Client's Name *Date *Street Address *Apartment, suite, etcCity *State *ZIP / Postal Code *If confidential billing address is different, please check this box.Confidential Billing Address:Confidential CityApartment, suite, etcCityStateZIPPrimary Phone *TypeHomeWorkCellAlternate Phone 1TypeHomeWorkCellAlternate Phone 2TypeHomeWorkCellOK to leave you a text message?OK to leave you a voice message?Voicemail OK for which number(s)?OK to contact you by email?Email Address(see Services and Fee Agreement for limits of confidentiality for email and text messages)Birth Date *Age *Social Security Number0 / 11Child's Current SchoolGrade *Parents' Marital/Relationship Status *Please select an optionSelect One:DatingEngagedMarriedSeparatedDivorcedWidowedWith whom does child live?Parent/Guardian 1 *Age *Relation to child *Education *Employer *Position *Parent/Guardian 2Age *Relation to child *Education *Employer *Position *Parent/Guardian 3Age *Relation to child *Education *Employer *Position *Names and ages of ALL children, either in the home or living away from home:Has a family member served in the military? Who? When?Who referred you to Horizons? *Emergency Contact Name *Emergency Contact Phone *InsurancePlease bring your insurance card(s) to the initial appointment.Who will pay noninsured balance? *You may skip Primary and Secondary insurance information if we can copy your insurance card(s).Primary InsurancePolicy Holder's NameD.O.B. *Policy Holder's SSN:Secondary InsurancePolicy Holder's NameD.O.B. *Policy Holder's SSN:All clients using health insurance please sign below.I hereby grant authorization to Horizons Counseling Services, Inc, to release any Protected Health Information (except Psychotherapy Notes) to my insurance company that is necessary for billing, or to process my claim for payment of services. I authorize my insurance company to send payment directly to Horizons for all services provided. I also authorize Horizons to release claims forms (containing Protected Health Information but not Psychotherapy Notes) and supporting documentation to the Ohio Department of Insurance if Horizons files a claim against my insurance company under the Ohio Prompt Payment Law. I agree that a photocopy of this authorization shall be as valid as the original.Type Full Name to Indicate Signature *Date *Parent or guardian please sign:I hereby consent for Horizons Counseling Services, Inc. to provide treatment and evaluation to:Child/Adolescent's Name *Parent/Guardian Type Full Name to Indicate Signature *Date *Primary Care PhysicianPCP AddressApartment, suite, etcPCP CityPCP StatePCP ZIPPCP PhoneApproximate date of most recent physical examination *List all allergiesYou have my permission to contact my Primary Care PhysicianYesNoList all current medications:Name of Medication, Dosage, Reason for Taking, Prescribing Doctor, Start DateList health problems and any major surgeries:Current/RecentPastWhat brings you to Horizons/What do you need help with? *List all inpatient psychiatric treatment, and all psychiatrists, psychologists, counselors your child has seen, with approximate dates of treatment:Developmental milestones:CrawledWalkedSpoke Single WordsSpoke SentencesSkippedEntered KindergartenOther developmental concerns?Note any concerns about school adjustment or acheivement:Is there any other information you’d like us to know, which may help us in working with your child/family?Please indicate which substances you currently use:Cigarettes/nicotineChild/Teen's UseParent's UseAlcoholChild/Teen's UseParent's UseMarijuanaChild/Teen's UseParent's UseOpiatesChild/Teen's UseParent's UseStimulantsChild/Teen's UseParent's UseOther(s)Child/Teen: What substance(s), Amount Used & How OftenParent: What substance(s), Amount Used & How OftenPlease indicate if your child or teen is having any of the following problems, or has in the past:Difficulty falling asleep or staying asleepCurrentlyIn the pastSleeping too muchCurrentlyIn the pastSchool performance has declinedCurrentlyIn the pastFrequently defiantCurrentlyIn the pastToileting problemsCurrentlyIn the pastRefuses to go to school or cuts class frequentlyCurrentlyIn the pastInappropriate sexual behaviorCurrentlyIn the pastChange in appetite, weight loss, or weight gainCurrentlyIn the pastFrequent cryingCurrentlyIn the pastPanic or anxiety attacksCurrentlyIn the pastSelf-harming behaviorCurrentlyIn the pastTalks about killing or hurting selfCurrentlyIn the pastAttempts to kill or hurt selfCurrentlyIn the pastProblems concentratingCurrentlyIn the pastProblems remembering thingsCurrentlyIn the pastPeriods of daily sadness lasting more than two weeksCurrentlyIn the pastStartle easilyCurrentlyIn the pastDifficulty controlling temperCurrentlyIn the pastPhysically hurts other peopleCurrentlyIn the pastThrows or breaks thingsCurrentlyIn the pastWorry too muchCurrentlyIn the pastPreoccupations with routines, rituals, or ideasCurrentlyIn the pastOften complains of feeling tiredCurrentlyIn the pastSelf-induced vomiting to lose weightCurrentlyIn the pastUse of laxatives or excessive exercise to lose weightCurrentlyIn the pastWorry that something is wrong with his or her bodyCurrentlyIn the pastFrequent argues with other family membersCurrentlyIn the pastOther (please list):Horizons Counseling Services, Inc. - Services and Fee Agreement Welcome to Horizons. This document contains important information about our professional services and business practices. It also details our obligations and your rights under the Health Insurance Portability and Accountability Act (HIPAA), a federal law that regulates the use and disclosure of your Protected Health Information (PHI). Protected health information is health information that is individually identifiable. HIPPA requires that we notify you of our privacy policies and these are described in detail in the Confidentiality and Privacy Policies section below. APPOINTMENTS AND CANCELLATIONS During the initial consultation, your therapist will attempt to gain a general understanding of your situation and determine the most appropriate treatment. We believe it is important for clients to take an active part in their treatment, so don’t hesitate to ask questions. Psychotherapy has been shown to have many benefits - better relationships, solutions to specific problems, feeling less distressed. While it is likely that you will make progress, there are no guarantees. If you cancel an appointment, you must notify us at least 24 hours before the scheduled time, or you will be billed the full session rate, not your copay. Insurance will not cover charges for unkept/late cancelled appointments, so you will personally be responsible for such charges.However, there will be no charge if you call at least 24 hours before the appointment time to cancel. There may be valid reasons such as illness, for cancelling without charge. If you have a contagious illness, do not come to the office. Call to cancel, even without 24 hours notice. You will not be charged. FEES AND HEALTH INSURANCE Most health plans cover part of our fee. There are two kinds costs you may incur that are not covered by your insurance company - deductibles and co-pays. Please pay any non-insured portion of the feebefore each visit. Horizons contracts with insurance companies to cover our services at rates lower than our standard fees (see below). In such cases, your account balance will be adjusted when we receive insurance payment. However, if the insurance pays less than 100% of the contracted fee, you will owe any balance up to 100% of that contracted fee. Deductibles and co-pays determined by your insurance companymay change during the course of your treatment. Sometimes health insurance companies will authorize more sessions than your insurance benefits will pay for. If you see your therapist for visits that are authorized but not paid for by your insurance benefits, by signing this form you agree to pay Horizons’ fee, as listed below, for each authorized visit that is not covered by your insurance plan. These are our fees for the following procedures (listed with the code numbers that may appear on the explanation of benefits statement from your insurance carrier):90791- Diagnostic Evaluation - $20090834- Individual psychotherapy 45 minutes (38-52 minutes) – $17090837- Individual psychotherapy 60 minutes (53 minutes and above) – $18590846/90847- Family psychotherapy, client not present/client present - $185 Although health insurance may aid in payment, you alone are responsible for paying for services. Your therapist will answer any questions about payment arrangements. For routine problems involving payments and insurance, please call our office staff Monday through Thursday, 9 AM to 5 PM or Friday 9 AM to 12 Noon. All accounts are payable in full within 30 days after billing. Overdue accounts may be charged at 10% per year interest. If an account is overdue, regular payments are not being made, and no provision forpayment has been made, we may turn the account over to a collection agency or attorney, as authorized by state or federal law. We reserve the right to collect any unpaid balance due. Clients will be notified in writing before Horizons takes such action to collect.Payment Arrangement *STANDARD PAYMENT ARRANGEMENT: Payment for any deductible or noninsured portion of your fee is due before each session. This applies unless you initial “Alternative Payment Arrangement” on the next line.ALTERNATIVE PAYMENT ARRANGEMENT: Initial this line AND discuss with your therapist.Initial Here to Indicate Acceptance of Payment Arrangement *Days/Times Available for Appointments:CONFIDENTIALITY AND PRIVACY POLICIESHorizons will maintain a clinical record of your case, which is the property of Horizons. This includes your protected health information (PHI). Your therapist and Horizons are required by law to maintain the privacy of your PHI. In most situations, Horizons can release your PHI to others only if you permit us to do so by signing a written authorization form. However, there are situations in which we are permitted to use and disclose your PHI for the purposes of treatment, payment, and heath care operations. Your signature on this agreement is written, advance consent for the following uses and releases of information:• Your therapist practices at Horizons with other mental health professionals and we employ secretarial staff. In most cases, your therapist needs to share information with them for purposes such as billing, scheduling, and quality assurance. Also, Horizons’ clinical staff routinely consults with each other concerning our clients. Please let your therapist know if you would prefer that other clinical staff not be consulted about your case. Our professional staff is bound by the same rules of confidentiality.• Your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During consultations, your therapist makes every effort to avoid revealing the identity of clients. The other professionals are also legally bound to keep the information confidential. The therapist will note all consultations in your Clinical Record.• Your therapist may find it helpful to share information with your primary care physician or other health and mental health professionals who are currently treating you. Your signature on this Agreement is written consent for us to release information to these professionals. A record of these disclosures will be kept in your Clinical Record.Check this box to direct us to NOT RELEASE any information to other mental health and health professionals who are currently treating you.• Horizons uses collections agencies, an accountant, and technical support service for our billing software. As required by HIPAA, these businesses have signed contracts with us in which they promise to maintain the confidentiality of PHI except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with the names of these organizations and a blank copy of the contract.• If you are being seen in couples, family or group therapy, you should be aware that Ohio laws concerning confidentiality are not clear. Horizons will not release information to other parties without your written permission except when allowed or required to do so by State or Federal law, unless a court order requires us to release information about your case.• You have the right to restrict certain disclosures of PHI to your health insurance plan when you pay out-of-pocket in full for our services.In some situations we are permitted or required to disclose information without either your consent or authorization:• If, in our judgment, a client is likely to seriously harm himself/herself or someone else. • If we have reason to believe that abuse of a child or senior citizen has taken or is taking place.• If the client is a minor, both parents have access to the minor child’s complete Clinical Record, including Psychotherapy Notes (see below), unless there is a court order prohibiting one of the parents from access.• If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by the psychologist-client privilege law. Horizons cannot provide any information without your (or your personal or legal representative’s) written authorization. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.• If a government agency (such as Medicare) is requesting the information for health oversight activities, Horizons may be required to provide it for them.• If a client files a complaint or lawsuit against Horizons or any of its staff, Horizons may disclose relevant information regarding that client in order to defend itself.• If a client files a worker’s compensation claim, the client must sign an authorization so that Horizons may release the information, records or reports relevant to the claim.• Horizons staff may present disguised case material in seminars, classes, or scientific writing. All identifying information is removed and client anonymity is maintained.• Your health insurance plan has the right to review your Clinical Record for any services you have asked them to pay for. Health insurance companies (with the exception of Worker’s Compensation)are not entitled to see Psychotherapy Notes, which are notes your therapist may make describing or analyzing therapy sessions. These notes are kept separately from your clinical record. Any disclosure of Psychotherapy Notes (with the exception of Worker’s Compensation)would require a separate written authorization from you. However, insurers are entitled to see PHI in your record, including information about dates of therapy, symptoms, your diagnosis, your overall progress towards those goals, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your health insurance company. TELEPHONE AND EMAIL COMMUNICATIONS Please try to make any telephone calls to your therapist during normal business hours. Lengthy telephone consultations may be billed at your usual hourly rate. In emergencies, our 24-hour answering service can contact your therapist. If the emergency cannot wait until your therapist returns the call, please call the 24-hour mental health emergency number at 216-363-2538 or go to a hospital emergencyroom. Email is not a secure means of communication. Therefore confidentiality of content transmitted via email cannot be guaranteed. If you choose to use email to contact or communicate with your therapist, please be advised that Horizons and your therapist cannot be responsible for its confidentiality. COMPLAINTS If you are concerned that your therapist has violated your privacy rights, or you disagree with a decision your therapist made about access to your records, you may contact Katherine Kratz, PsyD, (440) 845-9011. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Dr. Kratz can provide you with that address upon request. I HAVE READ THIS AGREEMENT AND WITH MY SIGNATURE AGREE TO ITS TERMS.Type full name to indicate signature *WitnessDate *INFORMED CONSENT CHECKLIST FOR TELEPSYCHOLOGICAL SERVICES Prior to starting video-conferencing services, we discussed and agreed to the following: There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions. Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s). We agree to use the video-conferencing platform Doxy.me for our virtual sessions, and I will explain how to use it. You need to use a webcam/microphone or smartphone during the session. It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. It is important to use a secure internet connection rather than public/free Wi-Fi. It is important to be on time. If you need to cancel or change your tele-appointment, you must notify me in advance by phone or email. We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. We need a safety plan that includes at least one emergency contact and your home location, in the event of a crisis situation. If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions. You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment. As your psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person.Type full name to indicate signature of client or client's legal representative: *Date *Name of Therapist: *Please select an optionPeter Barach, PhDFelicia Bergman, PsyDFrancis Chiappa, PhDTai Chiappa, PsyDChristine M. Comstock, PhDKatherine Kratz, PsyDMartha Langenbahn, EdDKrista Leighty, LPCCLori Mendenhall PsyDPaul Snowball, MEd, LPCC-SJanilee Wheaton, PhDJoan William, PhD CandidateNot Sure YetSubmitPlease do not fill in this field.
