Intake Information

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All clients or their parent or guardian will need to complete the information below. In addition, if you are seeing an adult therapist, please complete the Adult Behavioral Health Questionnaire; if your child is being seen by a child/adolescent therapist, complete the Child Behavioral Health Questionnaire; and if you or your child is seeing the nurse practitioner, please compete the Nurse Practitioner Questionnaire.

ACKNOWLEDGEMENT WAIVER AND EMERGENCY CONTACT INFORMATION

I have reviewed the following information provided to me or from the website www.newclientinfo.com and understand what I have read.

In the rare event of an emergency, someone close to you (e.g. relative, spouse, close friend) may need to be contacted. Please indicate your chosen contact person's name, phone number and relationship to you.

PAYMENT AGREEMENT AND ASSIGNMENT OF BENEFITS

Fees Fees vary by service and provider. Fee ranges are found at www.malecherringandkrause.com/RatesInsurance.en.html Except for brief phone contacts, you will be billed for phone therapy, emails or other professional services (including assessments and letters to outside professional, extended coordination of care with other professionals) at the provider's hourly rate. You will be informed of any services requiring additional payments before the services are rendered. You may request a receipt to submit to your insurance company for any covered service. Insurance Reimbursement Your therapist may participate with several insurance plans and documentation may be submitted to your insurance company at no additional cost. Most insurance plans have a deductible and/or session copayment that is your responsibility. Payments of session fees are due at the time of service. Acceptable methods of payment are cash, check, and most major credit cards. You are also responsible for any fees not covered or not paid or denied by your insurance company. Account balances must be paid prior to or at the beginning of the next session. Continuation of services may be dependent on having your account in good standing. Please contact your insurance company to determine your benefits and authorization requirements. If your insurance company requires a pre-authorization, please have the required information with you at the first session. Every effort will be made to verify coverage and identify financial liability (such as deductibles, co-pays, etc.), however, it is ultimately the client’s responsibility to know his/her coverage and resolve any non-payment issues directly with the insurance company. No Show and Cancellation Policies Please give at least 24 hours’ notice of cancellation of your appointment. You will be billed at the same rate as your normal session fee for not giving a minimum of 24 hours. This fee is your responsibility and will not be billed to your insurance company. It must be paid prior to additional psychotherapy service being delivered. Any overpayment that might occur due to misquoted benefits or deductible completion will be refunded to you or held in your account to pay for future services, when applicable. Any fees incurred by your therapist from credit card companies, collection agencies or banks due to non-sufficient funds, payment disputes, or non-payment of fees will be passed along to the client. I agree that I am responsible for the charges for services provided by this therapist to me (or this client) although other persons or insurance companies may make payments on my (or this client’s) account. I hereby assign all mental health benefits, including major benefits to which I am entitled, as well as Medicare and other government-sponsored programs, private insurance, and any other health plan to the designated therapist. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I hereby authorize the designated therapist to release all information necessary to secure payment.

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