Intake Form for Living Well Counseling

Spiritual History
How would you describe your spiritual or religious beliefs? *
Why did you choose a Christian Counselor?
Have you accepted Jesus Christ as Savior?

Yes No
If yes, when?

Social History
Do you do any of the following? (Please check all that apply)

Exercise Use tobacco products Consume caffeine Sleep well at night Drink alcohol Take vitamin supplements Visit or go out with friends Eat nutritious meals
If you checked any of the options above, please detail below:
What do you do in your spare time?
Are there things you used to do or would like to do but currently don't? *

Living Well Counseling and Wellness 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 Living Well Counseling and Wellness before submitting this form.
Financial Responsibility

As the financial responsible person for the account, I understand my initial appointment for
Please check the one which applies: *

Psychotherapy will be 50 minutes and charged at a fee of $100 plus any testing/assessment fee. All psychotherapy sessions scheduled thereafter will be charged at $100 for each 50-minute clinical hour. Any discounts offered will be honored. Marriage and Family Therapy will be 60 minutes and charged at a fee of $125 plus any testing/assessment fee. All marriage and family therapy sessions scheduled thereafter will be charged at $125 for each 60 minute clinical hour. Any discounts offered will be honored. Life Coaching will be 30 minutes and charged at a fee of $50. All life coaching sessions will be charged at $150 per month for three 30 minute sessions per month. Any discounts offered will be honored. Life Coaching will be 60 minutes and charged at a fee of $100. All life coaching sessions will be charged at $200 per month for two 60 minute sessions per month. Any discounts offered will be honored.
I understand I will be financial responsible for any charges. I acknowledge that I accept these terms for services for mental health treatment, marriage and family therapy or other wellness services.

I understand I will be charged and am required to pay for phone consults with the therapist which last longer than 15 minutes or longer unless the call is a free initial 30-minute consultation. Fees are based on the 50-minute psychotherapy clinical hour and are prorated accordingly.

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. However, if this should occur a second time, I understand I will be charged. I understand I will be required to pay for the psychotherapist’s full fee for service missed.

I understand and agree that I am ultimately financially responsible for all fees described in this agreement.
I have read and understand the above financial responsibility policies of Living Well Counseling and Wellness. *

Yes
Insurance Reimbursement Information

At this time, we do not accept insurance. However, 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?
90801 (initial visit)

90806 (1 hr. individual counseling)

90847 (1 hr. couples counseling)
- 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.
I have read and understand the above insurance reimbursement information from Living Well Counseling and Wellness. *

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

Yes
Patient/Client Signature *

First Name Last Name
Patient/Client's Date of Birth *

- Month - Day Year
I have read and understand all of the above policies of Living Well Counseling and Wellness. *

Yes
Today's Date *

- Month - Day Year
at
: Hour Minutes

Treatment Agreement

This document is intended to clarify in writing some of the issue we may have already discussed verbally that need to be brought to your attention regarding our professional relationship. I have found it is best to specify the content of our therapy relationship by making a mutual agreement in order for you to receive the service you desire. Be assured that I am aware and respectful of your basic rights as a consumer and that I will respond to your needs in the most highly ethical manner, according to the standards of care for my profession. I remain personally and professionally committed to providing you with the highest quality of service.
Client Rights

As a client of Living Well Counseling and Wellness, 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 7334 Berry Ave., Jacksonville, Florida 32211.

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 cancelling appointments with this therapist and this agreement.

Consent and Authorization for Treatment

I consent to and authorize the assessment and/or treatment I will receive as a client/patient of Living Well Counseling and Wellness. 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.
I have read and understand my rights and responsibilities as a patient of Living Well Counseling and Wellness. *

Yes
Signature and Submission
Please type your name below to indicate consent to treatment.
Client's Name *
Date *

Month Day Year
Signature
If the patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Parent/Guardian Signature
Date

Month Day Year
Signature
Enter the message as it's shown *
Should be Empty:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Intake Form

Please complete the following form. This information will be discussed more thoroughly in sessions and used to determine goals for counseling.

Personal History

Spiritual History

Social History

Family History

Financial Responsibility

Signature and Submission