Lillian D. Knox, MA, LMFT
Client Information Form
Name: __________________________________________ Date: ________________
Address: ______________________________________City: ________________ State:____ Zip: _________ Email: _______________________________________________________
Birth date: ______________
Home Phone#: ___________________ Cell# _______________________________________
Occupation: ____________________________________Employer: ____________________
Name and Age(s) of Child(ren): ______________________________________________________________________________
Referred by: _________________________________________________________ ___ Internet ___ Yellow Pages/Phone Book ___ Church/Pastor ___ Psychology Today
Please state in your own words why you have come to this office today:
Number of years in this relationship: ______________________________________________________________________________________________________________________________________________
Current living Situation:
Social / Family History:
Biological parent’s marital status (circle):
Married to each other
If divorced from one another, has either remarried? Mother Yes No
Father Yes No
Please check any of the following stressors that presently affect you:
___ Family financial problems
___ Family relationships
___ Legal problems
___ Child rearing problems
___ Drug or alcohol problems
___ Abuse behavior
___ Health problems
___ Employment problems
___ School problems
___ Peer relationships
___ Frequent change of household
___ Frequent moves
___ “Other” problem ______________________________________________________
Do you have a history of any medical problem? Yes □ No □ If so, what? ___________
Are you presently being treated for any medical problem? Yes □ No □ If so, what?
Past surgeries: _______________________________________________________________________
Client Contract and Disclosure Statement
Your therapist is a Therapist with experience in individual, marriage, family, and group counseling. She is a licensed counselor in the State of Alabama and has earned a master’s degree.
Counseling requires effort on the part of the client. Homework will be decided on collaboratively between the client and the counselor and will be determined by the nature of the presenting problem(s). Clients are expected to show up for scheduled sessions, pay for scheduled sessions before the beginning of each session, do homework, and keep the identity of other clients confidential.
Your therapist’s responsibility is to keep confidences as prescribed by law, not share any information that is learned through counseling unless someone is going to harm him/her self, someone is going to harm someone else, and if a child is being abused, and/or required by law. All records are confidential, and clients must sign a release before case information can be given to anyone. In marriage and family counseling, the release must be signed by ALL family members involved. Your therapist does not provide expert testimony in court proceedings. If required by law to testify, she will testify only to the process and content of therapy as prescribed by law.
The first session evaluation fee is $150.00 or billed to your insurance. Please provide a copy of your identification and insurance card. Additional session fees will follow the schedule below:
SCHEDULE OF FEES:
$150.00 per session in office or billed to your insurance provider
$250 per session when on destination retreat
*Retreat prices are individualized based on season and location
The fees are payable prior to your session with the therapist.
NO SHOW AND CANCELLATION POLICY
This appointment time is reserved for you. If you must cancel your appointment, it will be necessary for you to give 48 hours’ notice.
1. Clients who forget an appointment or for some other reason do not come for an appointment and fail to give prior notice will be responsible for their full fee.
2. Clients who call and give less than 24 hours’ notice of cancellation will be responsible for 1/2 fee.
3. Unless otherwise notified, the therapists are obligated to wait only 15 minutes for a late client.
4. Your signature confirms your understanding of all these policies explained on this intake form.
Limits of Confidentiality
Information discussed in counseling sessions is held confidential and will not be shared without your permission except under the following circumstances:
1. The client threatens suicide or other physical harm to self.
2. The client threatens physical harm to another individual.
3. The client is a minor under 18 years of age and reports behavior indicative of child abuse, including but not limited to physical and sexual abuse.
4. The client reports sexual exploitation by another medical or mental health professional.
State law requires that mental health professionals must report these situations to the appropriate persons and or agencies.
Records are also required to be released when a subpoena or other court order is received ordering the release of records.
Further, when consultation and/or supervision of therapy is required, counseling sessions will be discussed confidentially with a supervisor or professional colleague as deemed necessary.
Communication between the counselor and the client will otherwise be deemed confidential as stated by the laws of the state of Alabama.
Having read and understood the above, I agree to these limits of confidentiality.
Client/Parent/Legal Guardian Date
Client/Parent/Legal Guardian Date
NOTICE OF PRIVACY PRACTICES
This notice describes how your personal health information (PHI) may be used and disclosed and how you can get access to this information. Please review it carefully.
• Request and receive a copy of your paper or electronic treatment record (appropriate fees may apply).
• Request confidential communication: You must sign a Release of Information Form for us to communicate with friends, family, coworkers, attorneys, etc.
• Ask us to limit the information we share: You may specify your requests on a Release of Information Form.
• Pay full price for your therapy and request that your counselor keep session notes and diagnoses private from your health insurance provider.
• Get a list of those with whom we’ve shared your information.
• Get a copy of this privacy notice,
• File a complaint if you believe your privacy rights have been violated.
o If you feel we have violated your rights, your complaint should be addressed to Lillian Knox, MA, LMFT at [email protected]
o You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights
o We will not retaliate against you for filing a complaint.
Our Uses and Disclosures
We may use and share your information as we:
• Treat you: We may obtain records from other medical or mental health professionals that you have previously seen.
• Run our organization: directors, office managers, and business associates may access your information in order to collect payment, schedule appointments, or communicate with you or those you give us permission to contact.
• Bill for your services: Business Associates of Northview Health Services or your counselor may contact your health insurance provider or a designated payer to obtain payment for services
• Comply with the law: *We are required to report suspected abuse, neglect, or intent to harm self or others.*
• Address law enforcement and other government requests
• Respond to illegal behavior, lawsuits, and legal actions: We are required to respond to court orders by providing session notes and by possibly testifying in court. We will contact local authorities should illegal activity occur on our premises.
• We are required by law to maintain the privacy and security of your protected health information. We will never disclose your PHI for marketing or fundraising activities: All counselors and business associates of Northview Health Services utilize HIPAA- compliant electronic communication services. All paper and digital PHI records are stored, secured, and disposed of as outlined in HIPAA guidelines.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
NOTICE OF PRIVACY PRACTICES:
ACKNOWLEDGEMENT OF RECEIPT
ACKNOWLEDGEMENT OF RECEIPT
By signing this form, you acknowledge the receipt of the Notice of Privacy Practices of Northview Health Services and your counselor. This Notice of Privacy Practices provides information about how Northview Health Services and business associates may use and disclose your protected health information. We encourage you to read it in full.
This Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting Northview Health Services.
If you have any questions about our Notice of Privacy Practices, please contact:
Lillian Knox, MA, LMFT.
I acknowledge the receipt of the Notice of Privacy Practices of Northview Health Services.
Client’s Name: _____________________________________________
Signature:___________________________________________________ Date: __________________
INABILITY TO OBTAIN ACKNOWLEDGEMENT
Complete only if no signature is obtained. If it is not possible to obtain the individual’s acknowledgement, describe the good faith efforts made to obtain the individual’s acknowledgement, and the reasons why the acknowledgement was not obtained.
Client’s Name: ________________________________________
Reasons why the acknowledgement was not obtained:
q Client refused to sign this acknowledgement even though the client was asked to do so and was given the Notice of Privacy Practices.
Signature of provider representative: _______________________________________ Date:__________________
Patient/Guardian signed authorization for release of information for transactions and assignment of benefits for claims