Client Intake Form

I hereby authorize my insurance benefits to be paid directly to North Shore Counseling Solutions Inc for medical services rendered.

I also authorize North Shore Counseling Solutions Inc and Tai Pryjma to release any information necessary to process this claim.

CLIENT INFORMATION & SERVICE AGREEMENT

Please read carefully and sign this agreement. Feel free to discuss it with me before signing if you have any questions or concerns.

APPOINTMENTS: Standard appointments are 50 minutes but half sessions or extended sessions are available. You may extend a 50-minute session by an additional 15, 30 or 45 minutes if previously arranged.

TELEPHONE CALLS and E-mail: I return most calls within a few hours if you leave a message before 7pm. On rare occasions voice mail may fail to record messages, so if I have not returned your call within 24 hours, please call again. The best way to reach the practice after hours or on weekends is at 617-645-3393. I check e-mail daily, but it's best to use voice mail when notifying us of appointment changes for the same day. Extended telephone calls or email correspondences may be billed as part of my work, but reasonable exceptions will be made.

CANCELLATIONS: Hours set aside for our clients are not easily filled when they are canceled with short notice. You will be expected to pay for appointments that are not cancelled with at least 48 hours notice, including appointments scheduled at the beginning of the week. You will be charged $150 for late cancellations and missed appointments unless an adjusted fee is previously agreed upon.  Exceptions include cancellations due to sudden illness, hazardous driving conditions, or certain emergency situations. Appointments missed for reasons related to your work will still be your financial obligation, so please schedule your appointments when your work demands are not likely to interfere with your scheduled sessions. Please remember that insurance cannot be billed for missed appointments.

INSURANCE AND FEE PAYMENTS: I will do whatever I can to clarify insurance matters when possible, but it is your responsibility to understand your insurance coverage, including deductibles and co-payments and to pay for non-covered services. Please make payments for sessions, including managed care co-payments, at the beginning of each session. Adjustments to fees and deferred payment arrangements can be negotiated for reasons of financial need so let the practice know if fee payments present a problem. The fee for a standard 50 minute appointment is $100-$200 depending on your insurance.

CONFIDENTIALITY POLICY AND EXCEPTIONS: Confidence in client / clinician confidentiality is an essential component of psychotherapy. Both written records and verbal communication are confidential and are protected by law. A written release for information is usually required for the transfer of information. There are some exceptions where information may be shared without an authorized release from a client. These exceptions include:

Abuse: I am required to report abusive treatment and/or neglect of a child, elderly, or a disabled person to the proper agency.

Harm: I must report the threat of serious bodily harm to oneself or to others. I may seek a client's hospitalization in order to protect him or her, and, if warranted, may notify the potential victim of threats, as well as the potential victim's family members or the police.

Legal/Courts: In some legal proceedings, upon a court order, testimony and/or records may be rendered.

Self Defense: If legal actions are brought against me by a client and/or family, information may be disclosed if necessary and relevant to the case.

Children: General feedback on the treatment progress is reported to the parents or guardians of children under 18.

Fee Collection: Information may be disclosed to a collection service or small claims court for the purpose of collecting payments owed.

Insurance: Disclosing information to a third-party payer and/or managed care organization will be necessary for reimbursement of fees.

Please refer to the Notice of Privacy Practices for additional information about confidentiality.

All insurance companies require information that includes, at a minimum, a psychiatric diagnosis and dates and type of services performed. Managed care companies may require considerably more information to authorize visits beyond those initially approved. I will be happy to explain the extent of this information. You must understand that I cannot control the confidentiality of any information once it is disclosed to insurance companies or their agents. I will not be able to tell you whether employers have access to information about you or if such information is distributed by the insurer to national data banks. Questions about these matters should be addressed to your employer or insurance company directly. If you would prefer not to use your insurance, please ask me about your option to pay privately.

TREATMENT OBJECTIVES, "MEDICAL NECESSITY" AND INSURANCE:

In order for treatment to be reimbursed by insurance it must be considered "medically necessary" regardless of the number of sessions that a policy might "allow". This means that clients must exhibit a certain level of emotional distress and/or functional impairment in order to quality for "medically necessary" care. This can cause confusion for many clients who believe they are entitled to a certain number of sessions under their plan. Many clients experience a reduction in symptoms and improvement in functioning before they consider that their therapy is completed. For many, the benefits of therapy extend far beyond the definitions of medical necessity. It's important that you understand what your insurance will and will not cover as well as your option to contract for services privately beyond those limits.

CANCELLATION POLICY

When you schedule an appointment with NSCS, you are "purchasing" that time. It is yours unless you cancel it PRIOR to 48 hours of your appointment time. As you read in the Client Information and Service Agreement, the charge for a scheduled appointment not cancelled prior to 24 hours is $150 unless it is an emergency.

"Emergencies" are considered events beyond your control such as snowstorms, car accidents, funerals, hospitalizations or illnesses of the degree which keep you out of work.

This policy applies to an appointment you did not cancel because you have decided not to continue counseling, an appointment you "forget," or an appointment which conflicts with another one you have made, or if you choose to do something that is important to you rather than come to counseling.

Charges for late cancellations or missed appointments are not billable to your insurance company.

If you cancel 2 consecutive appointments, before rescheduling, we will need to discuss your treatment goals and whether you are able to commit yourself to counseling at this time.

If at some point you decide not to continue in counseling, please call our office and leave a message, especially if you have appointments scheduled.

CLARIFICATION:

It is our intention to provide you with the greatest possible selection of appointment times. If you have ever waited for a "cancellation appointment", you can appreciate someone who cancels in sufficient time for you to take that appointment.

During the time we have to work together, YOU are our priority. We are always happy to hear from you and will always try to accommodate you within the guidelines of this policy. We hope this statement provides clarification to a system that has been working well for everyone.

HIPPA NOTICE

It is the intent of this office to be in compliance with the Privacy Standards for Private Health Information (PHI) covered under Health Insurance Portability and Accountability Act (HIPAA).

•   I understand that I have the right to request that certain information be excluded from my record unless the information is related to my diagnosis or safety.

•  I understand that I have the right to amend information but not expunge ("erase") information from my record.

•   I understand that I have the right to inspect and/or receive a copy of my Private Health Information (PHI) i.e. Record unless it is legally determined that it would adversely affect my well-being or I am a minor.

•   As additional HIPAA regulations are mandated and clarified, this office will be altering its policies and procedures to be in compliance.

•   If this office is found to be in violation of the Primary Standards put forth in HIPAA, I am urged to speak with my therapist and if not resolved, I have a right to file a formal compliant with the Office of Civil Liberties.

I have read and received a copy of the above Privacy Standards for Private Health Information covered under HIPAA.

  PHQ-9 Depression Scale

Over the last 2 weeks, how often have you been bothered by any of the following problems?

 GAD-7 Anxiety Scale

Over the Last 2 weeks, how often have you been bothered by any of the following problems?