New Client Form

Pandolfi Counseling Associates Client Information and Questionnaire
Basic Information

Gender
arrow&v
arrow&v
arrow&v

If the above patient is a minor complete the following:

arrow&v
arrow&v
arrow&v

If you will be using insurance to cover your sessions or a portion of the cost please
complete the following and allow us to make a photocopy of your insurance card:

Referral Source

Emergency Contact Information 

In case of an emergency, who should we contact?

History Information

Who is providing the history information?

arrow&v

Please describe the current complaint or problem as specifically as you can, in your own words.

How long have you experienced this problem, or when did you first notice it?

What stressors may have contributed to the current complaint or problem?

Pandolfi Counseling Associates
Informed Consent
Page 6
matters.

If you feel you cannot wait for a return call or it is an emergency situation, go
to your local hospital or call 911.
Email
Counselor may request client's email address. Client has the right to refuse to
divulge email address. Counselor may use email addresses to periodically check
in with clients who have ended therapy suddenly.
Counselor may also use email addresses to send newsletters with valuable
therapeutic information such as tips for depression or relaxation techniques.
Counselor also has a blog and if this is appropriate for the client, counselor may
send information through email about subscribing to the blog or information
related to mental health and wellness. If you would like to receive any
correspondence through email, please write your email address here
1f you would like to opt out of email correspondence, please check here
Consent to Counseling
Your signature below indicates that you have read this Agreement and agree to
its terms.

Consent  for Minors

Thanks for submitting!

Informed Consent Client-Counselor Agreement

Welcome to Pandolfi Counseling Associates.

This document contains important information about our services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAAJ, a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, its is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future. Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. We, as your provider, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

 

Goals of Counseling

There can be many goals for the counseling relationship. Some of these will be long term goals such as improving the quality of your life learning to live with mindfulness and self-actualization. Others may he more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behavior or decreasing/ending drug use. Whatever the goals for counseling, they will beset by the clients according to what they want to work on in counseling. The counselor may make suggestions on how to reach that goal but you decide where you want to go.

 

Risks/Benefits of Counseling

Counseling is an intensely personal process which ca n bring unpleasant memories or emotions to the surface. There are no guarantees that counseling will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly.

Pandolfi Counseling Associates
Informed Consent
Page2

Counseling requires a very active effort on your part. In order to be most successful,
you will have to work on things we discussed outside of session.
However, there are many benefit to counseling. Counseling can help you develop
coping skills, make behavioral changes, reduce symptoms of mental health
disorders, improve the quality of your life, learn to manage anger, learn to live in the
present and many other advantages.


Appointments
Appointments will ordinarily be 50-60 minutes in duration, once per week at a
time we agree on, although some sessions may be more or less frequent as
needed. The time scheduled for your appointment is assigned to you and you
alone. If you need to cancel or reschedule a session, we ask that you
provide us with 24 hours' notice. If you miss a session without canceling, or
cancel with less than 24-hour notice, you may be required to pay for the session
[unless we both agree that you were unable to attend due to circumstances
beyond your control]. It is important to note that insurance companies do not
provide reimbursement for cancelled sessions; thus, you will be responsible the
cancelation fee. In addition, you are responsible for coming to your session on
time; if you are late, your appointment will still need to end on time.
 

Confidentiality
Your counselor will make every effort to keep your personal information
private. If you wish to have information released, you will be required to sign a
consent form before such information will be released. There are some
limitations to confidentiality to which you need to be aware. Your counselor
may consult with a supervisor or other professional counselor in order to give
you the best service. In the event that your counselor consults with another
counselor, no identifying intonation such as your name would be released.
Counselors are required by law to release information when the client poses a
risk to themselves or others and in cases of abuse to children or the elderly. If
your counselor receives a courtorder or subpoena, she may be required to
release some information. In such a case, your counselor will consult with other
professionals and limit the release to only what is necessary by law.


Pandolfi Counseling Associates
Informed Consent
Page 3
Confidentiality and Technology

Some clients may choose to use technology in their counseling sessions. This
includes but is not limited to online counseling via Skype, telephone, email, text
or chat. Due to the nature of online counseling, there is always the possibility
that unauthorized persons may attempt to discover your personal information.
Your counselor will take every precaution to safeguard your information but
cannot guarantee that unauthorized access to electronic communications could
not occur. Please be advised to take precautions with regard to authorized and
unauthorized access to any technology used in counseling sessions. Be aware of
any friends, family members, significant others or co-workers who may have
access to your computer, phone or other technology used in your counseling
sessions. Should a client have concerns about the safety of their email, your
counselor can arrange to encrypt email communication with you.


RecordKeeping
Your counselor may keep records of your counseling sessions and a
treatment plan which includes goals for your counseling. These records are
kept to ensure a direction to your sessions and continuity in service. They
will not be shared except with respect to the limits to confidentiality
discussed in the Confidentiality section. Should the client
wish to have their records released, they are required to sign a release of
information which specifies what information is to be released and to whom.
Records will be kept for up to 7 years. Records will be kept either electronically
on a USB flash drive or a paper file and stored in a locked cabinet in the
counselor's office.


Professional Fees
You are responsible for paying at the time of your session unless prior
arrangements have been made. Payment must be made by check, cash or credit
card. If you refuse to pay your debt, we reserve the right to use an attorney or
collection agency to secure payment.
If you anticipate becoming involved in a court case, we recommend that you
discuss this fully with your therapist before you waive your right to
confidentiality.If your case requires your therapist participation, you will
be expected to pay for the professional time required. Fees are non- negotiable.
To receive sliding scale fees, you must present proof of income through recent
pay stubs or tax forms. Fees are subject to change at counselor's discretion.


Pandolfi Counseling Associates
Informed Consent
Page 4

Fee Schedule
90791 psychiatric diagnostic evaluation (Intake) ………………….$250
90834 psychotherapy 45 minutes ………………………………....$150
90837 psychotherapy 60 minutes ………………………………….$175
90846 family psychotherapy without the patient present...............$100

 

Sliding Scale
60 minute individual session
$30,000 (Yearly) and below...................$80

$30,000 (Yearly) to $50,000.................$100
$50,001 (Yearly) to $70,000 ................$150
$70,001 (Yearly) to $90,000.................$200
$90,001 and above………………………$250


Insurance
If you have a health insurance policy, it will usually provide some coverage for
mental health treatment. With your permission, we will assist you to the extent
possible in filing claims and ascertaining information about your coverage, but you
are responsible for knowing your coverage and for letting me know if/when your
coverage changes.
You should also be aware that most insurance companies require you to
authorize us to provide them with a clinical diagnosis. Sometimes we have to
provide additional clinical information which will become part of the insurance
company files. By signing this Agreement, you agree thatI can provide requested
information to your carrier if you plan to pay with insurance.


Pandolfi Counseling Associates
Informed Consent
Page 5

In addition, if you plan to use your insurance, authorization from the insurance
company may be required before they will cover counseling fees. If you did not
obtain authorization and it is required, you may be responsible for full payment of
the fee. Many policies leave a percentage of the fee to be covered by the patient.
Either amount is to be paid at the time of the visit by check, cash or credit card. In
addition, some insurance companies also have a deductible, which is an out-of pocket amount that must be paid by the patient before the insurance companies
are willing to begin paying any amount for services.
If we are or your therapist is not a participating provider for your insurance plan,
your therapist will supply you with a receipt of payment for services, which you
can submit to your insurance company for reimbursement. Please note that not all
insurance companies reimburse for out-of-network providers. If you prefer to use
a participating provider, we will refer you to a colleague.
Contacting Us
Your therapist is often not immediately available by telephone. We do not answer
our phone calls when we are with clients or otherwise unavailable. At these times,
you may leave a message on our confidential voice mail and your call will be
returned as soon as possible, but it may take a day or two for non-urgent