Child 12 and Younger - New Client Paperwork

A Better Way Counseling Service, LLC

New Client Information Form - Filled out by guardian(s) of child 12 years old or younger
Please note: If you do not already have an established appointment, filling out a New Client Form does not mean you are scheduled with that practitioner.

If you do not have an appointment scheduled please call us at (360) 281-6824.

Today's Date*

MonthDayYear
Date
Client's Full Name*

First NameMiddle NameLast Name
Client Date of Birth*

MMDDYY
Client SSN
(Social Security Number)
Legal Sex*
Gender Identity
Pronouns*
Parent/Guardian 1 Name*

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

First NameLast Name
Relationship to Client
Client Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Contact Person*
Name
Primary Phone Number*
Phone Number
Is it okay to leave detailed messages at this voicemail?*

YesNo
Secondary Contact Person
Name
Secondary Phone Number
Phone Number
Emergency Contact*

First NameLast nameRelationship to Client
Emergency Contact Phone Number*
Is it okay to leave detailed messages at this voicemail?*

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

YesNo
Secondary Email
example@example.com
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 NameLast Name
Guardian Signature: I consent to the above statements regarding Email and Phone Communication:*

Clear
Additional Parent/Guardian Name

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

Clear

What brings your child/family to counseling?*

0/500
Has your child had prior counseling? If yes, what was it for and how long ago was the treatment?*

0/500
Has your child had a mental health diagnosis? If yes, when were they diagnosed? Do you have any suspected diagnoses? (e.g., anxiety, depression, ADHD, etc.)*

0/500
Current Medications (if any)
Is your child currently or have they in the past expressed any Suicidal Ideation? If yes, how frequently, have there been any attempts or plans?*

0/500
Does your child/your family feel safe at home? If no, please elaborate.*

0/500
How did you hear about A Better Way Counseling Services*
If applicable, name of person who referred you

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 NameLast 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 NameLast 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 our approach to child therapy and agree to some policies about your child’s confidentiality during their 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 guardians; 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 our policy to provide you with general information about treatment status, including progress toward therapeutic goals and whether your child is attending sessions. Based on clinical judgment, issues may arise that could be impacting your child either inside, or outside the home.

If your child is an adolescent, they may 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 it is ever believed that your child’s personal safety is at serious risk (ie. of harming themselves or another, or of being harmed by someone else), we will inform you.

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

First NameLast 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 NameLast 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:*

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

It is understood that in cases where parents are separated or divorced and both have medical decision-making ability, both parents permit the clinician to release information obtained during therapy to the other if they believe it is in the best interest of your child. However, it is also understood that 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, the therapist may discuss with each parent only issues with their child occurring in their household. It is understood that their role is not as a “go-between” to share information about one household with the other.

If the therapist is required by a judge to testify about this case, they are ethically bound not to give a recommendation about parents’ custody, visitation, or capacity. Please note that if they are required to appear as a witness, the party responsible for my court participation agrees to reimburse the therapist 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 pertains to the care of the minor entering therapy. This can also be provided to us electronically at abetterwaycounseling@live.com, or directly to the therapist.
If you have a copy of the parenting plan or documents, please upload them here:

Browse Files

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Parent/Guardian Name*

First NameLast 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 NameLast 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 the treatment being successful. Our goal is to provide quality, individualized mental health care. We would like to remind you of our policy concerning appointments.

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 attend your scheduled appointment.

If it is necessary to cancel your appointment, we require that you contact the office at least 24 hours in advance. A no-show is missing a scheduled appointment. A late cancellation is canceling an appointment without calling us to cancel 24 hours in advance. Appointments are in high demand and your early cancellation will allow another client access to mental health care. When an appointment is made, it takes an available time slot away from another client. No-shows and late cancellations delay mental health care for other clients. Arriving too late to an appointment will be treated the same as a no-show or late cancellation. You will be charged the full appointment fee if you do not provide adequate notice, this is outlined in our Financial Policy.

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.
By signing below, you acknowledge our agency's 24-hour cancellation policy. If you cancel an appointment within this timeframe or miss it entirely, you will be charged the full fee unless you are covered by Washington Medicaid.
Parent/Guardian Name*

First NameLast Name
I read and consent to the Appointment Policy: Parent/Guardian Signature*

Clear
Additional Parent/Guardian Name

First NameLast Name
I read and consent to the appointment policy: Additional Parent/Guardian Signature

Clear

Financial Policy
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 as best we can.

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 associated fees. If your insurance is ending and you now have Cobra, please call the office to discuss alternatives.

With insurance, most clients will experience at least some out-of-pocket expenses. The amount insurance pays varies from one policy to the next. As a courtesy, we will call to verify the extent of your coverage and will contact you to let you know your payment responsibility before your first scheduled appointment. However, the final extent of your coverage and the exact amount of your expense 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 coverage for mental health care, specifically outpatient, before beginning treatment at our office. If you do this be sure to ask the representative for a reference number.

If for any reason your insurance company does not pay for services or deems certain services as non-covered, you will be responsible for the agency's contracted rate with your insurance company. Any balance outside of what has been previously quoted is your responsibility and payment is due upon receipt of a statement from our office unless otherwise agreed on.

In the event there is a difference between what was paid at the time of service and what the insurance company has listed as your patient's responsibility, the office will contact you. If you have any questions or concerns about an account balance, please contact our office at (360) 281-6824.

We require a 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. If you are planning on using a Health Saving Account or Flexible Saving Account, please let the office know as these are charged differently. There is a processing fee of 3.5% for those using a Debit or Credit card. The regular fee for your attended session will be automatically charged to this card on the business day following your appointment. Late cancellations (less than 24-hour notice) and no-show fees will be automatically 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. Please inquire with the office if you have questions about what the fee would be. If you are not using insurance then the cancellation fee is the full amount you pay for each session.

If your card payment does not go through, we will attempt to contact you before your next upcoming appointment. If we are not able to reach you, future appointments will be canceled until either payment is made or a payment plan is agreed upon.

Please call our office at 360-281-6824 and email us at, cancelabwcs@gmail.com if you need to cancel or reschedule. 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 have a clear understanding. If financial hardship exists, please speak with a member of our staff concerning your treatment options. We value you as a client and look forward to working with you.
By signing below, you acknowledge our agency's 24-hour cancellation policy. If you cancel an appointment within this timeframe or miss it entirely, you will be charged the full fee unless you are covered by Washington Medicaid.

You are also acknowledging any services not covered by your insurance will be your responsibility.
Parent/Guardian Name*

First NameLast Name
I have read and consent to the Financial Policy: Parent/Guardian Signature*

Clear
Additional Parent/Guardian Name

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

Clear

Insurance
Even in the event your provider cannot currently accept your insurance plan, or you are opting not to use insurance for your sessions, please share your information below.

This will allow us to check your benefits if you would like to start using insurance at any time or if your provider can accept it in the future.
Do you have Health Insurance?*

YesNo
Upload Front of Insurance Card

Browse Files

Cancelof
Upload Back of Insurance Card

Browse Files

Cancelof
Insurance Carrier*
ID Number*
Group Number*
Provider Phone Number
Typically on the back of the card
Is the client the Primary Subscriber?

YesNo
Your relationship with the Primary Subscriber:

SpouseDependent of
Primary Subscriber's Full Name*

First NameLast Name
Primary Subscriber's SSN*
Primary Subscriber's Date of Birth*

MonthDayYear
Date
Primary Subscriber's Legal Sex*

FemaleMaleOther
Phone Number
Address

Street Address

Street Address Line 2

CityState / 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:
- Intake Information
- Progress Report
- Discharge Summary
- Treatment Plan
- Dates of Service
- Phone Contact
- Payment Information
Please check all that apply:*

Intake InformationProgress ReportDischarge SummaryTreatment PlanDates of Service and PaymentPhone ContactPaymentOther
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 NameLast Name
I consent to release of the above information to my health insurance provider: Parent/Guardian Signature:*

Clear
Additional Parent/Guardian Name

First NameLast 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 PCPI 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 NameLast Name
Physician Phone Number

Area CodePhone Number
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

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

Clear
Additional Parent/Guardian Name

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

Clear

By clicking submit below I acknowledge that I have read and understand the policies and that my information is accurate.
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

By signing below, you acknowledge our agency's 24-hour cancellation policy. If you cancel an appointment within this timeframe or miss it entirely, you will be charged the full fee unless you are covered by Washington Medicaid.

Financial Policy

By signing below, you acknowledge our agency's 24-hour cancellation policy. If you cancel an appointment within this timeframe or miss it entirely, you will be charged the full fee unless you are covered by Washington Medicaid.

You are also acknowledging any services not covered by your insurance will be your responsibility.

Insurance

Release of Information for Insurance Provider

Release of Information for Primary Care Physician