give you a courtesy call reminder for your appointments? *

Yes No
Emergency Contact

First Name Last Name
Phone Number

Area Code Phone Number
Reason for seeking therapy
Current medications
Have you seen a therapist in the past?

Yes No
If so, when and for what reason?
Referred by:

Friend Insurance Website Healthcare Professional
Therapy Agreement

By signing this form, I understand and agree to the following fee schedule. I am responsible for the applicable service fees, if insurance does not pay.

LPC 60 min. Initial Assessment	$120
LPC 45 min Counseling	$90
LPC 30 min Brief Therapy	$90
LPC 45 min family/couples counseling	$90
LPC 15 min Phone Consultation	$30
LPC Group Therapy (45-60 min)	$50
LPC legal/court rate	$200
Late cancellation(Less than 24 hr or No Show)	$55
LPC intern 60min Intake (Initial Assessment)	$65
LPC intern 45min Counseling	$55
LPC intern 30min Counseling	$55
LPC intern 45min Family/Couple counseling	$55
LPC intern 15min Phone Consultation	$20
LPC intern Legal/Court rate	$150
Medical Records/Simple Letters/Reports	$25

At AWI, we attempt to balance the client’s wellbeing with the need to create a comfortable working environment. It is a simple reality that there are times when life is challenging and paying for services is difficult. Our process for addressing this concern is as follows:
a. Client may qualify for a fee on a sliding scale.
b. Client may see an intern for a reduced rate.
c. Client may be considered a “pro bono” case.
d. Client may be given references for services at another agency.

Signature *

Clear
Date *

Month Day Year
Date
Insurance
Name of Insured
Name of Client
Insurance ID#
Group #
DOB of Insured
Client ID# (if different from insured)
By signing this intake form, I acknowledge that all the information above is correct to the best of my knowledge and I assume responsibility for charges not covered by insurance.
Signature

Clear
Date

Month Day Year
Date
Notice of Cancellation and No Show Policies

Does not apply to Texas Medicaid clients
We understand that situations arise in which you must cancel your appointment. Therefore, it is requested that you must provide more than 24 hours notice to cancel or reschedule your appointment. This allows another person waiting to schedule in that appointment slot. Appointments which are canceled or rescheduled with less than 24 hours notification are subject to a $55.00 cancellation fee. Patients who do not show up for their appointment without a call to cancel are considered as no show and subject to a $55.00 fee as well. Patients who No-Show twice in a 12 month period, are denied any future appointments unless no show fees are paid in full. If client cannot pay the fees, they are provided referrals to other agencies. The Cancellation, Reschedule, and No Show fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment. Our practice firmly believes that a good counselor/client relationship is based upon understanding and good communication.

Thank You
Signature *

Clear
Date *

Month Day Year
Date
Required Credit Card Information

We require credit card information in order receive services. This card will be charged for copays/charges related to services provided. Please fill out this portion, and note that in the unlikely event there is a late cancel, no show or reschedule without 24 hour notice, we will charge this card $55 as indicated on the service fee portion of this document. You will be provided a receipt upon request.**Does not apply to Texas Medicaid clients**
Card Type

Visa MC Amex Discover
Card Number
Expiration Date
Security Number (Three digit code)
Name on card
Signature *

Clear
Date

Month Day Year
Date
Statement of Informed Consent
Upon entering into a counseling relationship, there are specific rights you should be aware of before consenting to treatment. Please review this document carefully and feel free to ask any questions you may have about its’ contents.

Purpose, goals, and techniques

Counseling is a professional relationship that empowers individuals to accomplish mental health, wellness, education, and career goals. To this end, your therapist will partner with you to identify specific problems you choose to address and help you develop solutions. This process involves discussions and activities identified by you and your therapist that explore the connections between your thoughts, emotions, and behaviors.

Potential Risks of Counseling

The discussion of sensitive issues may be part of the process and may put you in the position to experience some uncomfortable emotions/thoughts, as well as, face painful decisions about your life. Together you and your therapist will work through these thoughts and feelings

Right to appropriate referrals

You have a right to request referrals to other mental health professionals at any time. Your therapist is obligated to provide these referrals when:

Either you or your therapist determine, either individually or collaboratively, that the services provided are not meeting your needs.
When your needs are outside the therapist’s scope of practice
When you request referrals for any reason
Provider Consultation

Mental Health Professionals regularly seek consultation with their colleagues to ensure the highest quality of therapy for the clients and to analyze personal biases. Despite the extra expense to the therapist for this consultation, it is essential to maintain the highest standards for your care. All legal and ethical confidentiality laws and standards apply during these professional consultations.
Initials *
Records

Your medical records are property of Alba Wellness. Individual clients, legal guardians, and parents have a right to request copies of records. In cases, in which, a couple or a family is seen by a therapist, all adults have a right to those parts of records that pertain to themselves as a client (as well as a right to their children’s records). This does not mean that the individual has a right to the information in the record regarding the other partys. You may be given a copy upon request for a fee of $25.

Right to Terminate Therapy

While therapists strive to partner with clients to address important issues, there are understandable circumstances in which a client may need to terminate therapy. In most circumstances, you and your therapist will work together to determine when therapy should come to an end and how to make that transition as easy as possible. However, should you decide at any point to terminate this relationship it is your right to do so.

Termination

I understand that after the final session or in the event that I have not attended a therapy session in three months, the client/therapist relationship will be considered closed unless I initiate further contact. I further understand that I can reinitiate therapy after my case is closed.

Rights of Confidentiality (limits of confidentiality)

All information discussed in sessions is completely confidential, unless specified in writing on the Consent for the Release of Information form. There are three (3) conditions under which confidentiality is breached. These are:
- Situations involving child or elder abuse
- Situations involving abuse or exploitation of the disabled
- Situations in which a client expresses suicidal/homicidal thoughts, plans, and a willingness to carry out those plans
In situations when child or elder abuse is reported, it is our legal responsibility and policy to contact the appropriate state and local agencies. This requirement also extends to situations where there is reported exploitation or abuse of the disabled. Suicidal or homicidal thoughts when connected to a plan to carry out such actions, and a clear intention to follow through with such a plan legally require us to notify local crisis responders.

Adult Protective Services (800)252-5400
Child Protective Services (800)252-5400
San Antonio Police Department 911 or Non emergency (210)207-7273
Universal City Police Department 911 or non emergency (210)658-5353
Bexar County Sheriff's Department 911 or non emergency (210)335-6000

As outlined in the Alba Wellness Privacy Practices, insurance companies can request your medical records as part of treatment reviews and verification of services provided by an Alba Wellness Inc. provider. By signing below, I agree that I have read and understand the above information.
Signature *

Clear
Date *

Month Day Year
Date
Notice of Privacy Practices

You may find the Privacy Practices of Alba Wellness in the waiting room or online at www.albawellness.net. My signature below indicates that I have been informed where the Notice of Privacy Practices can be viewed. If you have any further questions, please ask a member of our staff or email us at info@albawellness.net.
By signing this intake form, I acknowledge that all the information above is correct to the best of my knowledge
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

Alba Wellness Intake

Therapy Agreement

Notice of Cancellation and No Show Policies

Required Credit Card Information

Statement of Informed Consent

Notice of Privacy Practices