MELISSA GRAY, MS, LPC, LPA
Licensed Professional Counselor Serving
Adolescents and Adults
New Client Information—Adult FormPage 1
Located in The Atrium
6900 I-40 West, Suite 275
Amarillo, TX 79109
806-651-9221
New Client Information—Adult FormPage 1
CLIENT INFORMATION AND FINANCIAL AGREEMENT
+++Adult Form+++
Date: ______
Client Name: ______Age: ______Date of Birth: ______
Social Security #: ______Marital Status: ______Gender: ______
Address: ______City: ______State: ______Zip:______
Home Phone: ______May we leave messages? ___Yes ___No
Cell Phone: ______May we leave a voicemail? ___Yes ___No
May we text you? ___Yes __No
Work Phone: ______May we leave a message? ___Yes ___No
Email address: ______May we email you? ___Yes ___No
May we send text reminders about your appointment time? ___Yes ___No
Primary Care Physician: ______
Referred By: ______Would you like us to have permission to thank
them for this referral? ___ Yes ___ No
Current Employment: ______
Emergency Contact: ______Relationship:______
Phone #: ______May we contact this person in case of an emergency? ___Yes ___No
I give Melissa Gray my consent to provide me with counseling services. I understand that I may terminate these services at any time. I received the Informed Consent and Treatment Information on pages 4-6 of this form regarding therapy, confidentiality, communication, billing, insurance, and risks and benefits of counseling, and had an opportunity to have any questions answered. (Initial) ______
I have been given the opportunity to review a copy of the HIPAA Notice of Privacy Practices.
(Initial) ______
Financial Agreement with Melissa Gray, MS, LPC, LPA
Client Name: ______Date: ______
I am planning to pay for services using:
_____ Insurance (Rates, copays and deductibles determined by individual policy.)
_____ Standard Rate ($125.00/session)
_____ Sliding Scale Rate (Verification of income may be required)
-My fee based on the total annual income of the household paying for counseling is
$______per session.
Responsible Party (must be present to sign form):
Name: ______Relationship: ______
Date of Birth: ______SSN: ______Home Phone: ______Cell: ______
Address: ______City: ______State: ______Zip Code: ______
Insurance Information (please complete if using insurance):
Insurance company: ______
Phone (on card): ______Address (on card): ______
Member ID #: ______Employer: ______
Insured Name: ______D.O. B.:______SSN:______
Please reviewcarefully and signbelow if you agree to the following policies:
- I acknowledge that I am financially responsible for all services provided, and agree to pay Melissa Gray for any services not covered by insurance or other means.
- I understand that my payment or my copay for each session is due at the beginning of the session.
- I understand that I am responsible for notifying Melissa Gray of any change in insurance or payment methods.
- I agree that if I do not attend an appointment and do not cancel the session 24 hours in advance, Melissa Gray has the option to charge me (not my insurance) a $50 fee for the missed session where allowed.
- I authorize the release of necessary information to third party payers/insurance companies.
- I authorize/request my insurance company to pay directly to the provider of care insurance benefits otherwise payable to me.
Date ______
Printed Name______Signature______
Additional Client Information
Rate your physical health: ___ Excellent ___ Good ___ Average ___ Fair ___Poor
Recently, I have: ___ Lost weight ___ Gained weight ___ No change noticed If so, how much? ______
Average hours of sleep per night ______Is that amount consistent? ___ Yes ___ No
I have trouble with ____ falling asleep or ____ staying asleep
I consume: ___ Caffiene (How much? How often? ______)
___ Alcohol (How much? How often? ______)
___ Marijuana, other substances (How much? How often? ______)
Do you have any health problems? If so, please list them below:
______
Describe use of non-prescription/over the counter drugs or homeopathic interventions:
______
Are you currently on any prescription medications? If so, please list them below:
Medication Name Symptoms treatedDosagePrescribing Physician
______
______
______
What problems/difficulties are you hoping to address in therapy?
______
How long have you been dealing with this? ______
Have you been in counseling before? _____ Yes _____ No
Have you ever been hospitalized for psychiatric reasons? _____ Yes _____ No
Please name all persons with whom you currently live: (write on back also if you need to)
NameAgeRelationship
______
______
______
______
INFORMED CONSENT AND TREATMENT INFORMATION
Welcome! I’m so glad you decided to come today. I am Melissa Gray, MS, LPC, LPA.You might have also been referred to me as Missy Gray, since that is what I have gone by for my whole life. I have been in private practice for five years, and have been working in various psychological fields for the last 16 years. I have a Master’s Degree in Clinical Psychology, and am licensed as a Licensed Professional Counselor and a Licensed Psychological Associate. If you would like, I will provide you with a copy of my Curriculum Vitae, which includes the places I have received my degrees, the continuing education I have received, and some of the areas of psychology in which I have worked in the past.
CONFIDENTIALITY
Trust is one of the most important components of a successful therapeutic relationship. One of the ways I hope to earn your trust is to maintain a high level of confidentiality. I will work to ensure that the things we discuss and the fact that you are in therapy with me is kept in confidence. I believe that each person should be allowed to control their own information, and if and how they tell their story to others, so I am passionate about keeping other people’s information private. In addition to your confidentiality being important to me, I am ethically bound to keep your information confidential and I follow all such guidelines as well. However, I must make you aware of those few circumstances where I am required to value safety over privacy and operate outside our agreement for confidentiality to disclose information. If you are the parent of a child, this applies to your child also.
It is Texas law that I have a duty to warn and protect the appropriate individuals if the counselee intends to take harmful, dangerous, or criminal actions against themselves or someone around them. Possible exceptions to confidentiality include but are not limited to the following situations: I am mandated to report any suicide attempts or intention to commit suicide, incidences of “reasonably suspected child abuse” (physical or sexual), abuse of the elderly or physically or intellectually disabled, sexual exploitation, AIDS/HIV infection and possible transmission, and criminal prosecutions. Situations where I have a duty to disclose, or where in my judgment, it is necessary to warn or disclose are: fee disputes between myself and the client, a negligence suit brought by the client against the therapist, or the filing of a complaint with the licensing or certifying board. I may occasionally consult with another professional about a case and if this should arise, your identity would not be revealed.
Lastly, if you are referred by court, state agency, or some other agencies that is paying for your evaluation or treatment, you waive the right to confidentiality. If this is necessary with your referring agency, I will disclose this to you in the first session. Please understand that if I am required to provide information to these organizations, I have no control over their use of that information once they have received it.
CONFIDENTIALITY OF ALL ELECTRONIC COMMUNICATIONS/SOCIAL MEDIA
Please know I will maintain your confidentiality to the best of my ability; however, we cannot guarantee confidentiality with any electronic communication. This includes but is not limited to the following: Email, texting, Skype/FaceTime, chat, mobile devices, or fax. Although I will never intentionally reveal any information, if you choose to contact me or be contacted on any of these modes of communication, you waive the right to confidentiality for these specific communications.
I have a professional and public Facebook page that you are welcome to use to find helpful resources, read blog posts, make public comments, or get information about my practice. This will not take the place of counseling sessions, but may be helpful now and in the future. However, I make it a policy to not accept friend requests to my personal social media accounts as an effort to protect your privacy.
New Client Information—Adult FormPage 1
Initials: ______
New Client Information—Adult FormPage 1
RECORDS AND RELEASE OF INFORMATION
It is state law that I maintain a record of the treatment or evaluation given to you. This record may contain the information that will help me to document sessions, goals, and progress. I will use this record for that purpose only. It is my intent that no unauthorized person will ever see what is contained in this file. You may get a treatment summary of the contents of this file by providing me with a signed and notarized release of information request. If you require a summary for yourself or someone else, then I will produce one at my usual hourly fee. This includes providing copies or reports to any court or legal representative or designate, or writing reports or recommendations for any service entity with whom you may request my help. In the event of your death, these requirements will be the same for any heirs, successors, or executor. In the event of my death or incapacitation, it will be necessary to assign your case to another therapist and for that therapist to have possession of your treatment records. If you would like your records sent elsewhere, a separate release will need to be signed.
If the therapy sessions contain more than one patient, you agree that no one person may get the complete treatment file. Each individual in treatment is only entitled to his or her own record. This is very difficult in the case of family therapy, couples therapy and assessments on children. In the case of combined records, you agree I may summarize the course of each individual’s treatment as opposed to providing a copy of notes made during our therapy or evaluation sessions.
The laws of this state require that your record be maintained for a period of 10 years. I will maintain them for that period of time or whatever is statutory. At the end of that period, they will be destroyed. A minor child’s records will be maintained for 10 years after they are a legal adult, then they will be destroyed.
If you would like me to receive records from or communicate with other professionals to assist with your care, or for me to send records of or discuss our treatment together, I can provide you with a Release of Information Form that will allow any people you choose to collaborate on your care.
CANCELLATION POLICY
Someone in my office will try to give you advanced notice if I have to cancel an appointment. My schedule stays full, and I want to be able to accommodate as many clients as I am able. For this reason, I ask that you let me know as soon as possible if you are unable to keep your appointment. I know that emergencies and conflicts come up, and will work with you on these. Whenever possible, I request a minimumof 24 hours cancellation notice from you if you must cancel. Failure to do so may result in a charge to your account as listed in your financial agreement.
INSURANCE POLICY
You are responsible for full payment at the beginning of each office visit. However, if your insurance plan has a co-payment you will be responsible to pay that co-payment or whatever amount of the fee that your insurance company designates. We will be happy to file your insurance claim for you. You will need to be prepared to pay your full bill in the case that your insurance carrier does not cover your services. My billing specialist will help you with any questions you have about your coverage.
If we are not a contracted provider for your insurance company, we require you to pay for your services at the time they are needed. We will provide diagnostic and procedural codes but you will need to file the insurance yourself.
Occasionally, insurance companies ask for treatment information to continue authorization for treatment. If this should occur, you will be notified by me and I will give the minimum amount of information necessary to obtain authorization.
New Client Information—Adult FormPage 1
Initials: ______
New Client Information—Adult FormPage 1
TERMINATION OF TREATMENT
The length of time required for evaluation and therapy will be determined by your personal situation, history, and current needs. I will do my best to fulfill your therapeutic needs and provide you with my best professional care. For your part, you agree to participate in the process to the best of your ability. It is intended that when your needs are met, to the extent that they can be met, we will terminate our sessions unless or until in the future you should want to meet again. There is no guarantee of a “cure” or “fix” for the things with which you are struggling, but I will say that the more open and engaged you are in and out of our sessions, the more likely you are to experience positive changes and growth.
For your part, unless court ordered, you may terminate my services at any time. This may be done in any one of these several ways. These include, but are not limited to, putting it in writing, informing me verbally, or failing to maintain your appointment scheduled without proper notification. If you wish a refund to another provider please let me know. If you feel that we are not a good fit, I would love to find you a therapist that can better meet your needs. If I feel that your needs could be better met by another therapist, I will discuss this with you as well.
If you do terminate therapy with me, it will be my decision as to whether we can re-establish our therapeutic relationship at a later date. Keep in mind that your decision to terminate therapy and the method chosen to end our relationship will impact any decision to resume a therapeutic relationship.
RISKS AND BENEFITS
For any therapy to be successful, it is necessary for the client to be engaged with the process of counseling both in and outside of sessions. While there is no guarantee that therapy will “solve” your problems or resolve any issues you might face, participating in the work of therapy affords you the best chance to gain the results you have come here to find. Counseling can have many benefits, including improved self-esteem and self-awareness, improved life circumstances and relationships, improved coping with difficult situations, resolution of issues, and ability to deal with painful life problems or memories. However, there are also risks associated with engaging in counseling. Please be aware that therapy may expose issues that may cause additional problems to you and bring more life distress. Participation in therapy means that you accept these risks and are willing to deal with the potential problems. If at any time you feel unwilling or unable to continue with your counseling experience, please discuss this with me so we can make a plan for you to be successful as you leave.
AVAILABILITY
In the event you encounter a personal emergency which will require prompt attention, I will attempt to see you in the office as soon as possible. In addition, my professional number can be used to leave a voicemail or text after hours, and in case of emergency or crisis I will attempt to return your call promptly. In non-emergency situations, I will in most cases return your call within 24 hours. However, if you have not received a callback and you need immediate care for your safety, please call the Crisis Line at 806-359-6699, call 911, or go directly to the nearest emergency department.
New Client Information—Adult FormPage 1
Initials: ______
New Client Information—Adult FormPage 1