New Client Packet Aug2017 - Chicago Christian …

1 S:\Forms - Clinical\Forms Client Fills Out\New Client Packet NEW Client Packet Thank you for choosing Chicago Christian Counseling Center (CCCC) as your provider for your mental health care. The documents in this New Client Packet are explained below. Please GIVE THIS NEW Client Packet TO YOUR THERAPIST AT YOUR 1ST APPOINTMENT after you have read and signed all the appropriate documents in it. NOTE: If you are typing your information into this form, please note that all signatures must be handwritten. This New Client Packet includes the following documents: Client Information Form: Please complete this in its entirety so we will have all the necessary information to assist with your insurance billing.

2 We also request that we be able to make a copy of your insurance card. Insurance Authorization and Assignment of Benefits, Confidentiality and Authorization for Treatment, Acknowledgement of Receipt of Notice of Privacy Practices: This form gives permission for filing with your insurance and treatment. This form also indicates that your therapist has provided a copy of our Notice of Privacy Practices (HIPAA). Both you and your therapist will sign this form. A copy of our Notice of Privacy Practices will be given to you by your therapist. Office & Fee Policies: This form explains the office and fee policies of CCCC.

3 Please provide the signature of the Responsible Party at the bottom of the form. A copy of our Office and Fee Policies will be given to you by your therapist. granting Permission Regarding Billing and/or Scheduling and Email/Text Authorization: This form gives Chicago Christian Counseling Center permission to speak to authorized parties regarding the Client s billing and/or scheduling information. This form also allows for email and/or texting appointment reminders with Client permission. Please sign and indicate which permissions are granted to our staff. Request to Release Information to Primary Care Physician (PCP): This form indicates your wishes in regards to releasing treatment information to your PCP.

4 If you check the box requesting a release of information, we are required to exchange information with your PCP regarding your treatment. If you do not want us to exchange information with your PCP, please check the appropriate box and sign the bottom portion. If you do not have a PCP, please check that box and sign at the bottom. Symptom Checklists: This provides your therapist with some information regarding why you are here today. Two checklists are provided. The first form is for the Client . The second checklist is for the parent/guardian or significant other/spouse.

5 S:\Forms Clinical\Forms Client Fills Out\New Client Packet Client Information Form (Please Print) Client First Name _____ Last Name _____ Date _____ Address _____ Apt. #_____ City _____ State ____ Zip _____ Phone H W C _____ Phone H W C _____ Social Security # _____ DOB _____ Age _____ Sex M F Marital Status: S M Sep D W Church Affiliation (if any) _____ Denomination _____ If Client is a minor, is there a joint custody agreement issued by the court?

6 YES NO If yes, please see Parental/Guardian Consent Forms. Please Check: Parent/Guardian Significant Other/Spouse Information First Name _____ Last Name _____ Address _____ City _____ State _____ Zip _____ Phone H W C _____ Phone H W C _____ Social Security # _____ DOB _____ Age _____ Sex M F Emergency Information Emergency Contact Name _____ Relationship _____ Address _____ City _____ State _____ Zip _____ Cell Phone _____ Alternate Phone_____ Insurance Information PRIMARY Insured _____ DOB _____ SS # _____ Relationship to Client .

7 _____ Employer _____ Primary Insurance Carrier _____ Phone _____ ID# _____ Group # _____ SECONDARY Insured _____ DOB _____ SS # _____ Relationship to Client : _____ Employer _____ Secondary Insurance Carrier _____ Phone _____ ID# _____ Group # _____ New Client Packet Page 1S:\FormI herand tChica Clien All inCounthe tr I givemutuadiscorespo _____Chris Clien Paren I, (plChrispermPleas I h I dhttp:/ SignaSigna Intern I MSignams Clinical\Form eby authorizetreatments to ago Christian nt/Authorized nformation reganseling Center wansfer of recore my consent toally determine ntinue treatmeonsibilities in th_____ (Please stian Counselinnt (age 12 or ont/Guardian Silease print cliestian Counselmitted under fese check one.)))

8 Have read anddecline of Recipature of Parennal Use Onlyhave provideMy Client has dature of Ments Client Fills Out\N Insue the Chicago Cthe Client s inCounseling CPerson s SignCoarding clients iwithout your wrds to another po (treating therto be approprint at any therapeutic initial if applicng Center licenover) Signatureignature _____Acknowent name) ling Center s ederal and stad received a cving a copy ofgochristiancoupient (age 12 nt/Guardian y: d my Client wdeclined recetal Health ProNew Client Packet urance AuChristian Cousurance carrieCenter. nature: _____onfidentiais considered swritten consentparty, the recorrapist) _____iate.

9 I am parti I have had threlationship. cable) I undersnsed therapist. e _____wledgemen Notice of Priate law, and I opy of the Nof the Notice over) with a copy ofiving a copy ovider thorizatiounseling Centeer(s) and (B) r_____ality and Astrictly confiden. Exceptions arrds will be forw_____icipating in mye opportunity ttand that the ab_____nt of Recevacy Practiceunderstand thotice of Privaof Privacy Pra/files/notice_of the Notice oof the Notice_____on and Ass er to (A) furnirequest the cli_____Authorizat ntial and will nre listed in our warded directly_____y treatment volto discuss reasobove named th_____eipt of Not es detailing hohe contents ofcy and amof_privacy_pr f Privacy Pra of Privacy P_____signment oish the informient s insuran_____tion for Trnot be given tor Notice of Privy to that party o_____ to proluntarily and unons for seekingherapist is recei_____tice of Priv have beeow my informf the Notice.

10 M aware that actices. Practices. _____of Benefitsmation concernnce carrier(s) t_____ Dreatment o anyone outsidvacy Practices. only upon receovide evaluationderstand that g services and iving weekly s____ Date _____ Date ___vacy Practen presented wmation may bethis Notice caDate Date _____ Dats ning the clientto direct paymDate _____de of Chicago C In the event oeipt of your wrion and treatmenI have the righI understand mupervision from_____tices with a copy oe used and dian be viewed te _____New Cliet s diagnosis ment to the _____Christian f a request for itten request.