Emmaus Counseling Center

Transcription

1 Emmaus Counseling Center We are committed to walking with you and helping you to find peace in your life. NEW CLIENT "YOUTH" REGISTRATION: AGES 2-12 Business Office: th Ave. NE Redmond, WA Phone: Fax: Bellevue Branch th Ave. N., #B200 Bellevue, WA Bothell Annex Bothell-Everett Hwy, #101 Bothell, WA Bothell on Main Street Main Street Suites #201 & #202 Bothell, WA Bothell Riverside Branch East Riverside Drive Bothell, WA Issaquah Branch SE 64th Place, #220 Issaquah, WA Kirkland Branch th Ave. NE, #210 Kirkland, WA Lynnwood Branch 3730 Serene Way Lynnwood, WA Redmond Annex Office th Ave. NE, #200 Redmond, WA Redmond Office th Ave NE Redmond, WA Woodinville Branch th Ave. NE, #203 Woodinville, WA Dear Parent/Legal Guardian: I would like to formally welcome you and your child to Emmaus Counseling Center. Attached you will find our New Client Registration packet which includes the information you will need to begin your child s counseling services. Please read, sign, and date all the forms where indicated. During your initial appointment call, our Care Coordinator set-up your SECURE PORTAL ACCESS and provided you with an describing how to access the portal. The portal allows you to manage your child's care privately and securely including messaging your child's therapist, viewing your real time Account Ledger, accessing your monthly e-statement and paying your bill on-line when it s convenient for you. We think you ll find that communicating via the portal brings a new level of efficiency to your child's care at Emmaus. As a paperless company, we use our Client Portal to provide you with a monthly e- Statement. The system will you (to the address you have provided) and notify you that there is a message for you from Emmaus Billing (re: invoice) and prompt you to log in to your secure client portal (simply click the link provided in the and enter your password) for direct access. PLEASE NOTE: if there is an amount due it is identified on the last page of your statement. If you have any questions, please contact our billing department directly at , ext. 18. As an appointment time has been set aside exclusively for your child, we do ask that you provide at least 24 hours notice of a cancellation to avoid an $80 charge. Please cancel a Monday session on Friday during business office hours (9am-5pm) by calling our Care Coordinators at , ext. 0. Please hand your therapist your completed and signed packet, insurance card, photo ID, co-payments (if applicable), and pre-authorizations (if required). In addition, please keep this cover letter for your records and information. Your experience at Emmaus is extremely important to us. Please feel free to contact our Clinic Manager at , ext. 17 to provide any feedback and let us know if there is any part of your experience we can improve. We look forward to working with you and your child. Richard Wemhoff, Ph.D. Licensed Clinical Psychologist Clinical Director

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3 Emmaus Counseling Center New Client "Youth" Registration (Ages 2-12) Therapist s Name: Full Legal Name: Date of Birth: / / Residential Address: Number Street or PO Apt /Unit # City State Zip Cell Home Work Gender: Male Female Other Preferred Phone: Preferred Communication: Cell HmPh WkPh * *(We use to send courtesy appointment reminders and to receive notifications re: Monthly e-statements via our client portal.) Okay to leave a message on my: Cell Home Phone Work Phone Emergency Contact: Relationship: Phone: Insurance Information (If you will be using your insurance benefits, please complete this section) Insurance Company: Policy/ID#: (Include Alpha Prefix) Group No.: (if on Insurance Card) Insurance Phone (back of card): Have you met your deductible? Yes No Insured Person s Name (Policy Holder): Date of Birth: / / Client s Relationship to Insured Person: Child Other Insured s Street Address: Number Street or PO Apt /Unit # City State Zip Insured s Phone Number: Insured s Employer: Continuity of Care I AUTHORIZE I do not authorize Emmaus Counseling Center to release information to my child s health care provider. PCP s Name: Clinic: Authorization Insurance Authorization: I authorize release of information, including copies of medical records to my insurance carrier, managed care company, clinical/case manager, primary care physician as needed to fulfill insurance requirements for processing my claims or as needed for treatment planning and management required by my insurance carrier. Assignment of Benefits: I authorize payment of insurance benefits for services rendered to Emmaus Counseling Center. Financial Responsibility: I understand that if my insurance company should deny payment for any reason, I will be responsible for any outstanding financial debt associated with therapy services. Authorization for Treatment of a Minor: I authorize treatment of the above client who is a minor and hereby state that I am the natural parent or legal guardian having custody of the named minor. Statement & Credit Card Receipt Authorization: I authorize my Provider to send my patient statements and/or credit card receipts to the address identified above for e-statements. In choosing this feature I understand that my patient statement and/or credit card receipts will no longer be mailed to my mailing address on file, but will be sent electronically via our CLIENT PORTAL. If at any time my address changes I understand that it will be my responsibility to update that information with my Provider s office. Statement Authorization Initials: Signature of Parent/Legal Guardian Printed Name Date New Client "Youth" Registration (Ages 2-12) Page 1 of 9 Emmaus Counseling Center: th Ave. NE, Redmond, WA P: F:

4 Emmaus Counseling Center New Client Intake Form (Ages 2-12) Has your child had prior counseling or psychiatric treatment? Yes No If yes: When? Where? Reason for and length of treatment: Check one: Treatment was helpful not helpful. Please explain: Medical/Physical Health Your child s primary care physician s name, clinic name, and phone number: Date of your child s last physical exam: Has your child been under a physician s care for any reason in the last five years? If yes, please explain. Medications Current Prescribed Medications Dose Frequency Purpose and Side Effects Please describe your child s medical history: Please describe your family medical history: Please describe your child s mental health history: Please describe your family mental health history: New Client "Youth" Registration (Ages 2-12) Page 2 of 9 Emmaus Counseling Center: th Ave. NE, Redmond, WA P: F:

5 Emmaus Counseling Center Please describe your child s developmental history. Did/do they struggle with meeting developmental timelines and/or a learning difficulty? Child s Behaviors & Symptoms Please check any behaviors and/or symptoms your child has experienced using the key below: C P C for currently experiencing. P for experienced in the past. C P C P Abuse Phobias/fears Fatigue Aggression Poor judgment Flashbacks Alcohol use Self-esteem problems Grief Anger Hallucinations Sexual difficulties Anxiety Sleep problems Heart palpitations Chronic pain Social withdrawal High blood pressure Compulsive behavior Hopelessness Suicidal thoughts Concentration Thoughts disorganized Hyperactivity problems Cyber addiction Trembling Impulsivity Depression Trauma Irritability Disorientation Worry Loneliness Distractibility Memory impairment Other (specify): Dizziness Mood swings Drug Use Obsessive thoughts Eating disorder Panic attacks For any of the items checked as currently experiencing, please provide additional information regarding your symptoms. How often and severe are these symptoms? Do you want to share additional information? For any of the items checked as experienced in the past, please provide additional information. At what age did your child first experience these symptoms? Can you identify a cause of these symptoms? How often and severe were they? If the symptoms stopped, can you identify why they did so? New Client "Youth" Registration (Ages 2-12) Page 3 of 9 Emmaus Counseling Center: th Ave. NE, Redmond, WA P: F:

6 Emmaus Counseling Center Substance Use Has your child received help for drug or alcohol use? Yes No If yes: When? Where? Check one: Treatment was helpful not helpful. Please explain. _ Has a friend or relative ever discussed concerns about your child s alcohol or drug use? Yes Is there a history of problems with alcohol or drug use in your family? Yes No Child & Family History Describe your child s relationship with their parents and siblings. What is your child s birth-order position in the family? How does your child perform academically? How do you feel about this level of performance? Does your child have a history of behavior problems? Yes No If yes, please describe. _ Has your child experienced trauma? Yes No If yes, please describe. _ What upsets your child? How does your child cope when they are upset? Who does your child go to when they upset? What activities does your child do for fun? What does your child do to relax and/or care for themselves? Is there anything else you think would be helpful for me to know about your child or their situation? No New Client "Youth" Registration (Ages 2-12) Page 4 of 9 Emmaus Counseling Center: th Ave. NE, Redmond, WA P: F:

7 Emmaus Counseling Center Consent to the Use and Disclosure of Health Information I understand that as part of my health care, Emmaus Counseling Center originates and maintains paper and/or electronic records describing my health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care or treatment, I understand that this information serves as: A basis for planning my care and treatment. A means of communications among the many health professionals who contribute to my care. A source of information for applying my diagnosis to the bill. A means by which a third-party payer can verify that services billed were actually provided. A tool for routine operations such as assessing the quality and competence of healthcare professionals. Notice of Privacy Practices: I have been provided (via website), read, understand, and agreed to the terms outlined in the Notice of Privacy that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: The right to review the notice prior to signing this consent. The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations. I understand that I may revoke this consent in writing, except to the extent that Emmaus has already taken action to use and/or disclose my information as described above. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section of the Code of Federal Regulations. I further understand that Emmaus Counseling Center reserves the right to change their notice and practices prior to implementation, in accordance with Section of the Code of Federal Regulation. Should Emmaus Counseling Center change their notice, they will send a copy of any revised notices to the address I ve provided. I understand that as part of this organization s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. I fully understand and accept the terms of this consent. Signature of Parent/Legal Guardian Printed Name Date Client Name Printed (age 12 & Younger) New Client "Youth" Registration (Ages 2-12) Page 5 of 9 Emmaus Counseling Center: th Ave. NE, Redmond, WA P: F:

8 Emmaus Counseling Center Consent for Treatment Emmaus Counseling Services, P.S. Agreement: Please review the following statements. If you have any questions concerning them, please feel free to bring up those questions to your therapist at the beginning of your first session. Therapist s Disclosure Statement: I have been provided, read, understand, and agree to the terms outlined in the Therapist s Disclosure Statement that describes their qualifications, education, the nature of our therapeutic relationship and my rights as a client of Emmaus Counseling Service, P.S. Informed Consent: I give permission to my therapist to confidentially share my personal health information with other therapists within Emmaus Counseling Center for purposes of consult and/or client transfer. Cancelation Policy: I realize that the appointment I set with my therapist is a contract that I have established with him/her. If that appointment needs to be changed, I expect a 24-hour notice from my therapist and I also realize that I must give a 24-hour notice to cancel or re-schedule my appointment. I understand that my therapist has reserved that time for me. If I have not shown up for the appointment or have not given the required 24- hour notice, I will be personally billed $80 for the missed appointment. I understand that my insurance company will not be responsible for payment of my missed appointment. Authorizations: I realize that I am responsible for obtaining any insurance authorization needed prior to treatment, otherwise I will be personally responsible for the entire bill. Financial Responsibility: If all or a portion of my fee is to be paid by my insurance company, I understand that Emmaus Counseling Service, P.S. will bill my insurance company for me. I also realize, however, that I am ultimately responsible for my account and am expected to pay for all services rendered. Statement Balances: I understand that unpaid balances will incur a billing charge of 2% or a minimum of $5.00 after 30 days. I hereby request and authorize the staff of Emmaus Counseling Service, P.S., to evaluate, treat and/or provide counseling services to myself and/or the individual listed below for whom I am the parent or legal guardian. By signing below, I confirm this document to represent the agreement between us, and that I have read and understand this Consent for Treatment along with our Notice of Privacy Practices, Consent to the Use and Disclosure of Health Information. Signature of Parent/Legal Guardian Printed Name Date Client Name Printed (age 12 & Younger) New Client "Youth" Registration (Ages 2-12) Page 6 of 9 Emmaus Counseling Center: th Ave. NE, Redmond, WA P: F:

9 Parent Report on Child MOOD AND FEELINGS QUESTIONNAIRE: Long Version This form is about how your child might have been feeling or acting recently. For each question, please check ( ) how s/he has been feeling or acting in the past two weeks. If a sentence was not true about your child, check NOT TRUE. If a sentence was only sometimes true, check SOMETIMES. If a sentence was true about your child most of the time, check TRUE. Score the MFQ as follows: NOT TRUE = 0 SOMETIMES = 1 TRUE = 2 To code, please use a checkmark ( ) for each statement. NOT TRUE SOME TIMES TRUE 1. S/he felt miserable or unhappy. 2. S/he didn t enjoy anything at all. 3. S/he was less hungry than usual. 4. S/he ate more than usual. 5. S/he felt so tired s/he just sat around and did nothing. 6. S/he was moving and walking more slowly than usual. 7. S/he was very restless. 8. S/he felt s/he was no good anymore. 9. S/he blamed him/herself for things that weren t his/her fault. 10. It was hard for him/her to make up his/her mind. 11. S/he felt grumpy and cross with his/her parents. 12. S/he felt like talking less than usual. 13. S/he was talking more slowly than usual. 14. S/he cried a lot.

10 Parent Report on Child 15. S/he thought there was nothing good for him/her in the future. 16. S/he thought that life wasn t worth living. 17. S/he thought about death or dying. 18. S/he thought his/her family would be better off without him/her. 19. S/he thought about killing him/herself. 20. S/he didn t want to see his/her friends. 21. S/he found it hard to think properly or concentrate. 22. S/he thought bad things would happen to him/her. 23. S/he hated him/herself. 24. S/he felt s/he was a bad person. 25. S/he thought s/he looked ugly. 26. S/he worried about aches and pains. 27. S/he felt lonely. 28. S/he thought nobody really loved him/her. 29. S/he didn t have any fun at school. 30. S/he thought s/he could never be as good as other kids. 31. S/he felt s/he did everything wrong. 32. S/he didn t sleep as well as s/he usually sleeps. 33. S/he slept a lot more than usual. 34. S/he wasn t as happy as usual, even when s/he was praised or rewarded. Copyright Adrian Angold & Elizabeth J. Costello, 1987; Developmental Epidemiology Program; Duke University

11 Emmaus Counseling Center Confidential Credit Card Authorization Client s Name: DOB (mm/dd/yyyy): CARD INFORMATION CARD TYPE: VISA MasterCard AMEX Discover HSA* Other: *Note: HSA Cards cannot be used to pay for any missed sessions. CARD NUMBER: EXP. DATE (mm/yy): CVV (SECURITY CODE): CARDHOLDER NAME (as shown on card): BILLING ADDRESS: RELATIONSHIP TO CLIENT: Self Parent/Guardian Partner/Spouse Other: CREDIT CARD & BILLING POLICIES We request that all clients provide a debit or credit card to keep on file in our secure electronic medical records program. Unless other arrangements are made with your therapist, Emmaus will charge your credit card for your copay or fee owed following your session and will collect coinsurance and deductible payments from the card on file at the time your insurance responds to our claim and has determined the exact portion owed by the client. Clients are responsible for tracking this claim and the amount due by carefully reviewing the Explanation of Benefits (EOB) mailed directly to the client by the insurance company. Clients will receive a monthly e-statement (via from our client portal) identified as Emmaus Billing (re: Invoice) which will prompt you to login to your Secure Client Portal to view. In addition, at any time you may check your account via your portal and view a real-time Account Ledger. Clients have a right to receive a statement of all charges, payments and balances associated with their account. A client who wishes to change their credit card on file may do so by notifying the billing department to update the credit card number on file and signing a new authorization form. A client who wishes to cancel a card on file must do so in writing, 5 business days prior to the date on which they wish the change to take effect. BY SIGNING BELOW, YOU AGREE TO THE FOLLOWING: My signature below indicates that I understand and agree to pay for therapy as outlined in this agreement. I authorize the Emmaus Counseling Center to run my credit card listed above for any balance I accrue after my insurance has processed my claims. I understand that my card will be run without prior notice to myself, unless otherwise specified above and that a receipt will be provided via . If I wish to terminate my credit card payment on file, I understand that I will need to give five (5) business days notice for this to take effect. Please note: parents or guardians of children under the age of 18 must have a signed authorization on file. Signature of Card Holder Printed Name Date Emmaus Counseling Center th Ave. NE, Redmond, WA Billing Department p: , ext. 18