Child 12 and Younger - New Client Paperwork

A Better Way Counseling Service, LLC

New Client Information Form - Filled out by parent(s) of child 12 years old or younger
Today's Date

Month Day Year
Date
Client's Full Name *

First Name Middle Name Last Name
Client Date of Birth *

Month Day Year
Client Age *
Parent/Guardian 1 Name *

First Name Last Name
Relationship to Client *
.
Parent/Guardian 2 Name

First Name Last Name
Relationship to Client
Client Mailing Address *

Street Address

Street Address Line 2

City State / Province

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

Yes No
Secondary Contact Person
Name
.
Phone Number
Is it okay to leave detailed messages at this voicemail?

Yes No
Email
example@example.com
Do you agree to receive email reminders? *

Yes No
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.
Parent/Guardian Name *

First Name Last Name
Guardian Signature: I consent to the above statements regarding Email and Phone Communication: *

Clear
Additional Parent/Guardian Name

First Name Last Name
Additional Guardian Signature: I consent to the above statements regarding Email and Phone Communication:

Clear

Current Medications (if any)
What brings your child/family to counseling? *

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

First Name Last name Relationship to Client
Emergency Contact Phone Number *

Disclosure
Therapist/Clinician's Name *
Please choose your child's clinician here, and open their profile to read their disclosure.
I am signing to agree that I was able to review the dislosure statement for the above therapist, whom, my child 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 am the legal guardian (managing conservator) of the client. With an understanding of the above requirements, I grant permission for my child to participate in counseling and release the counselor above from liability
Parent/Guardian Name *

First Name Last Name
I have received my child's therapist's disclosure statement and agree to the above statements. Parent/Guardian Signature: *

Clear
Additional Parent/Guardian Name

First Name Last Name
I have received my child's therapist's disclosure statement and agree to the above statements. Additional Parent/Guardian Signature:

Clear

Therapy Agreement Between the Parents/Guardians of a Minor and the Therapist
Prior to beginning treatment, it is important for you to understand my approach to child therapy and agree to some policies about your child’s confidentiality during the course of his/her treatment.

Therapy is most effective when a trusting relationship exists between the therapist and the client. Privacy is especially important in securing and maintaining that trust. One possible goal of treatment may be to promote a stronger and better relationship between children and their parents; however, it is often necessary for children to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for older children, and adolescents who are naturally developing a greater sense of independence and autonomy.

For this reason, it is my policy to provide you with general information about treatment status, including progress towards therapeutic goals and whether your child is attending sessions. Based on my clinical judgment, I may raise issues that could be impacting your child either inside, or outside the home. As a general rule, I will not share detailed information with you about what your child has disclosed to me without your child’s consent.

If your child is an adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of adolescent experimentation. At other times, they may require parental intervention, especially when safety becomes a concern. If I ever believe that your child’s personal safety is at serious risk (ie. of harming him/herself or another, or of being harmed by someone else), I will inform you.

Finally, it is understood that while I have a legal duty as a Mandated Reporter of potential child abuse, I am not conducting an abuse investigation. If you or I believe that one needs to be conducted, those services would be obtained from another independent professional or agency.
Parent/Guardian Name *

First Name Last Name
I have read the Therapy Agreement between the Parents/Guardians of a Minor and the Therapist. I understand them and agree to abide by them. Parent/Guardian Signature: *

Clear
Additional Parent/Guardian Name

First Name Last Name
I have read the Therapy Agreement between the Parents/Guardians of a Minor and the Therapist. I understand them and agree to abide by them. Additional Parent/Guardian Signature:

Clear

Additional Considerations for Families in which Parents are Divorced/Separated
Are the client's parents: *

Together Divorced or Seperated
Additional Considerations for Families in which Parents are Divorced/ Separated:

It is understood that in cases where parents are separated or divorced, both parents give permission for me to release any information obtained during the course of therapy to the other if I believe it is in the best interest of your child; however, it is also understood that for me to be the most help to your child, each parent needs to feel they can be honest about whatever difficulties they are having with parenting in their household. Therefore, I will discuss with each parent only issues with their child occurring in their own household. It is understood that my role is not as a “go-between” to share information about one household with the other.

If conflict between parents appears to be interfering with your child’s treatment and well-being, I may recommend mediation, or a parent coordinator, to help resolve conflicts.

If I am required by a judge to testify about this case, I am ethically bound not to give my recommendation about parents’ custody, visitation or capacity. Please note that if I am required to appear as a witness, the party responsible for my court participation agrees to reimburse me at the rate of $200 per hour for time spent traveling, preparing reports, testifying, and any other case-related costs.

*Please note that we require a photocopy for our files of the most current parenting plan or custody document, if any exist, that pertain to care of the minor entering therapy. This can also be provided to us electronically at abetterwaycounseling@gmail.com, or directly to the therapist.
Parent/Guardian Name *

First Name Last Name
I have read the Additional Considerations for Families in which Parents are Divorced/ Separated section of the Therapy Agreement between the Parents/Guardians of a Minor and the Therapist. I understand them and agree to abide by them. Parent/Guardian Signature: *

Clear
Additional Parent/Guardian Name

First Name Last Name
I have read the Additional Considerations for Families in which Parents are Divorced/ Separated section of the Therapy Agreement between the Parents/Guardians of a Minor and the Therapist. I understand them and agree to abide by them. Additional Parent/Guardian 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 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.
Parent/Guardian Name *

First Name Last Name
I read and consent to the appointment policy: Parent/Guardian Signature *

Clear
Additional Parent/Guardian Name

First Name Last Name
I read and consent to the appointment policy: Additional Parent/Guardian 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.

To reduce our costs and create savings for you, we prefer to have charges paid at the time services are rendered. We accept cash, check, and all major credit cards. 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 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.

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 financial policy and accept the above mentioned terms.
Parent/Guardian Name *

First Name Last Name
I have read and consent to the financial policy: Parent/Guardian Signature *

Clear
Additional Parent/Guardian Name

First Name Last Name
I have read and consent to the financial policy: Additional Parent/Guardian 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.

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. 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.

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 Card *

First Name Last Name
Card Number *
Card Number
Security Code *
Expiration Date *
Billing Zip Code *
Email Address to Send Receipts *
example@example.com
You may choose below if you would like the office to automatically charge your card on file at the time of your regularly scheduled appointment. If you chose this option, your card will be charged your copay/session payment amount just before or after the time of your scheduled appointment.
I give the ABWCS office permission to charge my credit card at the time of my child's scheduled therapy appointment: *

Yes No
Parent/Guardian Name *

First Name Last Name
I have read and consent to the credit card policy: Parent/Guardian Signature *

Clear
Additional Parent/Guardian Name

First Name Last Name
I have read and consent to the credit card policy: Additional Parent/Guardian Signature

Clear

Are you planning on using Health Insurance? *

Yes No

Health Insurance Provider
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
Your relationship with the Primary Subscriber:

Spouse Dependent of
Primary Subscriber's Full Name *

First Name Last Name
Primary Subscriber's Date of Birth *

Month Day Year
Date
Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

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 Information Progress Report Discharge Summary Treatment Plan Dates of Service Phone Contact Payment
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.
Parent/Guardian Name *

First Name Last Name
I consent to release of the above information to my health insurance provider: Parent/Guardian Signature: *

Clear
Additional Parent/Guardian Name

First Name Last Name
I consent to release of the above information to my health insurance provider: Additional Parent/Guardian Signature:

Clear

Release of Information for Primary Care Physician
Communication between Behavioral Health providers and your child's Primary Care Physician (PCP) is important to ensure that they receive comprehensive and quality health care. There are circumstances when your child's Behavioral Health condition and/or medications will influence treatment of their physical conditions. Many times behavioral health and physical health share a connection. This form will allow your child's Behavioral Health Provider to share Protected Health Information (PHI) with their 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 one): *

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

First Name Last Name
Physician Phone Number

Area Code Phone Number
Physician Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Name *

First Name Last Name
I consent to release the above information to my Child's PCP: Parent/Guardian Signature: *

Clear
Additional Parent/Guardian Name

First Name Last Name
I consent to release the above information to my Child's PCP: Additional Parent/Guardian Signature:

Clear
Thank you for your time completing this form. If you have any questions or concerns, please call the office at 360-281-6824.
Should be Empty:

A Better Way Counseling Service, LLC

Disclosure

Therapy Agreement Between the Parents/Guardians of a Minor and the Therapist

Additional Considerations for Families in which Parents are Divorced/Separated

Appointment Policy

Financial Policy

Credit Card Policy

Release of Information for Insurance Provider

Release of Information for Primary Care Physician