Couples New Client Paperwork

A Better Way Counseling Service, LLC

New Client Information Form - for Couples
Each individual must fill out their own copy of this form.
Today's Date

MonthDayYear
Date
Client's Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Legal Sex*
Gender Identity
Pronouns*
Client Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN
(Social Security Number)
Phone Number*
Is it okay to leave detailed messages at this voicemail?*

YesNo
Email*
example@example.com
Do you agree to receive email reminders?*

YesNo
Do you consent to receiving documentation via email?*

YesNo
I understand that all email messages are sent over the Internet and are not encrypted, are not secure, and may be read by others. I understand that my email communications with my therapist will NOT be encrypted and, therefore, my therapist can NOT guarantee the confidentiality and security of any information we send via e-mail. I understand that SMS/phone messages are even less secure than email, and the same conditions apply. I understand that for this reason my therapist has advised me not to send sensitive information via email or SMS message. This includes information about current or past symptoms, conditions, or treatment, as well as identifying information such as social security numbers or insurance identification information. Reminder and voicemail services will only be used for scheduling or billing purposes.
I consent to the above statements regarding Email and Phone Communication: Client Signature*

Clear

Current Medications (if any)
Are you employed?*

YesNo
Place Of Employment*
If unemployed please enter unemployed.
What brings you to counseling?*

0/150
Have you had prior counseling? If yes, what was it for and how long ago was your treatment?*

0/150
Have you had a mental health diagnosis? If yes, when were you diagnosed? (e.g., PTSD, anxiety, depression, bipolar, etc.)*

0/150
Do you use Drugs or Alcohol? If yes, is it used recreationally or medicinally, and how frequently are you using? *

0/150
Are you currently or in the past experienced any Suicidal Ideation? If yes, how frequently, have there been any attempts or plans? *

0/150
Do you currently feel safe at home, and has there been or is there currently any sort of abuse? (e.g., emotional, verbal, physical)*

0/150
How did you hear about A Better Way Counseling Services*
If applicable, name of person who referred you
Emergency Contact*

First NameLast nameRelationship
Phone Number*
Phone Number

Disclosure
Therapist/Clinician's Name*
Please choose your clinician here, and open their disclosure.
I am signing to agree that I was able to review the dislosure statement for the above therapist, whom, I will recieve services from A Better Way Counseling Services, LLC. I acknowledge that a copy of this document is always available to me upon request. I agree to all the sections of the disclosure statement, including:
(Please check all below*)*

I have read and reviewed my rights regarding my Protected Health Information (PHI).I have read and reviewed the terms of consent.I have read and reviewed the financial terms & conditions.I have read and reviewed email and phone messaging informed consent.
I have received my therapist's disclosure statement and agree to the above statements: Client Signature*

Clear

Appointment Policy
Thank you for choosing us as your mental health provider. We are committed to your treatment being successful. Our goal is to provide quality, individualized mental health care. We would like to remind you of our policy concerning appointments. It is required for us to make appointments in order to see our clients as efficiently as possible.

You will receive an automated appointment reminder email 48 hours before your appointment. In order to be respectful of the needs of other clients, please be courteous and call our office promptly if you are unable to show for an appointment. The time will be reallocated to someone who is in need of treatment.

If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance and email us at cancelabwcs@gmail.com. Appointments are in high demand and your early cancellation will allow another client access to timely mental health care. No-shows and late-cancellations cause problems that go beyond a financial impact on our practice. When an appointment is made, it takes an available time slot away from another client. No-shows and late cancellations delay the delivery of mental health care to other clients, some of which are in great need of our services. A no-show is missing a scheduled appointment. A late cancellation is canceling an appointment without calling us to cancel 24 hours in advance. Arriving too late to an appointment will be treated the same as a no-show or late cancellation. If you do not provide adequate notice, you will be charged the full appointment fee.

To cancel your appointment, please call 360-281-6824 AND email us at cancelabwcs@gmail.com. If you do not reach one of our office staff, you may leave a detailed message on our voicemail. We encourage you to ask any questions you may have regarding our attendance policy so that you may have a clear understanding. We value you as a client and look forward to serving you. If you cancel a session with less than 24 hours notice, the full session fee will be charged to the client. This fee can be waived in the case of an emergency, with permission from the counselor. By signing below you acknowledge that you have read and understand this appointment policy and accept the above-mentioned terms.
If you cancel a session with less than 24 hours notice, the full session fee will be charged to the client. This fee can be waived in the case of a documented emergency, or at your counselor’s discretion.

By signing below you acknowledge that you have read and understand this appointment policy and accept the above mentioned terms.
I read and consent to the cancellation policy: Client Signature*

Clear

Financial Policy
Thank you for choosing us as your mental health provider. We are dedicated to providing the best possible care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your
care and treatment. In order to reduce confusion and misunderstanding between our clients and our practice, we have adopted the following financial policy.

If at any time you are eligible for insurance or your insurance plan changes, please notify the office immediately. Without doing so there may be a lapse in reimbursement that you could be responsible for.

We do not under any circumstances accept Cobra insurance coverage. If we are alerted you are using Cobra you will be responsible for all fees. If your insurance is ending and you now have Cobra, please call the office to discuss what the cash rate would look like for your provider.

Whether you are paying fully out of pocket or have mental health coverage with your insurance, our staff is prepared to answer your questions and concerns. We understand that even with insurance, most clients will experience at least some out-of-pocket expenses. The amount insurance pays varies from one policy to another. As a courtesy service to you, we will call to verify the extent of your coverage and review the results with you. However, the final extent of your coverage and the exact amount of your liability can only be determined after your claims have been processed by your insurance carrier. We recommend all of our clients take the time to verify their own coverage for mental health care before beginning treatment at our office. The benefits quoted to us by your insurance company are not a guarantee of payment. Your insurance policy is a contract between you and your insurance company. If for any reason your insurance company does not pay for services or deems certain procedures as non-covered, you will be responsible for the complete charge. Any balance due is your responsibility and payment is due upon receipt of the statement from our office.

A bill for services rendered will be sent to you in the event there is a difference between what was paid at the time of service and what insurance has placed towards your responsibility. If you have a dispute concerning an account balance, we advise you to contact your insurance company first and then
contact our office.

We require a credit card to be stored in your file. This card number is stored in a secure and HIPPA-compliant system. It will only be charged in the instances stated below. All transactions will include a processing fee of 3.5%. The regular fee for your attended session will be automatically charged to this card the business day following your appointment. Late cancellations (less than 24 hours notice) and no-show fees will also automatically be charged to your card.

If you are a client who is using insurance, then the late cancellation fee charged will be the rate contracted with the insurance company for sessions. Please inquire with the office if you have questions about what the fee would be, based on your insurance. If you are a cash-paying client, then the cancellation fee is the full amount you pay for each session.

If your credit card payment does not go through, we will attempt to contact you before your upcoming appointment. If we cannot reach you, future appointments may be canceled until payment is received.

Please call our office at 360-281-6824 AND email us at cancelabwcs@gmail.com if you need to cancel or reschedule. Both are necessary to cancel your appointment. Please also indicate if you will attend your next scheduled appointment, in your email. Thank you for your cooperation.

We encourage you to ask any questions you may have regarding our financial policy so that you may have a clear understanding. If a financial hardship exists, please speak with a member of our staff concerning your treatment options. Our goal is to concentrate on returning you to optimal health and to establish overall well being. We value you as a client and look forward to serving you.
By signing below you acknowledge that you have read and understand this financial policy and accept the above mentioned terms.
I read and consent to the financial policy: Client Signature*

Clear

I read and consent to the credit card policy, and am aware the office will be charging my card for appointment fees and late cancellations: Client Signature*

Clear
Are you planning on using Health Insurance?*

YesNo

Health Insurance Provider
Insurance Carrier*
ID Number*
Group Number*
Provider Phone Number
Authorization Number (Only if insurance coverage is through an EAP program)
Are you the Primary Subscriber?*

YesNo

Release of Information for Insurance Provider
I authorize the following information to be exchanged between the below party and A Better Way Counseling Service, LLC:
Please check all that apply:*

Intake InformationProgress ReportDischarge SummaryTreatment PlanDates of ServicePhone ContactPayment
Insurance Provider:*
This release is valid for one year after completion or termination of designated treatment. A patient may revoke in writing a disclosure authorization to a health care provider at any time unless disclosure is required to effectuate payments for health care that has been provided or other substantial action has been taken in reliance on the authorization. A patient may not maintain an action against the health care provider for disclosures made in good-faith reliance on an authorization if the health care provider had no actual notice of the revocation of the authorization. In compliance with WAC 388-60-0145 we will have to consider if the release is required for continuing your treatment program. If a required release is revoked we may terminate you from our program.
I consent to release of the above information to my health insurance: Client Signature:*

Clear

Release of Information for Primary Care Physician
Communication between Behavioral Health providers and your Primary Care Physician (PCP) is important to ensure that you receive comprehensive and quality health care. There are circumstances when your Behavioral Health condition and/or medications will influence treatment of your physical conditions. Many times behavioral health and physical health share a connection. This form will allow your Behavioral Health Provider to share Protected Health Information (PHI) with your PCP. This information will not be released without your signed authorization. This PHI will only include diagnosis, treatment plan and medication, if necessary. Information relating to any psychotherapy notes or conversations will not be shared.

I, the undersigned, understand that I may revoke this consent at any time. I have read and understand the information and give my authorization.
Client Authorization (please check all that apply):*

I agree to release any applicable mental health/substance abuse information to my PCPI WAIVE notification of my PCP that I am seeking or receiving behavioral health services and I direct you NOT to notify him/her.I do not have a PCP and do not wish to see or confer with such an individual. I, therefore, WAIVE NOTIFICATION of a PCP that I am seeking or receiving behavioral health services.
If you agree to release any applicable mental health/substance abuse information to your PCP, then please proceed filling out the following:
My Primary Care Physician Name: (write n/a if you do not have a PCP)*

First NameLast Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Phone Number

Area CodePhone Number
I consent to release the above information to my PCP: Client Signature:*

Clear

Partner Release of Information

Please fill out the Release of Information below for information to be released to your partner.
I authorize the following information to be exchanged between my partner (who will be in counseling) and A Better Way Counseling Service:
Please check all that apply*

Summary of TreatmentProgress ReportsDischarge SummaryDates of TreatmentTreatment PlanPhone ContactIn Session CommunicationPayment
Partner's Name*

First NameLast Name
Relationship to you*
Phone Number

Area CodePhone Number
I agree to release the above information to my partner: Client Signature*

Clear
This release is valid for one year after completion or termination of designated treatment. A patient may revoke in writing a disclosure authorization to a health care provider at any time unless disclosure is required to effectuate payments for health care that has been provided or other substantial action has been taken in reliance on the authorization. A patient may not maintain an action against the health care provider for disclosures made in good-faith reliance on an authorization if the health care provider had no actual notice of the revocation of the authorization.
Should be Empty:

A Better Way Counseling Service, LLC

Disclosure

Appointment Policy

Financial Policy

Release of Information for Insurance Provider

Release of Information for Primary Care Physician

Partner Release of Information