New Clients

Insurance Information

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.

Consent of Notice of Privacy Policy

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:

Adverse Adult Experiences (AAEs)

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