Client Intake Form Stenzel Clinical Services

Client Intake Form

PLEASE FILL OUT THE FOLLOWING INFORMATION AS COMPLETELY AS POSSIBLE.

Client’s Full Legal Name:   Date:

Address:

City:   State:   Zip:

Phone: (H)   (C)   If child, second parent phone:

Date of Birth:   Will Stenzel Clinical be billing your PPO insurance for you?

Email:

Subscriber Relationship to Client: Self Spouse Parent (Please complete below if other than self)

Subscriber Name:   Subscriber’s Date of Birth:

Address of Subscriber:

(If different than above)

City:   State:   Zip:

Place of Employment:

Job Title:   Number of years at current job:

Highest education completed: High school/GED Some college College Graduate/other

Marital Status: Single Engaged Married Separated Divorced Widowed

If married, spouse’s name:   Date of Birth:

Spouse’s occupation and place of employment:

Number of years married:

If you have children, please list their names and ages:

Name:   Age:   Name:   Age:

Name:   Age:   Name:   Age:

How were you referred to Stenzel Clinical Services, Inc.? Insurance Co. Physician School Church

Friend Advertising Google Other search engine

Therapist:

Dx:

Is there a racial or ethnic group you identify with (or your parents) that you’d like me to be aware of?

Do you consider your spiritual life a resource? Yes No

What is your religious affiliation (optional)

Attendance: Regularly Sometimes Never

THE FOLLOWING QUESTIONS ARE DESIGNED TO HELP ME UNDERSTAND YOUR BACKGROUND. PLEASE COMPLETE THEM AS THEY APPLY TO YOU. THANK YOU.

Parent’s names: (F)   Age   Deceased

(M)   Age   Deceased

Married Separated Divorced Widowed

Number of brothers   sisters

Has anyone in your family of origin had counseling? Yes No

If so, for what?

Is there any history of drug or alcohol abuse in either of your parent’s families? Yes No

If yes, please describe

Was there any physical, sexual, or emotional abuse done to you or your siblings? Yes No

If yes, please describe

Are you in any way fearful of your current partner? Yes No

Does your partner have angry outburst or temper tantrums? Yes No

Has your partner ever pushed, grabbed, slapped, or hit you? Yes No

Please list any specific medical conditions that you have

Are you taking any prescription medications at this time? Yes No

If yes, what are they?

How long have you been taking this?   Who prescribed it for you?

What is your daily or weekly alcohol intake?

Do you have a past or current history of other drug abuse? Yes, current Yes, past No

If yes, please list

Have you been in therapy in the past? Yes No

If yes, when, for what, how long, and with whom?

Was the therapy helpful?

What is your reason for contacting Stenzel Clinical Services, Inc and seeking therapy? What are your goals for therapy?

Is there anything else that you feel is important to this therapy process?

PLEASE FILL OUT THE CHECKLIST AND RETURN THIS FORM TO YOUR THERAPIST.

If you will be utilizing your PPO insurance benefits please bring in your insurance card for your therapist to copy.

We look forward to working with you.

Client Checklist

PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU AT PRESENT:

Informed Consent

We would like you to have a clear understanding of the services we provide and our expectations of you, our client. If you have questions or need clarification, please ask your therapist for assistance before you sign.

SERVICES OFFERED

Stenzel Clinical Services, Ltd, provides outpatient counseling services. We work with all age groups. Licensed practitioners provide individual, group, couples and family counseling, as well as case coordination.

We strive to return all messages as quickly as possible Monday through Friday. Routine messages left on the weekend may be returned Monday. We do not guarantee 24 hour crisis coverage and if your therapist is not available when you feel you are in crisis, please call the DuPage Crisis line at 630-627-1700, proceed to your local hospital emergency room, or call 911.

INITIAL ASSESSMENT, DIAGNOSIS, AND COUNSELING PROCESS

Initial assessments take place at the first appointment. These appointments are used to gather data, complete intake information, and to determine the best course of care. A diagnosis will be given for each client being seen, just as with a visit to a medical doctor.

If ongoing counseling is recommended, we will diligently work to provide the best therapeutic methods and tools available. For counseling to be successful, your commitment to the process is absolutely essential. This includes regular attendance and active participation, homework between sessions to enhance or speed your growth, and completion of the process through planned termination of counseling services. You may begin to find some relief of symptoms initially, and it may be tempting to terminate. However, this initial relief is often temporary if counseling is stopped abruptly. Because all therapists want to see you have the greatest growth possible during the time you are here, we will work with you to plan a successful wrap-up. This is an important part of the counseling process, and we highly encourage you to honor your own effort by not neglecting this phase.

FEES AND INSURANCE

Initial assessments are $160. Standard sessions are $135. Telephone consults less than 10 minutes are complementary if not overused. Phone sessions that last more than 10 minutes will be charged to the client directly, as phone sessions are not covered by insurance. Phone sessions are the same cost as office sessions. Payment is due at the time of service. Any checks returned by the bank will incur a fee. Any balances unpaid after 90 days will be forwarded to collections. All accounts forwarded to collections will incur a 25% Collection Fee. Continued non-payment will result in a report to the credit bureau and remain until the balance has been paid in full. We bill most insurance as a courtesy to you. If we are unable to bill your insurance company, you will be considered a Self-Pay client and must pay in full at the time of session. You will be given a receipt for your session, which you may use to request reimbursement from your insurance company. If you receive an insurance payment meant for us we ask that you send payment to us immediately.

CANCELLED OR MISSED APPOINTMENTS

Due to the nature of counseling services, we never overbook our schedules. We require 24-hours notification of cancellation. We charge an $85 Cancellation Fee for any appointment not cancelled 24-hours in advance. Insurance companies WILL NOT COVER missed appointment fees. These fees are immediately due by you. Please note that two or more instances of missed appointments without notifying your therapist may result in termination of services. In the event of inclement weather, as determined by the local school district, the cancellation fee may be waived. In order to have your fee waived you must contact the office prior to your appointment to notify the therapist that you will not arrive due to inclement weather. You are financially responsible for the time you have reserved with your therapist. You will be billed for any services not covered by insurance.

CONFIDENTIALITY

Legal and ethical standards require us to maintain confidentiality. Information cannot be divulged to any outside parties without your written consent with the following exceptions: if you are or become a danger to yourself or others, we become aware of any real or alleged abuse to children, elderly, or incapacitated people (in which case we are mandated reporters to the State of Illinois), and if we receive a properly issued subpoena accompanied by a court order to produce records.

If your therapist receives clinical supervision, s/he will inform you of that process. If you are here with family members, your therapist will discuss expectations and limitations of confidentiality.

TRANSFER PLAN

In the event of the incapacitation, death, or termination of a therapist’s practice at Stenzel Clinical during the course of your care, your records will remain in our possession and a new therapist will be made available to you. If you desire to transfer care outside of our practice, you may sign a release of records and we will release a standard extract from your file of the initial intake and the most recent progress notes. It is our standard policy to release records directly to another provider. Any variance will be arranged with the Director/designee.

AGREEMENT

I have read and understand the above statement on services, policies, and procedures. My signature below indicates that I give my full consent to receive services at Stenzel Clinical Services, Ltd.

Notice of Privacy Practices

TREATMENT
We use and disclose health information to:

• Provide, manage or coordinate care
• Consultants
• Referral sources

PAYMENT
We use and disclose health information to:

• Verify insurance and coverage
• Process claims and collect fees

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL/MENTAL HELATH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Stenzel Clinical Services, Ltd. established 12-1-03

Stenzel Clinical Services, Ltd. only releases information in accordance with state and federal laws and the ethics of the counseling profession. This notice describes our policies related to the use and disclosure of our client’s healthcare information.

“Use and disclosure of protected health information for the purpose of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.”

CLIENT RIGHTS

In the Notice of Privacy Practices counselors are required to inform clients as to their rights under state and federal law.

CLIENT RIGHTS (continued)

Right to request where we contact you

Home yes no   Leave message? yes no

Work yes no   Leave message? yes no

Cell Phone yes no   Leave message? yes no

Email yes no   Email:

If not, how may we contact you:

RELEASE OF ACCOUNT INFORMATION

This is not an authorization to release any medical information, this is simply an authorization for who we may speak with regarding your account balance and insurance claims.

I authorize the release of information including account and claims information. This information may be released to:

Spouse   Phone

Other   Phone

Information is not to be released to anyone

This document will remain in effect until terminated by me in writing.

I have read and received a copy of this document outlining notice of privacy practices

Credit/Debit Card Release

This form is provided for your convenience to make checking out after each session easier. I understand that it is office policy that payments are required at the time of service or charge accrual. Charges and fees are described in the Benefits Inquiry and Informed Consent. Please use this credit card authorization for the following client accounts:

1-Client name (print)   Date of birth

2-Client name (print)   Date of birth

3-Client name (print)   Date of birth

4-Client name (print)   Date of birth

I voluntarily authorize Stenzel Clinical Services, Ltd. to charge my credit/debit card(s) for any and all balances that I accrue. This includes the cost of sessions, phone consultations, and no show/cancellation fees.

Type: Visa Master Card Discover Flex/HSA

Card number (16 digits)   Expiration date (xx/xx)   V code (3 digits)

Please include the billing address that is on file with the credit card company

Address

City/State/Zip

Email Address

Authorized for all balances as they accrue   Authorized for one-time payment only

Therapist:

Sign Now