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New Client Information, Financial Responsibility, & Informed Consent

This form is multi-purpose.  It is for me, Deborah Lee (Debbie) Urban, LPC, to (#1) provide information to you, (#2) for you to request information from me, (#3) for you to provide initial assessment information to me, (#4) to verify financial responsibility, and (#5) for you to consent to treatment (if applicable). If you are not comfortable with on-line communication, please read through this information, call 314-304-2942 or 573-727-6007, or email me at DebbieUrbanLPC@aol.com to make an appointment.

Please read all sections, fill out and submit this at the end of the "Client Information, Financial Responsibility, & Informed Consent" section.

You will not be billed for submitting this form, but, if submitted, I will take it as you are stating that you understand and agree with what is contained in the form. Please read it carefully. It is legally required that I provide you with this information. Some of it may seem redundant, however, I am working to downsize it as soon as I figure out what is necessary and what is not. Meanwhile bear with me...

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Aims and Goals of Treatment:

The major goal of treatment is to help you identify and cope more effectively with problems in daily living and to deal with inner conflicts which may disrupt your ability to function effectively. This purpose is accomplished by:

You are responsible for providing the necessary information to facilitate effective treatment. You are also expected to play an active role in your treatment, including working with me to outline your treatment goals and needs and to assess your progress. There can also be negative consequences if you do not follow through with recommended treatment(s). I will always try to answer any questions that you may have.

During the course of treatment, I may ask you to do homework assignments or to practice certain behaviors. It is important to remember that your progress in therapy often depends much more on what YOU do between sessions than on what happens in the session.

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Appointments:

Initial appointments are usually scheduled for up to 90 minutes. Following sessions are scheduled for approximately 45-60 minutes. My hours are varied and scheduled according to individual needs and my availability.

You may discontinue therapy at any time, but please discuss your decisions with me as my goal is for you to receive the best, whatever that may be. I do not bite and can handle it if we do not click.

In the event of an emergency, I can be reached at 314-304-2942 or 573-727-6007, however, if you are suicidal or homicidal, please call 911, or take yourself or have someone else take you to the hospital.

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Confidentiality:

Issues discussed in therapy are important and are generally legally protected as both confidential and “privileged.” However, there are limits to the privilege of confidentiality. These situations include:

    • Suspected abuse or neglect of a child, elderly person or a disabled person.
    • When your psychiatrist or therapist believes you are in danger of harming yourself or another person or you are unable to care for yourself.
    • If you report that you intend to physically injure someone the law requires your therapist to inform that person as well as the legal authorities.
    • If your psychiatrist or therapist is ordered by a court to release information as part of a legal involvement in a company litigation, etc.
    • When your insurance company is involved, e.g. in filing a claim, insurance audits, case review or appeals, etc.
    • In natural disasters whereby protected records may become exposed or
    • When otherwise required by law.

You may be asked to sign a "Release of Information" so that your therapist may speak with other mental health professionals, family members, or someone else, if it is in your best interests. You have the right to refuse this, however, legal issues (noted above=) can override your refusal.

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Record Keeping:

 

IF YOU ARE
SERIOUSLY CONSIDERING SUICIDE, PLEASE LOG OFF YOUR COMPUTER AND
TELEPHONE THE POLICE (911) OR EMERGENCY MEDICAL SERVICES.

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Fees:

Initial phone call, online chat, email, or IM inquiries about my services are free.

My standard fees are as following:

    • Office sessions are $125 and by appointment only. If you have insurance and my services are covered, my fees are according to the contract I have as a provider with your insurance company. You are responsible for knowing if you have a co-pay or co-insurance. Those payments are due at each session.

    • Scheduled phone calls, online chats, email consultations, or IMs over 15 minutes are billed the same as office sessions however your insurance may not cover these. You are responsible for these fees and must be prepaid.

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Payments:

Payments are due at the time of the session unless other arrangements have been made. I will file your insurance claim, but you are ultimately responsible for deductibles, co-insurance, co-payments, and if your insurance fails to pay me. It is your responsibility to familiarize yourself with your insurance benefits.

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Cancellations and Missed Appointments:

It is your responsibility to notify me, Debbie Urban, at least 24 hours in advance of any cancellations. You may leave messages 24 hours per day. My voicemail has the time and date for CST.

Except in the event of a REAL emergency, you will be billed directly for $125.00, for less than a 24 hours notice. Insurance companies generally do not reimburse for failed appointments. My time is valuable and can possibly serve another if there is enough time to schedule someone in your place.

Two missed appointments without a 24 hour notice will result in a cancellation of my services as this usually indicates that you do not really want therapy.

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Client Information, Financial Responsibility, & Informed Consent:

Please provide as much of the following information as you can and submit it at the end. Please note that if you have submitted this form, you will not have the similar form to fill out at your first session with me, saving time and trees:

Client Information:

            Name
   Date of Birth
             Sex Male Female
       Soc. Sec. #

Address, etc.:

  Street Address
 Address (cont.)
            City
  State/Province
 Zip/Postal Code
         Country
      Work Phone
      Home Phone
             FAX
          E-mail
             URL

Primary Care Physician (PCP):

            Name
           Title
    Organization
  Street Address
 Address (cont.)
            City
  State/Province
 Zip/Postal Code
         Country
      Work Phone
             FAX
          E-mail
             URL

Client's Legal Guardian:

            Name
           Title
    Organization
  Street Address
 Address (cont.)
            City
  State/Province
 Zip/Postal Code
         Country
      Work Phone
      Home Phone
             FAX
          E-mail
             URL

Primary Insurance Information:

Secondary Insurance Information:

Acknowledgement of Receipt of Notice of Privacy Practices:

You may review the Notice of Privacy Practice, which explains when, where, and why your  confidential health information might be used or shared. By submitting this form, you acknowledge and understand that Debbie Urban, LPC, may share your confidential health information with others in order to treat you, in order to arrange for payment of your bill, and for issues that concern Debbie Urban’s operation and responsibilities.

Choose one of the following options:

I choose not to receive a copy of Notice of Privacy Practices.
I choose to receive a copy of Notice of Privacy Practices.

Assignment of Counseling Benefits:

BY SUBMITTING THIS FORM, You hereby assign payment of insurance benefits, including but not limited to Medicaid health maintenance organizations or preferred provider organizations, to be paid directly to Debbie Urban, LPC, for treatment charges and on your behalf.

Future Authorizations for Sessions:

SUBMITTING THIS FORM will also allow Debbie Urban, LPC, to complete the necessary paper work to request additional sessions from your health insurance/third party provider if additional sessions are necessary.

Explain what your concerns are:


Describe the history of the problems, past treatment, hospitalizations:


Would you like me to respond to this form?

Yes
No

RELEASE OF INFORMATION

BY SUBMITTING THIS FORM BELOW, you, as the client or guardian, authorize and direct any holder of medical and other information about you as it pertains to your health care, to release all needed information to determine benefits payable, process your claims, or to collect the fees for counseling. You also understand and agree that certain elements of your treatment information may be used for research and education. All reasonable efforts will be made to maintain personal confidentiality.

INFORMED CONSENT FOR TREATMENT

BY SUBMITTING THIS FORM BELOW, you are requesting treatment by Deborah (Debbie) Lee Urban, who is a Licensed Professional Counselor in Missouri and a National Board Certified Counselor. You consent to routine assessment evaluations and counseling as deemed necessary. You understand that Debbie Urban LPC makes no guarantee as to the results of treatment or evaluation. The therapy process is one in which you seek to understand yourself, your feelings, and your concerns more clearly, and to make changes in your life as a result of what you have learned. The role of the therapist in this process is to help you gain a different perspective on yourself, your feelings and your life. The therapist will seek, first, to get to know you so that she can better understand your concerns. You will aid the therapist by being open and honest in your sessions and providing as much information as you can concerning the issues that trouble you. Occasionally, the therapist may say things that you find difficult to hear. Your therapy goals will best be achieved if you can remain open to emotions, insights, and ideas, which may be different than what you have experienced before. Because the therapy process sometimes involves an examination of aspects of yourself, which have previously remained hidden, you may be surprised by the intensity of new emotions. Be assured that this is a normal part of healing and change that occurs through therapy.

BY SUBMITTING THIS FORM BELOW, YOU ARE CERTIFYING THAT YOU HAVE READ THE STATEMENTS SET FORTH, HAVE COMPLETED THE INFORMATION CORRECTLY, AND ACCEPT, UNDERSTAND AND AGREE TO ABIDE BY THE CONTENTS AND TERMS OF THIS AGREEMENT, AND FURTHER, CONSENT TO PARTICIPATE IN EVALUATION AND/OR TREATMENT, THAT YOU MAY WITHDRAW FROM TREATMENT AT ANY TIME, AND THAT YOU AGREE TO BE FINANCIALLY RESPONSIBLE FOR ALL FEES THAT ARE NOT COVERED BY A THIRD PARTY.

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