Adolescents 13 to 17 - Parent Form - New Client Paperwork

A Better Way Counseling Service, LLC

New Client Information Form - To Be Filled Out By Person Financially Responsible for the Adolescent Client's Treatment
Today's Date

Month Day Year
Date
CLIENT Full Name *

First Name Last Name
CLIENT Date of Birth *

Month Day Year
Date
Financially Responsible Party: Name *

First Name Last Name
Relationship to Client *
Financially Responsible Party: Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Financially Responsible Party: Phone Number *
Is it okay to leave detailed messages at this voicemail? *

Yes No
Email
example@example.com
Do you consent to receiving documentation via email? *

Yes No
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.
Financially Responsible Party Name

First Name Last Name
I consent to the above statements regarding Email and Phone Communication: Financially Responsible Party 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 necessary for us to make appointments in order to see our clients as efficiently as possible. 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 cancelling 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, a fee will be assessed and will be due in full at the time of the missed appointment.

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 voice mail. 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 the client cancels 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.
Financially Responsible Party Name

First Name Last Name
I have read and consent to the appointment policy: Financially Responsible Party 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.

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 expense. 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 his or her 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 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 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 on the day of your appointment, before the session with your therapist has begun. 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 are not able to reach you, future appointments may be cancelled 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.
Financially Responsible Party Name

First Name Last Name
I read and consent to the financial policy: Financially Responsible Party Signature *

Clear

Credit Card Policy
As stated in the appointment and financial policy you have just read, failing to give 24 hours notice of needing to cancel your therapy appointment will incur a fee. If you do not show up to an appointment or don’t cancel your session at least 24 hours before the scheduled time, then we will automatically charge the late cancellation fee to the card that you provide us. 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.

The regular fee for your attended session will also be automatically charged to this card after your appointment with your therapist has begun. If you have questions about what your rate or copay for sessions will be, please contact the office.

All transactions will include a processing fee of 3.5%.

If you haven't provided this card information already, please expect a call from the office where we will ask for your credit or debt card number, so that we can put it on file. This card number is stored in a secure and HIPPA compliant system. It will only be charged in the instances stated above.

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.
Name on Credit Card *

First Name Last Name
Number *
Number
Security Code *
Expiration Date *
Billing Zip Code *
Email Address to Send Receipts *
example@example.com
I give the ABWCS office permission to charge my credit card at the time of my scheduled therapy appointment: *

Yes No
Financially Responsible Party Name *

First Name Last Name
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: Financially Responsible Party Signature *

Clear
Are you planning on using Health Insurance? *

Yes No

Health Insurance Provider
Upload Front of Insurance Card

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Cancel of
Upload Back of Insurance Card

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Cancel of
Insurance Carrier *
ID Number *
Group Number *
Provider Phone Number
Authorization Number (Only if insurance coverage is through an EAP program)
Is the client the Primary Subscriber? *

Yes No

Primary Subscriber
Client relationship with the Primary Subscriber: *

Spouse Dependent of
Primary Subscriber's Full Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Thank you
Should be Empty:

A Better Way Counseling Service, LLC

Appointment Policy

Financial Policy

Credit Card Policy

Thank you