Transforming Lives, Connecting Marriages & Families IMPORTANT!INFORMATION!FOR!CLIENTS!

Welcome to Li e onnection o nseling We as t at o read t e ollowing in ormation and ring an estions o mig t ave to o r attention Fee e ee or a min te session is We re est t at pa ment or all services e made at t e time o services are rendered t is t e polic o t is o ice to t rn delin ent acco nts over to a collection agenc nl in ormation w ic is non clinical in nat re will e given to t e collection agenc or t is p rpose

elep one al ls r o ice is open Monda t ro g Frida rom : a m : p m ter o rs o ma leave a message on o r voice mail o r t erapist determines t at it is necessar or o to e a le to contact im er, special arrangements will e made n t e case o an emergenc or li e

t reatening event, call and not L ppointments W en o ma e an appointment, a speci ic time is reserved or o o s o ld ave

to e late, o will e seen or t e remaining portion o o r reserved time ver e ort will e made to see o on time, owever, in some n s al circ mstances o ma ave to wait e ore eing seen n s c cases o will e seen or o r ll visit

I f#you#must#cancel#an#appointment,#please#do#so#at# least#24#hours# in#advance.#I f#not,#you#will#be#charged#$150.00#for#the#ful l #session.#

Ins ran e Services in t is o ice ma e covered medical ins rance plans However, ew policies cover o t e cost o re est, t e o ice sta will assist o wit ins rance iling, t collection of insurance claims is ultimately the insured client’s responsibility, regardless of your in network or out of network benefits o will e responsi le or w atever ins rance does not cover according to o r c arges Please n erstan that o are f l l res onsi le for the

a ment of all fees for ser i es ro i e re ar less of the e tent of an ins ran e o era e o ma ha e t e t erapist is not in networ wit t e client s ins rance compan , it is not

o r polic to accept t e amo nt an ins rance compan ma o er as pa ment, i t e amo nt is less t an t e reg lar ee CC il l e notifie of an ersonal a ress han e or han es in ins ran e o era e

Ps holo i al estin i t ional Fees n order to etter nderstand a client s pro lems and to acilitate treatment, ps c ological tests are re entl tili ed n s c cases t e p rpose o ta ing t e tests will e e plained and t e res lts will e reviewed wit o Fees or testing are separate rom ees or reg lar visits and var according to t e test sed stimates o t e cost o testing will e rnis ed pon re est and in advance o test administration lso, an assessments, report writing, p one cons ltations, and emails will e additional ees and will e e plained o r t erapists i t e need arises

Confi ential i t ll in ormation t at o reveal to o r t erapist, incl ding test res lts, notes and records, is con idential and will not e released to an o tside person or agenc wit o t o r written a t ori ation W en more t an one amil mem er is seen d ring a session, eac o t ese legall competent individ als m st sign s c a t ori ation ere are several limitations to t is w ic incl de: ) i , in t e t erapist s opinion, revealing t e in ormation wo ld e necessar to prevent a person s deat or serio s in r , ) ins rance compan re ests or a diagnosis and general description o services rendered, and ) ot er circ mstances w ere it is legall re ired, s c as t e p sical or se al a se o a minor

I have read and understand the above policies and cl ient information. I am responsible for any unpaid balance on my account.

lient Signat re ______________________________________________________ Date ______________ arent ardian Signat re _____________________________________________ Date ______________

Patient Health Information Consent Form

We want o to now ow o r atient Healt n ormation (PHI) is going to e sed in t is o ice and o r rig ts concerning t ose records e ore we will egin an ealt care operations we m st re ire o to read and sign t is consent orm stating t at o nderstand and agree wit ow o r records will e sed o wo ld li e to ave a more detailed acco nt o o r policies and proced res concerning t e privac o o r atient Healt n ormation we enco rage o to read t e H N t at is availa le to o at t e ront des e ore signing t is consent

e patient nderstands and agrees to allow t is o ice to se t eir atient Healt n ormation (PHI) or t ep rpose o treatment, pa ment, ealt care operations, and coordination o care s an e ample, t e patientagrees to allow t is o ice to s mit re ested H to t e Healt ns rance ompan (or companies)provided to s t e patient or t e p rpose o pa ment e ass red t at t is o ice will limit t e release oall H to t e minim m needed or w at t e ins rance companies re ire or pa ment

e patient as t e rig t to e amine and o tain a cop o is or er own ealt records at an time andre est corrections e patient ma re est to now w at disclos res ave een made and s mit inwriting an rt er restrictions on t e se o t eir H r o ice is o ligated to agree to t ose restrictionsonl to t e e tent t e coincide wit state and ederal law

patient s written consent need onl e o tained one time or all s se ent care given t e patient in t iso ice

e patient ma provide a written re est to revo e consent at an time d ring care is wo ld not e ectt e se o t ose records or t e care given prior to t e written re est to revo e consent t wo ld appl to ancare given a ter t e re est as een presented

r o ice ma contact o periodicall regarding appointments, treatments, prod cts, services, orc arita le wor per ormed o r o ice o ma c oose to opt o t o an mar eting or ndraising comm nications at an time

For o r sec rit and rig t to privac , all sta as een trained in t e area o patient record privac and aprivac o icial as een designated to en orce t ose proced res in o r o ice We ave ta en all preca tionst at are nown t is o ice to ass re t at o r records are not readil availa le to t ose w o do not needt em

atients ave t e rig t to ile a ormal complaint wit o r privac o icial and t e Secretar o HHSa o t an possi le violations o t ese policies and proced res wit o t retaliation t is o ice

r o ice reserves t e rig t to ma e c anges to t is notice and to ma e t e new notice provisionse ective or all protected ealt in ormation t at it maintains o will e provided wit a new notice at o rne t visit ollowing an c ange

is notice is e ective on t e date stated elow

t e patient re ses to sign t is consent or t e p rpose o treatment, pa ment and ealt careoperations, t e t erapist as t e rig t to re se to give care

!

For#further#information#regarding#this#notice,#please#contact#LCC#at#918G946G9588#!

Date:!___________________!

CLIENT

Last Name _________________________ First Name ________________________________ MI________

Address ___________________________________ City, State ___________________ Zip _____________

Date of Birth ____________________ Age ____________ Social Security#__________________________

Employer ___________________________________________ Occupation _________________________

Highest Education Completed ______________ Church Affiliation _________________________________

Phone: Home ____________________Work ___________________ Cell __________________________

Contact me by: Home Number Work Number Cell Number

Email___________________________________________ May we contact you via email: Yes No

SPOUSE/PARENT/GUARDIAN

Last Name ____________________________ First Name ____________________________ MI ________

Address ___________________________________City, State _______________________Zip __________

Date of Birth _________________ Age ______________ Social Security # __________________________

Employer ___________________________________________ Occupation _________________________

Highest Education Completed _____________ Church Affiliation ________________________________

Phone: Home ____________________ Work _______________________ Cell ____________________

Email:_____________________________ May we contact you via email: Yes No

INSURANCE PROVIDER: In order for us to verify your insurance, we wi l l need a photo copy

of your insurance card and driver ’s l icense . We wi l l not f i le your insurance without them.

Insurance Co.

Name: __________________________________ Policy/Group# _______________________

Owner of Policy: ____________________________________________ ID# ________________________

Address of Insurance Co. ________________________________________Phone # _______________

**Please note that we f i le insurance as a courtesy . You wil l ult imately be responsible for

your account and whatever they do not cover according to our charges**

____Married, Separated) ____Remarried (How Long :_________)

Please!Circle:!

arital tat s ____ Single, Never Married ____ Single, Widowed ____ Single, Divorced ____ First Marriage (How Long :________) Husband’s:!1st,!2nd,!3rd,!4th!!!!Wife’s:!1st,!2nd,!3rd,!4th!

mer en Conta t erson ot er t an o se old mem erName: Relations ip

ddress:__________________________________ it :_____________ State: ___________ ip: ________

one: Home:________________ Wor : ___________________ ell: _____________________

i t ional Famil em ers (List all c ildren an marriages w et er living at ome or not)

!!!!!! Name!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Sex!!!!!Age!!!!!!!!! DOB!!!!!!!!!!!!!!!!Education!!!!!!!!!!!!!Occupation!!!!!!!!!!!!!!!Living!@!Home?!

Please list an re ent stressf l e ents or han es hi h ha e o rre in the last ear eaths of frien s or relati es marria es i or es han es in or s hool

resi en e h r h et

e i al Histor

! ! ! ! ! ! ! !List!Any!Recent!Illness,! List!All! !Family!Member! !Tests,!or!Hospitalizations! !!!!!!Medications!Taken! Physician!

W o re erred o ere ______________________________________________

Have o een in co nseling t erap previo sl __________________________

W en ________________ W om _________________ How Long ________________

n w at wa wo ld o li e t e co nselor t erapist to assist o ______________________________________________________________________________________________________________________________________________________________

Do o consider ristian Fait to e an important reso rce __ es __no

redit ard arantee Form

N NS R D L N S

lients w o are nins red or w ose ins rance does not cover t e cost o mental ealt co nseling, eca se o ig ded cti les or eit er limitations are personall responsi le or pa ment n alance not paid t e end o t e wee will e a tomaticall c arged to o r designated card elow is proced re will ena le o to spread o t o r pa ments i o wis and ma e t em smaller w ile eeping o r acco nt c rrent

NS R N SS NM N

r ns rance ssignment rogram is designed to eep o r o t o poc et e pense to a minim m s a co rtes to o , we will ill o r ealt ins rance carrier on o r e al and wait

p to da s or pa ment lease remem er, t at o are responsi le or pa ment n Da , i t e ill as not een paid o r ins rance compan , we will c arge o r designated credit card elow or t e amo nt o t e claim n pa ment made on t ese claims t erea ter will e

immediatel re nded to o

R D RD: M S !!M !!!D S !

RDH LD R S N M _______________________________________________________

LL N DDR SS __________________________________________________________

__________________ S __________________ _______________

M L DDR SS R R S _______________________________________

RDN M R ______________________________________________________________

D ______________________ HR D D N M R: _____________

______________________#DATE