Personal Information

Last Name *

First Name *

Middle Name

Preferred Name

Birth Date *

Gender *

Age *

Marital Status *

Street Address *

City *

State *

Zip Code *

Primary Phone *

Cell Phone

Email Address *

Last 4 Digits of SSN

Primary Care Physician *

PCP Phone Number

How did you hear about us?

In Case of Emergency

Emergency Contact Name *

Relationship *

EC Phone Number *

Signature

The above information is true to the best of my knowledge. I understand that I am financially responsible for any and all fees. I also authorize Jeni Bowen, LPC to obtain information from my Primary Care Physician, if necessary.

Electronic Signature *

Signature Date *

Client Name *

Parent / Guardian Name (Client under 18)

1) I understand the concepts and conditions of informed consent, privacy and confidentiality.

2) I understand that I have the opportunity to discuss these concepts and conditions, and to ask for clarification if needed.

3) I understand that I will be informed of goals, expectations, procedures, benefits and drawbacks of the counseling process.

4) I understand that the process of counseling is an interactive process requiring self-disclosure, self-exploration and responsible action. Sometimes this process can be stressful and emotionally uncomfortable, and at other times very fulfilling. I understand that there are no guarantees of positive outcomes for the therapy process, and I hold Jeni Bowen, LPC harmless.

5) I have the right to refuse or withdraw from any counseling, evaluation procedures or intervention unless otherwise required by law.

6) I have the right to question any procedure, intervention, rationale or discussion that I do not understand.

7) I understand that all communication will be private, legally privileged and confidential unless otherwise specified by the laws presented below or I provide written consent on a separate release of information. I understand that this consent may be withdrawn by me at any time, documented in writing.

8) I have been informed as to the Notice of Privacy Practices as required by HIPPA.

PLEASE NOTE THE FOLLOWING EXEMPTIONS TO PRIVACY, PRIVILEGED COMMUNICATION AND CONFIDENTIALITY:

There are laws that allow for the release of confidential information that have been developed to protect the client and the public. Information that the client discloses may be released without consent to the appropriate parties involved.

1) If there exists a danger or harm to the client or someone else;

2) If the client needs to be involuntarily hospitalized due to the debilitating effects of mental illness or drug addiction;

3) If the client is required to undergo a court ordered examination;

4) If the client discloses information about the abuse or neglect of a child;

5) If the client discloses information about the abuse, neglect or exploitation of an aged or disabled adult;

6) If the client's mental or emotional condition is being used as a legal defense or if a civil, criminal or disciplinary action arises from a complaint filed in behalf of the client against a mental health professional in which case the disclosure and release of information shall be limited to that action.

I have read and understood the Notice of Privacy, Consent for Evaluation and Treatment. I understand that if Jeni Bowen, LPC wishes to use my personal health information in a manner that is different than described by the Notice, Jeni Bowen, LPC must first get my permission in writing.

Client / Guardian Signature *

Signature Date *

Appointments

(Please Initial Each Line)

ALL PAYMENTS MUST BE SUBMITTED ONLINE 24 HOURS PRIOR TO THE SCHEDULED APPOINTMENT TIME, UNLESS ARRANGEMENTS FOR CASH PAYMENT HAVE BEEN MADE IN ADVANCE. *

IF YOU ARE UNABLE TO KEEP YOUR SCHEDULED APPOINTMENT TIME, A 24 HOUR NOTICE IS REQUESTED. *

A TEN (10) MINUTE GRACE PERIOD WILL BE ALLOWED IF YOU ARE RUNNING BEHIND FOR YOUR SCHEDULED APPOINTMENT. IF YOU WILL BE MORE THAN TEN (10) MINUTES LATE, YOUR SESSION WILL NEED TO BE RESCHEDULED. *

IF YOU DO NOT SHOW UP FOR YOUR SCHEDULED APPOINTMENT TIME, YOUR PAYMENT FOR THAT MISSED SESSION TIME WILL BE FORFEITED. *

Counseling appointments are offered in-person for individuals 5 years and older, or via phone / virtually for individuals 12 years or older.

Professional Fees

Payment may be submitted with cash or credit. A receipt for payment will be automatically sent to you once payment is made online. In-person cash payments will have the option to receive a text or emailed receipt.

Insurance is not accepted at this time. However, please see the section below in "Additional Service Fees" for more information regarding insurance reimbursement.

Counseling sessions are 60 minutes for adults, and 45 minutes for children/adolescents between the ages of 5-17. This allows for a scheduled 15 minute phone call post appointment with the parent(s) / guardian(s) to discuss treatment progress and the scheduling of future appointments. Extended sessions for individuals, couples and families may be scheduled upon request.

Fee Schedule (effective January 18, 2021):

Individual Adult -

$115

Individual Child / Adolescent -

$115

Couples -

$135

Family / Group (3 or more) -

$165

Weekend / After Hours Adult -

$165

Weekend / After Hours Couples -

$185

Additional Service Fees:

(Please Initial Each Line)

REPORTS - THE TIME REQUIRED TO COMPOSE A REPORT FOR COURT PROCEEDINGS IS CHARGED TO CLIENTS AT A FEE OF $115.00 PER HOUR. *

INSURANCE CLAIMS - AS MENTIONED ABOVE, INSURANCE IS NOT ACCEPTED BY OUR OFFICE AT THIS TIME. HOWEVER, A DETAILED RECEIPT (WHICH INCLUDES NECESSARY TREATMENT AND PROVIDER CODES) CAN BE PROVIDED FOR THE CLIENT TO SUBMIT A CLAIM TO THEIR INSURANCE COMPANY FOR FULL OR PARTIAL REIMBURSEMENT. A COMPILATION OF ALL DETAILED RECEIPTS WILL BE PREPARED AND SUBMITTED TO THE CLIENT ON THE LAST DAY OF EACH MONTH FOR A FEE OF $5 PER OFFICE VISIT. *

Termination of Service:

JENI BOWEN, LPC CONSIDERS ALL CASES TO BE CLOSED (WITH OR WITHOUT NOTICE) SIX (6) MONTHS AFTER THE LAST VISIT. CASES CAN BE REOPENED BY SCHEDULING ANOTHER APPOINTMENT. *

Signature:

I HAVE READ AND AGREED TO THE OFFICE POLICIES, PROCEDURES AND FEES. *

CLIENT / GUARDIAN SIGNATURE *

SIGNATURE DATE *

Thanks for submitting New Client Paperwork!

We appreciate you taking the time to fill out the questionnaire. We will reach out to you if we have any questions or concerns prior to your first visit. Otherwise, we look forward to meeting with you soon!

Thank you

Thanks for submitting New Client Paperwork!

Thank you

New Counseling Client Form

Personal Information

In Case of Emergency

Signature

PLEASE NOTE THE FOLLOWING EXEMPTIONS TO PRIVACY, PRIVILEGED COMMUNICATION AND CONFIDENTIALITY:

Appointments

Counseling appointments are offered in-person for individuals 5 years and older, or via phone / virtually for individuals 12 years or older.

Professional Fees

Fee Schedule (effective January 18, 2021):

Additional Service Fees:

Termination of Service:

Signature:

Thanks for submitting New Client Paperwork!

Thanks for submitting New Client Paperwork!

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