Every Girl Living Intake Form

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Every Girl Living Policy and Procedures 

It is important to go over a few policies and procedures. Please read carefully the following information. You will be required to acknowledge your reading and understanding of the policies and procedures of Every Girl Living before submitting this form. Every Girl Living is a service under the Living Well Collective Co.

Every Girl Living Policy and Procedures 

It is important to go over a few policies and procedures. Please read carefully the following information. You will be required to acknowledge your reading and understanding of the policies and procedures of Every Girl Living before submitting this form. Every Girl Living is a service under the Living Well Collective Co.

Wellness Plan Benefits:

• Personalized Health and Wellness Plan
• Continuous access to trained wellness personnel
• Minimal wait time for appointments
• Yearly wellness assessments
• Session of your choice: video or live; psychotherapy, life coaching or yoga.
• Every Girl Living Exclusives:
  • Soul Bourn: a bimonthly women's group coaching session (in person or video)
  • Every Girl Private Facebook Group
  • Worksheets/Printables
  • Videos and webinars
  • First to know and sign up for Every Girl Living Retreats
  • Interactive Self Coaching Journal
    • Free PDF journal download or purchase 90-day Every Girl Journal for only $12
    • Includes access to Every Girl exclusive self-coaching worksheet
  • Complete 4 Self Coaching sheets in one month and earn a 30-minute session that you can combine with another session. These earned sessions can only be used the month they were earned.  

You have two months to use all of your sessions that are purchased under your plan including the month of the original session.

Most of the amenities offered by Every Girl Living are not covered by insurance plans and are not reimbursable by insurance and/or other health plans (including Medicare). Only psychotherapy for a diagnosable disorder is reimbursable by insurance.

All monthly fees are due at the 1st of each month, unless previous arrangements have been communicated and made between the client and Every Girl Living. Any late payments over 7 days will result in a late fee of $49. If you are having trouble making a payment for any reason, please contact our client liaison at Every Girl Living PRIOR to the due date, or before the 7 day grace period expires. Sessions may only be completed with a paid invoice, otherwise your session will have to be rescheduled until the invoice is paid.

I authorize regularly scheduled charges to my checking/savings account or credit card. I will be charged the amount indicated above each billing period. A receipt for each payment will be emailed to me and the charge will appear on your bank statement as an “ACH Debit.” I agree that no prior notification will be provided to me unless the date or amount changes, in which case, I will receive notice at least 5 days prior to the payment being collected.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Every Girl Living in writing of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date.

If the above-noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. 

In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that Every Girl Living may at its discretion attempt to process the charge again within 30 days, and agree to an additional $50 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.  

I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

I understand Every Girl Living also reserves the right to cancel my membership for any cause, including nonpayment; any issues regarding repeated non-compliance with policies; any threats to staff, counselors, or other patients (verbal or physical), or to Practice's property.

I understand I will be financially responsible for any charges. I acknowledge that I accept these terms for services for mental health treatment, life coaching, or other wellness services.

I understand I shall keep all scheduled appointments unless a personal emergency occurs. In this situation, I will give at least 24 hours' notice of my intention to cancel my appointment.

I understand if I do not cancel my appointment at least 24 hours notice or fail to show for my scheduled appointment, the FIRST time this occurs, I will NOT be charged a session. However, if this should occur a second time, I understand I will be charged a session (meaning you will lose the session). Please note there is no charge if cancellations or reschedules are within 24 hrs. notice, and no sessions are lost if the change is due to an Every Girl Living cancel or reschedule. Any rollover sessions must be used within 60 days of your purchased plan, which includes the month of the unused session. Rollover sessions are not intended to replace paid sessions for the following month. They will be additional sessions to use and a monthly membership plan will still be charged each month. Please communicate if you are stepping down in plans as soon as possible.  

I understand and agree that I am ultimately financially responsible for all fees described in this agreement.

I authorize Every Girl Living (The Living Well Collective Co.) to charge my credit card every month for the package I indicate below.

 

Using Insurance Information

We use a company called Headway to process insurance payments. We accept UHC, Aetna, Oscar, Oxford. If you want to use your insurance from a differenct company, we will provide you with a “superbill”. You can submit this form to your insurance company for reimbursement. We would be considered an out of network provider. If you are unsure about whether your policy covers mental health care (some do not), please contact your personnel/HR department or by calling your insurance company directly.

Most PPO plans will reimburse you for some portion of the cost of your sessions, as long as you or your spouse meet the clinical criteria for a reimbursable disorder. Upon your request, our office will provide you with a receipt to file with your insurer. To determine your coverage, you may contact your insurer and ask the following questions:

• Do I have out of network mental health benefits? If so, how many sessions am I allowed per year
• What is my deductible and is there a separate deductible for mental health care? 

• What is the cost if I see an out-of-network provider and what is the copay/coinsurance? 

• What is the reimbursement for the following procedure codes?

90791 Psychiatric/psychological diagnostic interview without medical services (intake interview)

90832 Individual psychotherapy, 30 minutes

90834 Individual psychotherapy, 45 minutes

90837 Individual psychotherapy, 60 minutes

90853 Group psychotherapy

• Is there a limit on the number of sessions that you will cover?

In order to use your insurance benefits, you will need to meet the reimbursable diagnosis (e.g. dysthymia, generalized anxiety disorder, depression, etc.). We can discuss this further at your initial session.

As a result of the lack of respect demonstrated by most insurers related to client privacy and confidentiality, I have minimized participation on managed care provider panels.

All fees are due at the time of your session. Please sign below to indicate that you understand our office policy regarding insurance and payment.

Telehealth Policy

1. I hereby authorize Every Girl Living to use the telehealth practice platform, Google Meet, for telecommunication for evaluating, testing, and diagnosing my mental health condition.

2. I understand that technical difficulties MAY occur before or during the telehealth sessions, which may affect my appointment's start time or end time.

3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met.

4. If I am submitting claims to my insurance, I understand that my current insurance may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance company does not cover.

5. I agree that my medical records on telehealth can be kept for further evaluation, analysis, and documentation, and in all of these, my information will be kept private.

Notice of Privacy Practices

As required by the Privacy Regulations Created as a Result of Health Insurance Portability and Accountability Act of 1996 (HIPPA)

Notice of Privacy Practices Receipt and Acknowledgement of Notice

I hereby acknowledge that I have received and have been given an opportunity to read a copy of the “Notice of Privacy Practices” of Every Girl Living. I understand that if I have any questions regarding the Notice of my privacy of rights, I can contact Every Girl Living.

Treatment Agreement

This document is intended to clarify in writing issues that may have already been discussed verbally. It is best to specify the content of the therapeutic relationship by making a mutual agreement in order for you to receive the service you desire. Be assured that the staff of Every Girl Living are aware and respectful of your basic rights as a consumer and that we will respond to your needs in the most highly ethical manner, according to the standards of care for our profession. We remain personally and professionally committed to providing you with the highest quality of service.

Client Rights

As a client of Every Girl Living, I have certain rights which are:

To participate voluntarily in treatment with your therapist and to terminate at any time without penalty.

To understand that “treatment” could include individual or conjoint therapy for up to 60 minutes (a therapy hour) conducted by your licensed therapist with no absolute guarantee of your desired results by your therapist.

To participate with your therapist in exploring and setting your treatment goals and discussing possible benefits and risks.

To have reasonable access to your therapist.

To have information available to you regarding your therapist’s professional license and credentials as well as access to the ethical guidelines or “Standards of Practice” in Mental Health Counseling. Your counselor is licensed under Florida Statute 491 of the Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling of the Agency for Health Care Administration in Tallahassee, Florida.

To be aware that your therapist works in private practice at 12400 Yellow Bluff Rd. #107 Jacksonville, FL 32226.

To have all records and other information concerning your involvement with this office held in strict confidence and all communication with your therapist privileged, which means that no information is ever to be released to a third party without your written permission. Certain exceptions are: if you are in clear and imminent danger to yourself and others, in child abuse and neglect cases, therapist’s subpoena or court order, or if there is a medical emergency.

Client Responsibilities

As a client/consumer, I have carefully read over and signed all of the policies regarding financial responsibilities, making, keeping and canceling appointments with this therapist and this agreement.

Consent and Authorization for Treatment

I voluntarily consent to and authorize the assessment and/or treatment I will receive as a client/patient by the staff of Every Girl Living.  Treatment may be provided by a licensed counselor or an individual supervised by any of the professionals listed. Services may include interviews, assessment or testing, psychotherapy, and/or wellness services.

Behavioral health and wellness treatment have both benefits and risks. Risks may include experiencing uncomfortable feelings because the process often requires discussing difficult aspects of one’s life. However, treatment has been shown to have benefits. It often leads to a significant reduction in feelings of distress, increased satisfaction in relationships, greater awareness, and insight, increased skills, and resolutions to specific problems. A small number of clients may not improve because of treatment or may terminate before it is clinically indicated. It is important to keep your clinician advised of any difficulty you may encounter during your treatment.

I have read the policies of this office and received a copy of them. I understand these rules and policies and agree to follow them.

Please type your name below to indicate consent to treatment.

 

If the patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.