Intake Forms


    General

    Emergency Contact

    Legal Guardian

    Closest Mental Health Facility

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    Social History Questionnaire

    Relationship Status

    Never MarriedMarriedSeparatedDivorcedWidowedSignificant Relationships

    Do you use any of the following?

    AlcoholSleeping PillsMarijuanaDiet PillsCocaineLaxativesEcstasyNicotineHeroinCodeineCaffeine

    Medical History

    How do you view your health?

    ExcellentGoodFairPoor

    Social History

    Family Members (Mother, Father)

    Family Members (Stepmother, Stepfather)

    Family Members (Brothers and Sisters)

    Family Members (Spouse)

    Family Members (Children)

    Education

    Employment

    Military History

    Legal

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    Insurance Authorization and Assignment

    I authorize the release of any medical information necessary to process any insurance claims and I authorize payment of medical benefits directly to Brill Counseling, for myself and/or dependents. I understand that I am responsible for any deductibles, co-insurances, or amounts for services not covered by the insurance carrier, including full session charges for missed appointments and those canceled less than 24 hours in advance.

    I also authorize Brill Counseling, to release any medical/mental health information that may be necessary for either medical care or in processing applications for financial benefit. I request that payment of authorized benefits be made on my behalf. A photocopy of these assignments shall be as valid as the original. I am aware and do consent and authorize, to disclose information pertaining to my identity, diagnoses, and treatment to the Utilization Manager and/ or any authorized Utilization Review/Managed Care Company or subcontractor employed by my insurance company. This information needs to be disclosed for the purpose of obtaining health insurance payments for charges incurred by the client as a result of treatment by Brill Counseling.

    I am aware that my records are protected under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (45 CFR, Parts 160 and 164), Federal regulation 42 CFR, Part 2 (Confidentiality of Alcohol and Drug Abuse Treatment), and the General Laws of the State of Wisconsin and cannot be disclosed without my written consent except as otherwise specifically provided for by law. I understand that, by law, I need not consent to the release of this information; however, I choose to do so willingly and voluntarily for the purpose specified above.

    Signature

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    Credit Card Authorization

    I, authorize Brill Counseling to keep my signature on file and to charge my account.

    I am aware that if I choose to use a credit card to make payment for my copay, deductible, statement balance or late cancellation fee, there is an additional 3.5% + 15 cents charge per transaction, for processing.

    Card Type

    VisaMasterCard

    Authorization Signature

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    Electronic Communication Informed Consent

    CLIENTS MUST CONSENT TO THE USE OF ELECTRONIC COMMUNICATION FOR CONFIDENTIAL MEDICAL INFORMATION AFTER HAVING BEEN INFORMED OF THE FOLLOWING:

    • Electronic communication cannot be guaranteed for the following risk factors:
      Can be immediately broadcast worldwide and received by many intended and unintended recipients
    • Can be forwarded to other recipients without the original sender's permission or knowledge
    • Can be falsified more easily than written or signed documents
    • Can be easily misaddressed
    • Back up copies of electronic communication may exist even after the sender or recipient has deleted the information

    CONSENT TO THE USE OF ELECTRONIC COMMUNICATION FOR CONFIDENTIAL MEDICAL INFORMATION INCLUDES AGREEMENT WITH THE FOLLOWING CONDITIONS:

    • The therapist and client will agree upon the appropriate use of electronic communication. If it is used inappropriately Brill Counseling will not allow electronic communication as an option.
    • All electronic communication concerning diagnosis and/or treatment will be printed out and made a part of the client's case record
    • Caution should be used in conveying sensitive/personal information due to security risks.
    • Clients do not have a right to privacy in their employer's email system, so should not use that system to transmit confidential information.
    • Clients who have consented to use electronic communication are responsible for informing their therapist of any type of information they do not want sent in this format.
    • Promptness in responding to electronic communication cannot be guaranteed. If you need an immediate response, use our phone system.
    • EMERGENCIES cannot be handled through electronic communication. In the case of an emergency please dial 911 or go to your nearest emergency room. For urgent matters please leave a telephone message.
    • This consent is valid for the entire course of treatment and may be withdrawn, in writing, at any time

    Signature

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    Information about Fees

    Initial Assessment fee $165
    38-52 minute fee for Individual or Couples Psychotherapy $140
    51-60 minute fee for Individual or Couples Psychotherapy $160

    If you are a member of a HMO/PPO, payment to your provider may be discounted from that stated above. It is important to be aware of your plan deductible and your co-pay responsibility. The expectation is that co-pays (or full fees for self pay clients) are paid on a per session basis to your treating psychotherapist. Cash or check are accepted forms of payment.

    I understand that I am responsible for any deductibles, co-insurances, or amounts for services not covered by the insurance carrier, including full session charges for missed appointments and those cancelled less than 24 hours in advance.

    I am aware that if I choose to use a credit card to make payment for my copay, deductible, statement balance or late fee, there is an additional 3.5% + 15 cents charge per transaction, for processing.

    I hereby authorize Brill Counseling to release such information as may be requested by my insurance company for purposes of billing or coverage clarification. Further, I hereby authorize any insurance coverage providing benefits or payments for psychological/mental health services received to be assigned to Brill Counseling. I also permit a photocopy or other facsimile of this authorization to be used in place of the original assignment.

    Signature

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