Gelsomina 'Jessie' Williams, LMHC
1633 East Vine Street, Suite 213 , Kissimmee, FL 34744
1120 West Minneola Ave Clermont, FL 34711
Client Information
Date:______
Patient Last Name:______First Name:______
Marital Status: Single Married Separated Divorced Widowed
Race:______Sex:______Religious preference______
SSN:______Date of Birth:______Age:______
Address:______
City:______State:______Zip______
Phone: Home______Cell:______Work:______
Email address: ______okay to contact ______
Employer/School:______Position/grade:______
Referred by______Phone:______
Referral source:______(for example) internet, phone book
(If patient is a minor, please provide name of parents/guardians, address and phone if different)
Name: ______
Address:______
Insurance and Payment information
Name of insured: ______SS# ______
Date of Birth: ______Home Address______
Home Phone: ______Cell Phone: ______
Employer: ______Work Phone: (____)______
Marital Status: Single Married Separated Divorced Widowed
Insurance Company______ID#______Group#______
Phone Number for customer service: ______
Phone # for Mental Nervous/SA benefit: ______
Please provide authorization number: ______
Payment Policy : Payment for services is due at the time they are rendered. Payment may be made by cash, check, credit card or debit.
I authorize the release of medical or other information necessary to process any insurance or EAP claims.
Initial: ______
What would you like to get out of counseling today?
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Have you had previous counseling (when/ where/ issue at the time?)
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Current medical conditions and medications:
Medical Condition Medication Name of treating physician
______
______
______
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List 2 goals you would like to accomplish in the next 4 months.
1.______
2. ______
Please list the name/ relationship/ and age of people in your household.
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Statement of Understanding
Services and Confidentiality
Jessie Williams, LMHC is a private counselor providing assessment, referral and counseling services to you and your eligible dependents.
Your contact is voluntary and confidential and strictly protected within the limits of the law. Any information disclosed in counseling will be treated with the utmost respect for confidentiality. Information regarding your contact can only be released with your written permission, unless required by law.
As a mandated reporter, Jessie Williams, LMHC is required to report to appropriate authorities the suspected abuse or neglect of a child or elderly person. Jessie Williams, LMHC is also required to take any action necessary to prevent imminent threats of harm to self or others.
Cost of Services
If your sessions are covered by your EAP benefit, there is no cost to you.
Sessions are 45-50 minutes in length. The fee for sessions is 85.00. If your sessions are covered through your insurance plan you are responsible for your co-payment. Payment is due at the time of service. Cash, check or credit/debit card is acceptable means of payment
No show Policy
If you can not attend your appointment and do not call by 5pm the day before your appointment there is a $25.00 fee. After hours messages can be left at 407-947-7984. Insurance does not cover these charges. Fees must be paid prior to your next appointment.
COURT APPEARANCES: Please note that I am unwilling to go to court to testify unless subpoenaed by a judge. My fees for having to appear in court are $300.00 an hour (3 hour minimum), paid in advance.
Fees for Summaries of any kind are $25.00 per summary.
Your signature indicates that you have read and understand the above information, give consent for treatment for yourself and/or your minor child, and that you authorize the release of medical or other information necessary to process any insurance claims.
A copy of this form will gladly be provided at your request.
I have been offered and have reviewed a copy of the Notice of Privacy Practice.
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Name of Client(s) (please print) Jessie Williams, LMHC
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Client signature
______Parent/ Guardian/ Partner Signature Date