First Name

Last Name

Birthday

Gender

Phone Number

Mailing Address

City

State

Zip Code

Place of Employment

Work Phone Number

List Medications

Spouse / Guardian's Name

Did Anyone Refer You? If Yes, Who?

Have you had previous Counseling or Treatments?

Yes No

Please list immediate Family Member's Name/s

Insurance Information

Primary Insurance Company

Primary Insured's First Name

Primary Insured's Last Name

Primary Insured's Birthday

Insured's Relationship to Client

Insured's ID Number

Insured's Group Number

Insured's Policy Number

Release Of Information and Assignment Of Insurance Benefits

I authorize The Counseling Agency and it's affiliated clinicians to disclose portions of the clinical record of the client names above to the Insurance Company and/or its constructed review agent for the purpose of reimbursement of counseling services. I hereby release The Counseling Agency and my clinician associated with my case from all liability that may arise as a result of disclosure of information to the Insurance Company. Also I hereby authorize payment directly to The Counseling Agency of all professional expense benefits payable to me, but not to exceed the regular charges or fees for services provided. I do understand that I am financially responsible for my amounts that are not paid by my insurance company. I further understand that if my insurance company requires a pre-authorization in order to pay for a session, I am responsible to obtain my pre-authorization. Not acquiring a pre-authorization does not eliminate my responsibility to pay for a session. If I am accessing Employee Assistance Program (EAP) benefits, any appointment scheduled but not attended (or cancelled within 24 hours) will be charged one EAP visit.

Initials of Primary Insured

Date Signed

Consent of Notice of Privacy Policy

Thank you for choosing The Counseling Agency! We would like to take this opportunity to explain our office policies and billing procedures.

Your insurance information is obtained on your first visit, allowing us to file a claim for you. We would like to have your portion of the bill paid at the time of your visits. If you do not have insurance, we would like payment in full at the time of service, unless previous arrangements have been made.

At The Counseling Agency, we see you as the expert on you and we see ourselves as assistants to the expert. You direct the focus of the counseling, the duration of the counseling term, and the frequency of visits. You “drive” the counseling “bus” and we get to “navigate.” Together, we can get you where you want to go. While many people benefit from counseling, there is no guarantee of a positive therapeutic outcome.

When payment in full is made at the time of service, you will receive a $10/hour discount. If you wish, The Counseling Agency can print a statement for YOU to submit to your insurance provider. If you choose to have The Counseling Agency submit the claim to your insurance provider, the same-day discount will not apply.

Our therapists’ counseling sessions are 50-55 minutes in duration and are charged at a rate of $120.00 per session unless other arrangements are made with the therapist. Unattended appointments will be assessed a $50 charge without 24 hours prior notice, at the therapist’s discretion. Insurance providers will not pay for missed appointments or late cancellations.

Insurance providers have different authorization requirements. Due to the number of clients with whom we work, our office cannot perform this service; this is your responsibility. Please call your insurance provider is you have questions. In order to submit claims to your insurance provider, it will be necessary to provide certain psychological/medical information to your insurance provider. All overdue accounts will accrue interest at the rate of 1.75% per month (21% per year) with a $5 minimum. Accounts with no payments in a 60-day period will be turned over to collections.

CONFIDENTIALITY: All information revealed in counseling is confidential with the following exceptions: 1. Intent to commit serious crime; 2. Intent to harm self or others; 3. Prior abuse or neglect of a minor, or intent to abuse or neglect a minor and/or vulnerable adult; 4. Unethical behavior by a previous counselor; 5. Responding to a subpoena or court order. If the information is legally confidential, therapists and staff at The Counseling Agency cannot be compelled to disclose the information without the client’s (or guardian’s) consent, subpoena, or court order. You may direct your therapist to share information by completing a Release of Information form. As a matter of policy, counselors employed by The Counseling Agency will not give testimony in court. By signing below, you understand and accept The Counseling Agency’s Noice of Privacy Practices and limits of confidentiality.

RECORDS: I acknowledge that my clinical and administrative records are the property of The Counseling Agency. I have the right to view and receive copies of the records upon request. I acknowledge that my files or information may be shared, without identifying information, with The Counseling Agency colleagues in case consultation. In the event of death or incapacitation of the therapist, I give permission for my records to be transferred to my new therapist.

RIGHT TO CHOOSE: You have the right to select a counselor, seek a second opinion, or stop counseling at any time.

LICENSING: The Idaho Division of Occupational and Professional Licenses has the general responsibility of regulating the practice of licensed professional therapists. The license of any individual under the licensing laws of Idaho does not imply or constitute an endorsement of that therapist nor guarantee effectiveness of treatment. The Idaho Division of Occupational Licenses, 11351 W. Chinden Blvd., Bldg. #6, Boise, ID 83714.

ETHICS: Licensed therapists are required to adhere to the professional code of ethics adopted by the American Counselors Association.

TRAUMA TREATMENT: FITT (Focused Imagery Trauma Therapy) is an effective, brief, and economically beneficial modality that has been successfully used for years and is a non-empirical method of decreasing trauma symptoms.

I Consent to The Counseling Agency's Office Policies

I Consent to The Counseling Agency's Privacy Policy

I Understand My Counseling Focus Will Be (Please Check One)

Individual Relationship Family

Adverse Childhood Experiences (ACEs)

The 10 questions below each cover a different domain of trauma, and refer to experiences that occurred prior to the age of 18. Higher scores indicate increased exposure to trauma, which have been associated with a greater risk of negative consequences. While you were growing up, did your first 18 years of life:

Did a parent other adult in the household often or very often... Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? If Yes, Who?

Did a parent or other adult in the household often or very often... Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? If Yes, Who?

Did an adult or person at least five year older than you ever... Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? If Yes, Who?

Did you often or very often feel that... No one in your family loved you or thought you were important or special? or Your family didn't look out for each other, feel close to each other, or support each other? If Yes, Who?

Did you often or very often feel that... You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? If Yes, please briefly explain

Were your parents ever separated or divorced?

Yes No

Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? If yes, please briefly explain

Did you live with anyone who was a problem drinker or alcoholic who used street drugs? If Yes, Who?

Was a household member depressed or mentally ill, or did a household member attempt suicide? If Yes, Who?

Did a household member go to prison? If Yes, Who?

Adverse Adult Experiences (AAEs)

Have you ever personally experienced a traumatic event, such as a car accident, sexual assault, physical assault, etc.? If so, please list your experiences:

Have you ever witnessed a traumatic event, such as a car accident, sexual assault, physical assault, death, etc.? If so, please list your experiences:

Have you ever learned of a traumatic event happening to a loved one, such as a car accident, sexual assault, physical assault, death, etc.? If so, please list your experiences:

Have you ever served in the military?

Yes No

Have you ever been a First Responder?

Yes No

Have you ever personally experienced, witnessed, or learned of traumatic event happening to a loved one that you have not yet listed?

How Did You Hear About Us?

How Did You Hear About Us? Please check ONE of the following:

Friend Relative Medical Referral Family Member internet Search Advertisement Presentation

Any additional comments you would like to give us?

New Clients

Insurance Information

Release Of Information and Assignment Of Insurance Benefits

Consent of Notice of Privacy Policy

I Consent to The Counseling Agency's Office Policies

I Consent to The Counseling Agency's Privacy Policy

I Understand My Counseling Focus Will Be (Please Check One)

Individual Relationship Family

Adverse Childhood Experiences (ACEs)

Adverse Adult Experiences (AAEs)

How Did You Hear About Us?