Thank you for choosing North Valley Christian Counseling. We
look forward to working with you. Please take a few minutes to
fill out the following forms. We will also take a few moments at
the beginning of your first appointment to answer any questions
you may have about these forms and our practice.
One of the questions we are often asked is how to find our office. You may visit our
website at northvalleychristiancounseling.com to view a Google map. For you
convenience, some instructions are also included below.
ARROWHEAD: Go north on 79th Avenue from Bell Road. We on are the forth floor in
the white four story building between Costco and Arrowhead Mall next to Desert Schools
Federal Credit Union.
METRO: Go north on 35
thavenue from Peoria Avenue. Turn right on the fifth drive way
and you will see Trinity Bible Church through the iron fence. We are located in the first
door on the left off the lobby in the Education building.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH CARE INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please speak with your counselor/psychologist at NVCC. This Notice of Privacy describes how this office may use and disclose your protected health care
information to carry out treatment, payment, or health care operations and for those other purposes that are permitted or required by law. It also describes your rights to access and control you protected health
information. “Protected Health Information” (PHI) is information about you that may identify you and
that relates to your past, present, or future physical or mental health condition and related health care services.
This office is required to abide by the terms of this Notice of Privacy Practices. This office may change the terms of the notice at any time. Upon your request, you will be provided with any revised Notice of Privacy Practices.
Under most circumstances, this office is required by law to obtain your written permission for any disclosure (electronic, written, or oral communication) of identifying information about you and your treatment. If you or your counselor/psychologist believe that communication with a third party would be beneficial (for example, previous psychotherapists, physicians, school personnel, court system), you will be asked to sign a release of information to that effect.
PAYMENT: Your PHI may be used as needed to obtain payment for your mental health care services. Please be aware that your PHI may be electronically submitted (i.e., sent via fax or the Internet) for these purposes.
If you choose to use insurance to pay your healthcare bills, you will be asked to sign a release of information to your insurance company for purposes of authorization of sessions and payment. Examples of information sometimes required by insurance companies to approve or pay for services include your name, diagnosis, treatment plan, prognosis, and, if your chart is chosen for review, notes that document your progress in treatment.
If you are being seen through Workers’ Compensation, you will be asked to sign a release of information to that organization for purposes of authorization of sessions and payments. Examples of information required by Workers’ Compensation to approve and pay for services include your name, diagnosis, treatment plan, prognosis, and notes that document your progress in
HEALTHCARE OPERATIONS: This office may use or disclose your PHI as needed in order to support the business activities of this practice. This office may share your PHI with third party business associates that perform activities such as billing and accounting services for the practice. Whenever an arrangement is made between this office and a business associate that involves disclosure of your PHI we will have a written contract that contains terms that will protect the privacy of your PHI.
There are some circumstances that require your counselor/psychologist to disclose your PHI, even without your consent. The following are examples of the types of uses and disclosures of your PHI that this office must make. If appropriate, your counselor/psychologist will make efforts to communicate imminent disclosures to you prior to their occurrences
If your counselor/psychologist suspects that a child has been hurt physically or sexually, or neglected (this includes witnessing violence in the home), Child Protective Services will be contacted.
If an adult is living in a relationship that is violent, Adult Protective Services will be contacted. If you are at high (imminent) risk for suicide, communication with appropriate persons (e.g., hospital personnel, police officers) to ensure your safety may occur.
If you report to your counselor/psychologist that you intend to kill another person, your counselor/ psychologist will contact the targeted person(s), appropriate persons to ensure your safety, and local law enforcement.
If a judge issues a court order, your PHI may be disclosed to the relevant judicial body.
I fully understand and accept/decline (circle one) the terms of this content.
__________________________________ ________________________________ Signature Date Relationship to the client
(Client or guardian)
__________________________________ ________________________________ Signature Date Relationship to the client
_________________________________ Witness Date
CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR OFFICE OPERATIONS
I, ________________________________, understand that as part of my health care, the office of North Valley Christian Counseling originates and maintains the paper and/or electronic records describing my health history, symptoms, diagnoses, treatment, and any plans for future care or treatment. I understand that my information serves as:
A basis for planning my care and treatment
A source of information for applying my diagnosis and services obtained to my bill A means by which a third-party payer can verify that services billed were actually provided I understand and have been provided with a copy of the Privacy Notice that provides a more complete description of information uses and discloses. I understand that I have the following rights and privileges:
The right to review the notice prior to signing this consent
The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or office operations.
I understand that this office is not required to agree to the restrictions requested. I understand that I may revoke this request in writing, except to the extent that action has already been taken. I also understand that by refusing to sign this consent or revoking this consent, North Valley Christian Counseling may need to refuse to provide treatment by Section 164.506 of the Code of Federal Regulations.
I further understand that the office of North Valley Christian Counseling reserves the right to change this notice and practices in accordance with section 164.520 of the code Federal Regulations. Should this office change this notice, a copy will be sent to the address I have been provided.
I wish the following restrictions to the use or disclosure of my health information:
I understand that as part of this office’s treatment, payment, or office operations, it may become necessary to disclose my Personal Health Information to another entity, and I consent to such disclosure for these permitted purposes, including disclosures via fax.
I fully understand and accept/decline (circle one) the terms of this content.
__________________________________ ________________________________ Signature Date Signature Date
Billing and Cancellation Policy
The following rates apply to services provided by NVCC. Payment is expected at the time of service unless other arrangements have been made. Your counselor/psychologist will provide a bill suitable for submission to your insurance company upon request.
Initial Assessment 50-55 minutes $120 Individual therapy 45-50 minutes $120 Family Therapy 45-50 minutes $120 Marriage therapy 45-50 minutes $120
Appearance for court or depositions, whether testimony is given or not: Four hour minimum fee includes travel time and preparation ($250 per hour). Telephone testimony includes same fee of 250 dollars per hour and 4 hour minimum.
NVCC reserves the right to charge a fee of $50 for missed appointments not cancelled within 24 hours in advance.
I have read and agree to the above terms.
__________________________________ ________________________________ Signature Date Relationship to Client
(Client or guardian)
__________________________________ ________________________________ Signature Date Relationship to client
(Client or guardian)
_________________________________ Witness Date
Information Questionnaire for Adults
Name: ________________________________________ Today’s Date: _____________
Address: ______________________________________ Home Phone#: ____________
City: _________________________________________ Work Phone #: ____________
State: _________________________ Zip: _________ Cell Phone #: ____________
Date of Birth: ___________________ Age: ________
E-mail address: __________________
(Include address only if NVCC may contact you by e-mail.)Marital Status:
(Please circle one)Single Married Divorced Separated
Widowed
Please indicate the date (month/year) for the marital status circled above: _____________
Spouse’s Name: ________________________________ Date of Birth: ____________
Children’s Names:
Date of Birth Age Sex
________________________________ _____________ ________ M / F
________________________________ _____________ ________ M / F
________________________________ _____________ ________ M / F
________________________________ _____________ ________ M / F
Emergency Contact Person: ____________________________ Phone #: ___________
Describe any current medical problems: _______________________________________
Family Physician: __________________________________ Phone #: _____________
List any medications currently being taken: ____________________________________
Highest Grade or Degree Completed: ________ Major: ____________Year: _________
Employed by: ___________________________________________________________
Job Title: _______________________________________________________________
Spouse Employed by: _____________________________________________________
Job Title: _______________________________________________________________
Client Intake
Name: ____________________________________ Today’s Date: ____________________ Brief comment regarding reason for counseling: ____________________________________ ___________________________________________________________________________ If you have been married before, please list first name of former spouse(s) and dates of marriage: Name: _________________________________ Married from: __________ To: __________ Name: _________________________________ Married from: __________ To: __________ ____My mother is still living and is _______ years old. She lives in ____________________ ____My mother has been deceased since ____________________.
____My father is still living and is ________ years old. He lives in _____________________ ____My father has been deceased since _____________________.
____My parents are not/never were divorced.
____My parents are divorced after _________ years of marriage.
____Growing up, I lived with my: _____biological ____adoptive ____step _____foster parents. List all siblings, according to birth order: (include step and half siblings):
Name: ____________________________________________ Age: _____________ M / F Name: ____________________________________________ Age: _____________ M / F Name: ____________________________________________ Age: _____________ M / F Name: ____________________________________________ Age: _____________ M / F Name: ____________________________________________ Age: _____________ M / F Please list where you were born and the last two cities/states you have lived in:
Place of birth: ________________________________________________________________ City/State: _________________________________________ From: ________ To: ________ City/State: _________________________________________ From: ________ To: ________ Have you received professional/pastoral counseling within the last five years? ____Yes ___No With whom? ____________________________________ When? _____________________ Have you ever been hospitalized for a psychological condition? _________Yes _________No Name of hospital: ____________________________________From: _______ To: ________ Do you currently have trouble sleeping? ______Yes _____No If yes, describe: __________ _____________________________________________________________________________ How is your appetite? Good________ Poor_______ I eat when not hungry _____________ Other, Please describe: __________________________________________________________ Do you drink alcohol? ______Yes ______No Describe how often: ___________________
