To enable us to provide you with the best care possible be sure to fill out all pages front and back

Download 106.21 Kb.
Size106.21 Kb.
New Client Packet Checklist:
Welcome to Life in Balance Center. The following list will help us provide you better service. This packet takes about 30 to 45 minutes to complete. Please provide us with as much information as possible, as this will help us to file your insurance.

To enable us to provide you with the best care possible be sure to fill out all pages front and back.

  • Insurance Card Please bring with you to your first appointment. We must have this to copy and put in your file.

  • Driver’s License or ID to be copied for records.

  • Any additional Medical Records or notes from previous practitioners.

  • HIPPA Form has been signed.

  • Informed Consent signed and initialed where indicted.

  • Clients Rights & Responsibilities signed and initialed where indicted.

  • Client Registration filled out completely. Under this if you are not the policy holder of the insurance please indicate the insured Date of Birth and social security number. This now required when we submit a claim. If you do not have this information, you will need to call us back. This will help insure that you are not billed for the service if insurance denies claim.

  • Client Intake Form please fill this out as completely as you can. This will help your practitioner understand more about your visit. Be sure to sign this form.

  • Brief Medical History please fill this out completely.

  • Brief Mood Survey please fill this out to the best of your ability.

  • Communication Sheet this needs to be completed and signed.

  • Please Review Check each page that it has been signed and initialed.

Thank you for your cooperation and patience in filling out these forms to help us better understand your needs. This insures we can bill your insurance correctly. We hope to continue to serve all your needs and appreciate the opportunity to serve you.

Date of Birth ____/____/______ Today’s Date: ____/____/______
Male/Female DOB_________________ Age________________
Child’s Full Name: _______________________________SS#:___________________

Name Child Goes By:____________________________

Child Lives With__________________________ Relationship to Child:___________________

Are you the Guardian over said child? yes no (If No please do not fill out further)
Home Address_________________________________________________________

City: ___________________________State: _________ Zip________________


School Name___________________________________ Current Grade Level________

Family Physician: ________________________________Practice Name:__________________

Referred by:__________________________________________________________

Emergency Contact: ________________________________Phone#:______________


Is There A Custody Agreement In Place? Yes No

If yes please explain:__________________________________________________________



Parent/Guardian Signature Date

Please use the space below to provide parent/guardians information. Please fill this section out regardless of insurance.

Name of Policy Holder/Guardian: ________________________________________
Relationship to Client:______________________ Date of Birth____________
Home Address: _____________________________Phone#: __________________
Employer_________________________________ Phone #: ________________
SS#:_____________________________ Male/Female
Single/Married Employed/Unemployed/Retired
Group#: _____________________________________

Clients Secondary Ins. Co._________________________ ID#:________________________



I authorize treatment deemed necessary by Life in Balance Counseling & Wellness Center Practitioners for my child. I authorize Life in Balance Counseling & Wellness to release to my child’s health plan any and all information deemed necessary regarding my child’s care and treatment to insure prompt payment of all charges for services provided. I hereby assign the payment for all insurance benefits to Life in Balance Counseling & Wellness for any and all charges incurred in connection with services provided to my child. I also consent to a copy of this authorization and assignment being used in place of the original.

I understand fully that I remain responsible to pay Life in Balance Counseling & Wellness Center for all charges not paid by either my insurance companies and/or employer, subject to the rules of any federal or state health insurance program such as Medicaid, or to other contractual provisions that may limit a patient’s responsibility to pay for medical costs and services. Payment shall be due at the time of the appointment or within thirty days of receipt of a statement.


All payments and/or co-payments are due at the time of each appointment.Our office accepts personal checks, cash, Visa, and MasterCard. A returned check fee of $35.00 will be charged.

Please note if payments are not made at the time of the appointment subsequent appointments will not be made until payment is paid in full.


Please contact our office within 24 hours if you are not able to make your appointment. If you do not show for a scheduled appointment a NO SHOW FEE of $50.00 will be charged for the cost of the missed appointment. This cost is not covered by insurance and is your responsibility and must be paid in full before your next appointment. If a second appointment is missed without canceling with a 24 hour notice, all future appointments will be canceled until you speak with your counselor concerning this matter. If a third appointment is missed all future appointments could be jeopardized.


Guardian Signature Date



Thank you for choosing the Life in Balance Counseling & Wellness Center. Today’s initial appointment will take approximately 50 minutes. We realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of our policies, State and Federal Laws and your rights. If you have other questions or concerns, please ask and we will try our best to give you all the information you need. All of the clinicians in our practice have earned a graduate degree (Masters or Doctorate) from an accredited University. All Life in Balance Clinicians are licensed to practice in the state of Virginia. Life in Balance also employs resident clinicians who have completed a graduate degree and are pursuing licensure under direct supervision of a licensed clinician. The clinical supervisors name and credentials may be obtained upon request. Our clinicians only practice within their scope of training and experience. In the course of our training and previous employment we have had experience in treating a wide variety of individuals including children, adolescents, adults, individuals, couples, families, and groups. Your counselor will have his/her own primary specialty areas of expertise.. Treatment practices, philosophy and plan imitations and risks will be discussed with you today. Laura Rumfeldt M.S., is a Counseling Resident in training under the weekly supervision of Dr. Alan Forrest, LPC, LMFT. If you should have any questions the contact information for Dr. Forrest is and his phone number is 540-831-5214.

Our practice consist of the following clinicians:

Angela McGoldrick, LPC, Alan Forrest, LPC, LMFT,

Dr. Mary M. Amtower, LPC, Barrie Bondurant, Ph.D, LPC, Alia Zaro, LPC,

Laura Rumsfeldt – Resident Counselor, Stacey Lester, MS-Under Supervision

CONFIDENTIALITY AND EMERGENCY SITUATIONS: Your verbal communication and clinical records are strictly confidential except for: a) information shared with consultants, b) information (diagnosis and dates of service) shared with your insurance company to process your claims, c) information you and/or your child or children report about physical or sexual abuse; then, by Virginia State Law, we are obligated to report this to the Department of Social Services Adult or Child Protective Services, d) where you sign a release of information to have specific information shared and e) if you provide information that informs me that you are in danger of harming yourself or others f) information necessary for case supervision or consultation and h) or when required by law. In the unlikely event that your clinician is unable to provide ongoing services another clinician within the group practice will provide those services and will maintain your records for a period of 7 years. Please contact the executive director Angela McGoldrick, LPC for any questions pertaining to this. If an emergency situation for which the client or their guardian feels immediate attention is necessary, the client or guardian understands that they are to contact the emergency services in the community (911) for those services. You may also contact ACCESS Services for Emergencies at 540-961-8400. Our Clinicians will

follow those emergency services with standard counseling and support to the client or the client's family.

FINANCIAL/INSURANCE ISSUES: As a courtesy we will bill your insurance company, HMO, responsible party or third party payer for you if you wish. We ask that at each session you pay your co-pay. Returned checks will carry a $30.00 NON-INSURANCE BILLABLE fee and are expected to be paid in full prior to your next appointment. If we receive more than one returned check from an individual we reserve the right to refuse future payment by check. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. If the balance is not paid after 45days any unpaid balance will be charged 1.5% interest a month (18% APR). In the event that an account is overdue and turned over to our collection agency, the client or responsible party will be held responsible for any collection fee charged to our office to collect the debt owed. We ask that every client authorize payment of medical benefits directly to the Life in Balance Counseling & Wellness Center.

Fee for Service

Initial Assessment & Diagnosis (45-55 minutes) $115.00

Clinical Therapy Session (50 minutes) $95.00

Session by phone (30 minutes) $95.00

Short Clinical Session (25-30 minutes) $47.50

Group Therapy Session (50 minutes) $40.00

Appearance in Court (per hr.) $500 + $100.00

Records and Document Review ($30 min.) $95.00 per hour Written Correspondence (depending on type) $50.00 per page


If you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise you will be billed $50.00 for the missed appointment. We sincerely appreciate your cooperation and at any time you have any questions regarding insurance, fees, balances or payments please feel free to ask. You may have a copy of this form if requested.

COORDINATION OF TREAMENT: It is important that all health care providers work together. As such, we would like your permission to communicate with your primary care physician and/or psychiatrist. Your consent is valid for one year. If you prefer to decline consent no inform will be shared.

____You may inform my child’s physician(s) ____I decline to inform my child’s physician

Primary Care Physician’s Name:_________________________________________________



NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS: I/We have read and received a copy of the, Notice of Privacy Practices and Client Rights document.
OFFICE HOURS Our office hours are Monday – Thursday 9am-8pm. Friday 9am-3pm and by appointment on Saturday. You may reach our office by phone at 540-381-621 to schedule an appointment. If we are unavailable you may leave a message on my confidential voice mail box and someone will return your call as soon as possible.

Guardian Signature Date


It is important for you to understand what counseling is about and what you may expect during therapy. Please read this material carefully and ask the therapist to explain anything that is unclear to you.

What are Counseling and Psychotherapy?

Counseling” and “Psychotherapy”, or simply “therapy”, are two words for the same process which is: using proven methods to assist people in changing how they feel and how they behave. Legitimate therapy is practiced by professionals Licensed by the state in the areas of Clinical Social Work, Professional Counseling, Psychology, or Psychiatry.

The Risks of Counseling:

Research has shown that competent therapy provided by trained and licensed professionals is helpful to most people. At the same time, therapy is not guaranteed to result in a successful outcome every time for everyone. It is important that you understand this before you invest time and money in counseling. The greatest risk of counseling is that it may not, by itself, resolve your problem or concern. Unexpected emotional strain, stress, and life changes may happen during therapy. Other people in your life may not react to changes you make during therapy in the way you would like for them to respond.

How does therapy work?

Therapy at Life In Balance, will involve several steps. Therapy sessions are usually 45 to50 minutes in length, and are typically held one time per week.

First, your child’s counselor will meet with parent(s)/legal guardian to address concerns that have brought your child to counseling. He/She will get to know you and how you view your child and yourself. You will probably understand your situation better as you and your counselor talk. After you and your child’s counselor explore your concerns, the counselor will then meet with your child to gather information and formulate goals and objectives for therapy. Next, your child their counselor will work together to develop a plan for meeting those goals.

Your child and their counselor will work toward accomplishing these goals by using research-proven methods. These methods include, for example, accessing inner strengths and resources, changing thoughts that affect how your child feels and what he/she does, or homework assignments in which your child will try on new behaviors to see how they fit. Your child’s counselor may decide to involve other family members in the session. Please know that any work in the sessions will occur only with your and your child’s permission. It is very important to your counselor to see that your child’s limits are respected. Your child’s specific needs and concerns will determine what is done.

Your counselor will frequently take time to examine your child’s progress toward their goals to make sure both are on the right track. Your child’s counselor will also meet with parent(s)/guardian(s) regularly to inquire about child’s progress at home and school. Parent(s)/Guardian(s) are encouraged to notify their child’s counselor of any concerns or questions regarding their child’s therapy. Your child and their counselor will decide together when the therapeutic goals are met and when to move toward completing therapy.


Guardian’s Signature(s) Date
Effective date: April 14, 2003
The Counseling Office of Life in Balance Counseling and Wellness has been and will always be totally committed to maintaining clients confidentiality. We will only release healthcare information about you in accordance with federal and state laws and ethics of the counseling profession.
This notice describes our policies related to the use and disclosure of your healthcare information.
Uses and disclosures of your health information for the purposes of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allows us to use and disclose your health information for these purposes.
TREATMENT We may need to use or disclose health information about you to provide, manage or coordinate your care or related services. Which could include consultants and potential referral sources.

PAYMENT Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. We may bill the person in your family who pays for your insurance.

HEALTHCARE OPERATIONS We may need to use information about you to review our treatment procedures and business activity. Information maybe used for certification, compliance and licensing activities.

Other uses or disclosures of your information which does not require your consent There are some instances where we may be required to use and disclose information without your consent. For example, but not limited to: Information you and/or your child or children report about physical or sexual abuse: then by Virginia State Law, we are obligated to report this to the Department of Children Protective Services. If you provide information that informs us that you are in danger of harming yourself or others. Information to remind you of /or to reschedule appointments or treatment alternatives. Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order.
I have read understand the above information:

Parent/Guardian Signature Date


Right to request how we contact you

It is our normal practice to communicate with you at your home address and daytime phone number that you gave us when you scheduled your appointment, about health matters, such as appointment reminders etc.. You have the right to request that our office communicate with you in a different way.

Please check all that apply:

You may contact me:

At home at_____________________Parent’s Name____________________May we leave a message?Yes No

At work at _____________________ May we leave a message? Yes No

 On my cell at____________________ May we leave a message? Yes No

 Please contact me only at the following number _________________________________

Please do not leave a message

 By e-mail_______________________________________

Right to release your medical records

You may consent in writing to release your records to others. You have the right to revoke this authorization, in writing, at any time. However, a revocation is not valid to the extent that we acted in reliance on such authorization

Right to inspect and copy your medical and billing records.

You have the right to inspect and obtain a copy of your information contained in our medical records. To request access to your billing or health information, contact the office manager. Under limited circumstance we may deny your request to inspect and copy. If you ask for a copy of any information, we may charge a reasonable fee for the costs of copying, mailing and supplies.

Right to add information or amend your clinical records.

If you feel that information contained in your clinical record is incorrect or incomplete, you may ask us to add information to amend the record. We will make a decision on your request with 60 days, or some cases within 90 days. Under certain circumstance, we may deny your request to add or amend information. If we deny your request, you have a right to file a statement that you disagree. Your statement and our response will be added to your record. To request an amendment, you must contact your therapist. We will require you to submit your request in writing and to provide an explanation concerning the reason for your request.

Right to an accounting of disclosures.

You may request an accounting of any disclosures, if any, we have made related to your medical information, except for information we used for treatment, payment, or health care operational purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to the Privacy Officer. We will notify you of the cost involved in preparing this list.

Right to request restrictions on uses and disclosures of your health information.

You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to the therapist. However, we are not required to agree to such a request.

Right to complain.

If you believe your privacy rights have been violated, please contact us personally, and discuss your concerns. If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individual will not be retaliated against for filing such a complaint.

Right to receive changes in policy.

You have the right to receive any future policy changes secondary to changes in state and federal laws. This can be obtained from the office manager.

You also have the right:

  • To be treated in a humane and dignified way.

  • To be informed of your treatment options, risks, and benefits.

  • To take an active role in treatment planning.

  • To have questions answered fully.

  • To have confidentiality and privacy within legal/ethical guidelines.

  • To facilitated review of your clinical information.

You have the responsibility:

  • To be honest in providing information.

  • To keep your appointments, to be on time, and to give a 24 hour notice if you should need to cancel your appointment.

  • To be free of alcohol/drugs during your therapy session.

  • To respect the therapist and facility.

  • To respect the privacy and rights of others.

  • To know your insurance requirements, deductibles, and co-pays.

  • To pay your co-pay at the end of each appointment.

______________________________________________________________________________________Guardian Signature Date


Children’s Intake Form

Date_______________ Date of Birth________________
Child’s Full Name:_____________________________________________
Name Child Goes By:___________________________________________
Mother’s Full Name:___________________________________________
Father’s Full Name:___________________________________________

Medical History

Has your child ever had any of the following:

 Allergies  Asthma Headaches Seizures High Fever Head Injury

 Loss of Consciousness  Hospitalization Hyperactivity

If so please explain:_______________________________________________


Is your child on a special diet? If so please explain:________________________


Has your child ever had a neurological exam or EEG? Yes No

Has your child ever had a psychological exam? Yes No If so when?____________

Has your child ever been to counseling before? Yes No If so when?____________


Would you say that it was helpful? Yes No Why or why not?_________________


Is your child currently taking medication? Yes No If so please list below:

Medication Dosage How Long? Prescribing Dr.
Does your child have problems with:  Hearing Sight Speaking

If so please explain:_______________________________________________


Are your child’s immunizations up-to-date? Yes No

Date of Last Medical Exam: _____________________

Have you ever been told that your child may suffer from any of the following:

ADD ADHD Anxiety Depression Other Please Explain________________


Is your child experiencing any of the following?

mood swings irritability aggression change in appetite fears/phobias

If so please explain:_____________________________________________________________

How has your child been sleeping? More or less than usual?

Please Explain__________________________________________________________________

Do you feel that your child understands directions and situations as well as other children their age?

Yes No

If No please explain:____________________________________________________________


How would you rate your child’s intelligence:

Below Average  Average Above Average

Does your child play primarily with children:  their age older younger

Describe any problems your child has interacting with other children:

Describe any problems your child has interacting with adults:


Developmental History

Pregnancy planned unplanned

Did the mother have problems during the pregnancy? Yes No If yes please explain:



Child’s weight at birth:_____________ Was child premature? Yes No

Check One:  Breast Fed Bottle Fed At what age was this type of feeding discontinued:_____________

Was your child: Colicky Yes  No Active Yes No

Was there any problems with weight gain? Yes No

At what age did your child walk? _____________

Were there any difficulties?___________________________________________________________

Were there or are there presently any problems with speech? Yes No

At what age was the child toilet trained? ___________ Were there problems with wetting or soiling afterward?____________________________________________________________________
What forms of discipline do you use when correcting your child?____________________________________

Family History

Is your child adopted or a foster child? Yes No If adopted at what age:________________

If a foster child how long has the child been in your care?__________________

Are the child’s parents living together? Yes No If no when did they separate?_______________________

What are the living/custody arrangements?_________________________________________________
Describe visitation arrangements:_________________________________________________________

Please List All Members of Household, ages, and Relationship to Child:






Has any blood relative of your child (parent, sibling, grandparent, aunt, uncle, ect.) ever had issues or been diagnosed with any of the following:

 Mental Illness Suicide Alcoholism Drug Problems Seizure Disorder

 Mental Retardation Chronic Illness ADD ADHD Bipolar Disorder


Name of School_________________________________________________


Phone______________________ Current Grade_________Teacher_______________________

Does your child have an Individualized Education Plan or 504 Plan? Yes No

Has your child ever had to repeat a grade? Yes No

Does your child’s teacher report any problems at school? Yes No

If so please explain:_____________________________________________________________



Additional Comments or Concerns you would like your child’s therapist to be aware of:









Parent/Guardian Signature Date

Authorization to Release Protected Health Information (PHI)
I __________________________________ guardian of
(Child’s Name)______________________________ (Date of Birth)_______________ give permission to Life In Balance Counseling and Wellness Center and
__________________________(Clinician’s Name) to send and/or discuss confidential case records and/or test results, to send treatment summaries and diagnosis information to and to receive confidential information from my child’s Primary Care Physician or Other Desired Person or Entity:





I understand my service record is protected under Federal and State regulations and that information to be released by my signature may contain information pertaining to medical, psychiatric, substance abuse treatment and/or confidential HIV/AIDS related information.

This consent shall be in effect for one year from date signed.

____________________________________ ________________

(Signature of Parent/Guardian) (Date)
_________________________________________________ _________________________

(Signature of Witness) (Date)

Initial Here________________

Share with your friends:

The database is protected by copyright © 2020
send message

    Main page