Client Form McDowell Counseling & Associates, LLC

Client Form

Name

Soc. Sec #

Date of Birth

Guardian Name

Address

City

State

Zip

Phone

Alternate Phone

Permission to leave a message at any of the above number?

Permission

Y N

Martial Status:

Married Separated Divorced Widowed Single

Employer

Occupation

School

Teacher / Grade

I would like a 24-hour reminder for my Appointments:

Yes Call Thanks Text Email

If yes, please provide phone # for reminder call or text

Emergency Contact

Phone Number

Physician Number

Address

Phone Number

Medications (Include Dosage)

Primary Insurance

Name ofInsured

Relation to Client

Insured Birth Date

Insured Soc. Sec #

Insured Employer

Insurance Co.

Group #

Policy #

Secondry Insurance

Name ofInsured

Relation to Client

Insured Birth Date

Insured Soc. Sec #

Insured Employer

Insurance Co.

Group #

Policy #

Informed Consent for Counseling:

McDowell Counseling & Associates, LLC therapists will not provide treatment to you in which they are not adequately trained in or certified to use. Please refer to our website for a complete list of the rapist certifications and services offered.

Confidentiality:

McDowell Counseling & Associates, LLC maintains a strict policy of confidentiality. All services are guided by the licensing laws ofthe State of Nebraska. I understand that all information I disclose within sessions is confidential and not to be revealed to anyone outside of McDowell Counseling & Associates, LLC with the exception of:

When communication of my diagnosis and other clinical information to my insurance company is necessary for payment;
WhenI have given permission for information to be shared with another person;
When disclosure is required by law (e.g. when there is reasonable suspicion of abuse ofchildren or adults; when there is a court order)
If I am under 19 years of age, my counselor may advise my parent(s) or legal guardian about developments that could significantly affect my health or well-being. In such situation(s), the specific content between my counselor and me will not be discussed, but my overall progress may be discussed in general terms; or
WhenI present an immediate risk of causing serious harm to oneself or another person.

Supervision and Consulting

Supervision is sometimes necessary for the purpose ofproviding the best possible service. Supervision may be required by your insurance company, office policy and/or licensing requirements. All staff at McDowell Counseling & Associates, LLC are under the supervision ofMeredith McDowell LIMHP #1968. At times the supervisor may be consulted about different cases. If your case is discussed with our supervisor it will be done without revealing any identifying information. All supervisors are bound by the same confidentiality standards as your therapist.

Active Participation:

Counseling is a mutual, collaborative process. You and your therapist will work together to develop goals for your therapy. You are responsible for making an effort to work on the problems or issues that concern you. Your therapist is committed to helping you in this process.

Risk/Benefits:

No one can guarantee that counseling or counseling services will produce certain results. There can be many benefits to participating in counseling. The benefits vary and can be maximized by active participation, honesty, and consistent attendance. There are also some risks associated with counseling services. The risks vary but can best be managed and minimized through open communication and reporting any changes that occur after or during treatment. There is also the potential for dual relationships, which can be very common in rural settings. A dual relationship is any routine contact that occurs outside oftherapy, such as attending the same church. If a dual relationship occurs, it is best to discuss this issue when it occurs to minimize the risk and assess its impact on the therapeutic relationship. Your direct honest feedback can help minimize risk. We can assure you that our counselors will use their professional skills, to the best oftheir ability, to address any concerns and help manage possible risk.

Appointments:

Services are by appointment only and generally last either 45 or 60 minutes. The frequency of appointments will be determined by you and your therapist.

Cancellations and No Shows:

There is a 24-hour cancellation policy and all appointments not cancelled with 24 hour notice are subject to a late cancellation fee that will not be covered by insurance. There is a no show policy and all appointments that you do not attend without calling to cancel are subject to a no show fee of $40.00 that will not be covered by insurance, and be paid by you, prior to your next appointment.

I agree to pay these fees, if incurred, I am aware that they will not be billed to my insurance company. I understand that I cannot be seen by my therapist again until these fees are paid or payment arrangements have been made.

Fees and Financial Arrangements:

McDowell Counseling & Associates, LLC fees are: $175.00 for the initial appointment and individual sessions are $125.00 (45 minutes) or as reimbursed by insurance. Additional fees for services, if unknown, should be inquired about prior to the appointment. Often we call on your behalf to inquire about insurance benefits. Any information we receive from your insurance is not guarantee oftheir payment or your financial liability. We ask for payment at the time of service. If this does not work for you, please speak with our Business Manager to make arrangements for a payment plan. Any returned check will be charged a $25.00 fee. (Initial below).

Outstanding balances afier 60 days will be assessed afinance charge unless apaymentplan has been arranged with the business manager. If no payment is made after 90 days your account will be sent to collections.

✔ I am aware of McDowell Counseling & Associates, LLC's fees for treatment and I agree to pay the remainder of what my insurance does not cover. I agree to be responsible for payment of all services on my behalf or my dependents. I understand that if payment for services is not made, my therapist may stop treatment and my account may be sent to Collections. I understand all services/materials are non-refundable.

Electronic Communication (email/texting)

Electronic communication is not a confidential means of communication. You may still choose to communicate electronically with McDowell Counseling & Associates, LLC (as indicated above on preferred contact method) but you must acknowledge the risks (initial below).

I authorize McDowell Counseling & Associates, LLC to contact me electronically regarding my appointments, as indicated above. I understand that electronic communication (email/text) is not a confidential means of communication.

I acknowledge that counseling will not be done electronically(email/text). If I send any informational electronically that is not in regards to scheduling, I understand that my therapist may not correspond immediately.

I understand that if I contact my therapist outside of work hours (evenings & weekends) they will not correspond until the following work day.

I understand that any electronic correspondence may become part of my client record.

I understand that McDowell Counseling & Associates, LLC cannot ensure that electronic messages

will be received or be promptly responded to. Therefore in case of emergency, I am encouraged to call Meredith McDowell at 308-708-9379, or 911.

Termination:

Also, please be aware of the following conditions in regards to discontinuing therapy. You may be discharged as a client due to:

If your therapist believes that they are unable to help you, because ofthe concerns you present or because their skills or training may not be appropriate to serve you. You will be informed of this fact and referred to another therapist who may meet your needs better.
If you have two consecutive “no shows” or same-day cancellations for appointments.
If you have not had and/or kept an appointment in our office in 6 consecutive weeks and this is not part of your treatment plan.
If you commit an act ofviolence toward, threaten, or harass any staff member of McDowell Counseling & Associates, LLC, you may be immediately terminated from treatment.
If you are terminated from therapy for something other than completing the agreed-upon treatment plan, you will be given contact information for other sources oftherapy. However, this is not a guarantee of further treatment.

My .signature below acknowledges that I have read, vnder.stand and agree to the above statements. I have received McDowell Counseling A Associates, LLC's privacy policies, unJerstanJ my rights as a client anJ how my information may be tiscJ anJ Jisclosed. I understand anJ authorize supervision ofm y case, i[ncces.sary. I unJerstanJ that my signature below i.s con.sent for treatment with McDowell Counseling ‹ Associates, LLC. I agree to actively participate in my counseling anJ/or other service.s offereJ at McDowell Counseling ‹ A.ssociatcs, LLC. I vnderstanJ that i[I have any I vnJerstanJ the ri.sk.s and benefits as.sociate‹I with covn.seling questions regarding the above statements, associated risk.s or my privac y rights, I can talk to my therapist abovt any que.stion.s or contact Meredith McDowell at 308-708-9379

Date

Witness