Beyond Horizons Counseling: MacArthur Gilmer MS, LPC: Minor / Child Intake
*For the Parent(s) & /or Guardian(s)*
Thank you for choosing Beyond Horizons Counseling. We are committed to providing quality and personal care. We look forward to getting to know you and your child(ren) and serving your needs.
At your first appointment, please check in with our receptionist to collect all paperwork and to make necessary payment. (If applicable) Mr. Gilmer will then review all of your information and call you into his office where you will spend approximately an hour for the session. At the end of the appointment, Mr. Gilmer will go over necessary treatment plans, strategies, &/ or goals with you.
We recommend that you read and complete all of the paperwork prior to your appointment. However, we do understand if you are unable to do so. (Please arrive 15-20 minutes early if the paperwork has not been completed)
We have included the following items in this packet of information:
- Office Policies
- Financial Policy Statement
- Intake / Client Assessment
- Medication Compliance Log
- Authorization For The Release Or Exchange Of Information
- Credit Card Authorization
Please read and complete all of the pages. If it does not apply, please write N/A.
Again, welcome to Beyond Horizons Counseling. If you have any questions or concerns, please feel free to contact us.
Thank you,
Beyond Horizons Counseling Staff
(817) 617-6425 ph
(817) 549-8283 fx
*For the Parent(s) & /or Guardian(s)*
Office Policies
CONFIDENTIALITY
Client confidentiality is the cornerstone of psychotherapy treatment. For adults, nothing you reveal during an appointment will be disclosed without your explicit consent, except when required by law. If our staff believes your life is in jeopardy, we will take necessary steps to protect you. Likewise, if someone else is in danger because of your actions, we will take necessary steps to protect third parties. Mr. Gilmer is also required by Texas state law to report that a child has been abused or neglected or may be abused or neglected.
It is often helpful for Mr. Gilmer to communicate with other therapists or physicians if necessary. He may ask for permission to communicate with a primary care doctor about basic information in order to enhance your continuity of therapy. If you are seeing a psychiatrist for medication management or if you are in therapy with another professional, he may ask for your consent to communicate with your therapist(s). In cases with two providers, it is very important that the lines of communication be clear in order to provide the best and safest care.
CANCELLATIONS AND MISSED APPOINTMENTS
Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of $25. Beyond Horizons Counseling does NOT double book appointments to ensure clients are seen in a timely fashion. When appointments are not canceled 24 hours in advance, there is not enough time to schedule another client during that appointment time.
CLIENT COMMUNICATIONS
For routine matters, please leave a message with the receptionist(s) in the office. If there is no one available, please leave a detailed message on our confidential voicemail and your phone call will be returned as soon as possible; generally within 1-2 business days. Mr. Gilmer also communicates via text and email.
PSYCHIATRIC EMERGENCIES
For emergencies, please call 911 or go to your nearest mental health facility. Once you have done this, please call Mr. Gilmer or leave a voicemail with details about the nature of the emergency and what facility you have gone to for emergency treatment.
AUTHORIZATION AND ACKOWLEDGMENT
I have read the Office Policies of Beyond Horizons Counseling and I understand and agree to its contents.
______Client/Parent/GuardianSignature______Date
*For the Parent(s) & /or Guardian(s)*
FINANCIAL POLICY STATEMENT
Thank you for choosing Beyond Horizons Counseling. To reduce confusion or misunderstanding, we ask that you read this policy, ask any questions that you may have, and sign the Authorization and Acknowledgment section of this form. Other than for true medical emergencies, agreement with this policy is required for all care.
Payment is required at the time services are provided. We accept cash, checks, and VISA, MasterCard, Discover, and American Express credit cards.
EAP: If you are using an EAP, the number of approved sessions will be covered at no charge to you. If you wish to continue therapy with Mr. Gilmer, you will be responsible for whatever payment(s) that your insurance does not cover.
Insurance: For all clients, payment of insurance co-pays, deductibles, and services not covered by insurance are to be paid for at the time the service is rendered. Sometimes, we will not know what your insurance will or will not cover until the claim has been submitted and processed. However, as soon as we know what was covered, we will let you know and collect payment at that time. You are responsible for any balances not covered by your insurance, including rejected claims. While every effort will be made to submit claims in accordance with insurers’ requirements for payment, in the event of a dispute or rejection, you as the insured or guarantor are responsible for payment.
Follow-up appointments: It is the patient’s responsibility to schedule a follow-up visit within the recommended time frame. Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of $25.
Requests for medical records: In accordance with Texas law, Beyond Horizons Counseling requires written requests for the release of medical records. The administrative fee associated with copying/ faxing medical records is based on current Texas law. There is a $25.00 fee for written correspondence to an employer or school (FMLA, STDisability, etc.) (Excluding excuses from work or school due to a routine office visit).
All patients are required to acknowledge their understanding of and agree to comply with the Financial Policy Agreement by signing the Authorization and Acknowledgment section of this patient information form prior to establishing care with Beyond Horizons Counseling. Except for emergency care, patients may be denied services for their failure to agree to this Financial Policy Agreement.
AUTHORIZATION AND ACKNOWLEDGMENT: I have read the Financial Policy Agreement Beyond Horizons Counseling and I understand and agree to its contents.
Patient /Guardian Signature ______
Date ______
*Please Read & Complete ALL of the Pages*
Date: ______Home Ph: ______
Cell Ph: ______
Client’s (Last name): ______First:______M:______
Client’s Sex (M):___(F):___Client’s Age:____Client’s DOB:____/____/______
Address:______City:______
State:______Zip:______
Client’s Employer(If Applicable): ______City:______State:___
Occupation: ______Education: ______
Who Is Responsible For This Account? ______Relationship: ______
Do You Have Medical Insurance? _____ Name Of Primary Insurance: ______
Member ID: ______Group#: ______
Name Of Secondary Insurance (If Applicable): ______
Member ID: ______Group#: ______
In Case Of Emergency, Who Should Be Notified? ______Ph: ______
How Did You Learn Of Our Practice? ______
If using EAP, EAP name (ex: Value Options, Mhn, Magellan, etc): ______
Authorization#: ______#ofSessions: ______
I, the undersigned, have insurance coverage with ______and assign directly to MacArthur Gilmer M.S., L.P.C. All medical and / or mental health benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges not paid by insurance. I hereby authorize the clinician to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions. If you do NOT cancel your appointment within 24 hrs, there will be a $25 non cancellation fee due prior to your next visit.
______
Signature of Insured / or Parent/ Guardian Date
Please provide the following information about your child:
Does your child have a nickname? ______If so, please share______
Behavioral Excesses:
What does your child currently do too often, too much, or at the wrong times that gets him / her in trouble? Please list all of the behaviors you can think of.
Behavioral Deficits:
What does your child fail to do as often as you would like, as much as you would like, or when you would like? Please list all of the behaviors you can think of.
Behavioral Assets:
What does your child do that you like? What does he / she do that other people like?
Other Concerns:
Do you have any other concerns about your child or your family that you have not mentioned yet?
Treatment Goals:
From your preceding list of your child’s behavior and your family concerns, what problem behaviors do you want to see change FIRST and how much must they change for you to be satisfied?
Please provide the following information about your child:
Family History:
The name of the child’s biological parents:
Mother:______Father: ______
Who has legal guardianship of your child? ______
Who does your child currently live with? ______
(Everyone in household)
Name / Age / Relationship to childPlease describe any past counseling that either your child or any family member has had:
Does anyone in the child’s family use currently (or in the past) any type of drug, tobacco, or alcohol? ______y/n If yes, please describe:
Education History:
What school does your child attend? ______
Address (If you know it): ______
Phone#: ______Teacher’s Name: ______
Current Grade: ______
What does your child’s teacher say about him or her?
Other schools attended (Including Pre-school)?
Has your child ever repeated a grade? ______If so, which one(s)? ______
Has your child ever received special education services? ______
Has your child ever experienced any of the following problems at school? (check all that apply)
____ Fighting ____ Lack of friends____ Drugs / alcohol ___Detention
____ Suspension ____ Learning disabilities ____ Poor Attendance ___Poor grades
____ Gang influence ____ Incomplete homework ____ Behavior problems
Medical History:
What is the name of your child’s medical doctor? ______
Address (If you know it): ______Ph: ______
Date of your child’s last medical examination (Roughly if you don’t know exactly): ______
Did the child’s mother smoke tobacco or use any alcohol, drugs, or medications during the pregnancy? ______If so, please list which ones:
Did the child’s mother have any problems during the pregnancy or during the delivery?______If so, please describe them:
Has your child experienced any of the following medical problems? (check all that apply)
___ A serious accident ___ Hospitalization ___ Surgery ___ Asthma ___ A head injury
___ High fever ___ Convulsions ___ Seizures ___ Allergies ___ Eye/Ear Problems
___ Meningitis ___ Hearing Problems ___ Fainting / Loss of consciousness
___ Other (please explain): ______
______
Please list any current medical problems or handicaps:
Please list any medications your child takes on a regular basis:
Other History:
Has your child ever experienced any type of abuse (physical, sexual, emotional, or verbal)? ______
If so, please explain:
Has your child ever made statements of wanting to hurt him/her self or seriously hurt someone else? ______Has he/she ever purposely hurt themselves or someone else?______If you answered yes to either question, please describe below:
Has your child ever experienced any serious emotional losses (such as a death of or physical separation from a parent or other caretaker)? Or a death of someone close to them (family member, friend, etc)? If yes, please explain below:
Finally, what are some of the things that are currently stressful to your child and his/ her family?
MEDICATION COMPLIANCE LOG
Client Name: ______
I am currently taking the following medications:
Medication Name Dosage Frequency Date Began Doctor’s Name
Client signature: ______Date: ______
Guardian signature (if client is under 18 years old): ______Date: ______
AUTHORIZATION FOR THE RELEASE OR EXCHANGE OF INFORMATION
(If you plan on having paperwork (records) faxed, emailed, or mailed as well as ANY information disclosed with your employer, school, and/ or primary healthcare professional, please fill out this portion of the document)
I authorize MacArthur Gilmer, MS LPC to disclose information from the health records of:
______
(Client)
______(DOB)
The Information is to be disclosed to: ______
Address: ______
Contact Person:______Ph: ______Fax:______
I authorize this information to be disclosed in the following ways (check all that apply):
___ Written/ Photocopy/ Paper___Verbal___faxed___mailed/emailed
Purpose of the disclosure: ______
Information to be disclosed (check all that apply):
___ Psychosocial Report___ Records from other facilities___ Therapist Orders
___ Diagnoses___ Crisis Intervention Reports___ Medical Records
___ Family Systems Eval___ Consultation Reports___ Educational Records
___ Discharge Summary___Physical Exam History___ Progress Notes
___ Treatment Plans___ Mental Status___ Court/Agency Documents
___Dates of Hospitalization___ Chemical Recovery History___Psychological Test Results
Other: ______
I understand that I may withdraw or revoke my permission at any given time. If I withdraw my permission, my information may no longer be used or released for the reasons covered by this authorization.
______
Signature of client (Guardian /Responsible Party)Date
______
Printed Name of client (Guardian /Responsible Party)Relationship to client if not self
CREDIT CARD AUTHORIZATION: *For the Parent(s) & /or Guardian(s)*
CREDIT/ DEBIT CARD INFORMATION:
______
Name as reads on credit/debit card
______
Credit/debit card number
______
Expiration Date
______
CV/ Security Code#
______
Zip Code
I, ______, hereby authorize the above credit/debit account be used for payments owed to Beyond Horizons Counseling for fees and services incurred by the patient including the following:
$25 no-show/ cancellation fee.
$25 administrative fees (FMLA, STDiability, LTDisability, etc.)
Any fees not covered by your insurance (Payment Plans can be discussed for insurance claims only)
FYI: You will always be contacted / notified before any billing takes place.
If you do not wish to leave your credit/debit card information, please note that any/ all fees that are due will be collected at the time of your next visit prior to being seen.
Thank you,
Beyond Horizons Counseling: MacArthur Gilmer MS, LPC