ADULT APPLICATION APPLICATION
Name of Therapist
Date
Your Name
SS #
Your Email
Maiden/Birth Name
Age
Date of Birth
Address
City, State
Zip
Telephone: (Home)
(Work)
(Cell)
Marital Status
Highest Grade Completed
Place of Employment:
Occupation:
Referred by:
Previous Counseling (Yes/No) YesNo
I understand that I will be responsible for any deductible or remaining balance not payable by my insurance company at the time service was rendered. Further, I hereby give permission to Bright Path Counseling Center toverify my insurance coverage and to provide my insurance company with any information requested by them for the purpose of determining benefits.
Signature: (required)
Date: (required)
Please Note: A No Show or Late Cancellation fee will be imposed if we are not notified of cancellations within 24 hours on the previous business day or more in advance. For instance, Monday appointments must be canceled on Friday!
Please initial here that you have reviewed our HIPAA Policies (required)
Page 1 7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com
Welcome to our office. We are committed to providing you with quality health care and treatment. Please understand that payment of your bill is considered an integral part of your health care and treatment. The following is a statement of our Financial Policy. 1.Before you see a therapist, our office manager must receive all the required administrative forms completely filled in and signed.
2.You are responsible for all fees at the time professional services are rendered to you. We accept check, cash,money orders, Visa, Master Card, and Discover card. A finance fee of $5.00 will be charged to any balance over30 days old. If your account is delinquent, counseling services will be interrupted until payment is received.
3.If our counselor chooses to perform urine screens, the lab we use for urine screens is Med Lab, Inc. You will be required to pay a $20 fee to Bright Path for this service unless covered by Medicaid. We do not submit claims to other insurance companies for urine screens. If you would like to submit your own claim, we will be happy to give you the necessary documentation to do so.
4.In the event that we are unable to file your insurance claim for any reason, our receipts are adequately itemized and coded for ease in filing for reimbursement with your carrier by yourself.
5.We will submit all claims to participating insurance companies. You will be responsible for any deductible(s) and/or co-payments that are due at the time of service. If for any reason claims are denied by your insurance company, payment for services rendered are still your responsibility.
6.Although we do everything we can to predetermine your insurance benefits and obtain prior authorizations where necessary, it is still your responsibility to check with your insurance company to ascertain your insurance coverage and to get any necessary prior authorization or physician referral. You are responsible for any denial occasioned by failure to do so.
7.No paperwork will be released to anyone unless your account is paid in full.
8.It is our policy to charge a fee for cancellations or failure to keep your appointment unless appointments are canceled twenty-four (24) hours of the previous business day or more in advance. For instance, Monday appointments must be canceled on Friday. Your insurance company is not responsible for such charges.
9.There is a $35.00 fee for checks that are returned for insufficient funds.
10.If we are required to engage the services of an attorney in order to collect any amount you owe us, you will be responsible for the reasonable attorney's fees and other collection expenses incurred.
If you have a balance due on your account today from previous visits, please remit this balance in full before you see the therapist today.
Please sign below to indicate your acceptance of these terms.
Client's Signature (required)
Date (required)
Page 2 7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com
1. Each client has a right to an individually designed plan of service based on his or her individual needs in which the client has participated in developing, and which includes goals that the client has agreed to work towards.
2.Each client shall be free of any personal involvement with any facility staff member.
3.Each client has the right to considerate and respectful care.
4.Each client has the right to receive services from staff which are competent and caring.
5.Each client has the right to be treated in a way which recognizes and responds to his or her cultural identity and/or sexual orientation.
6.Each client has the right to know the counselor responsible for coordinating his or her care and the name of any other person providing care to him or her.
7.No client shall be treated by a staff member who is known to be under the influence of alcohol or illicit drugs.
8.Each client has the right to obtain from his or her counselor current information concerning his/her diagnosis and treatment in terms that he or she can understand.
9.Each client has the right to receive services in a physical environment that is safe, sanitary, reflective of human dignity, conducive to effective treatment, and which appropriately safeguards the privacy and confidentiality of client-staff interaction.
10. Each client has a right to examine and receive an explanation of his/her bill, regardless of the source of payment.
11. Each client may object to conditions at the facility and has a right to reasonable, prompt response from either the Practice Manager or the Clinical Director. Each client also has the right to complain to the Clinical Director and obtain from the facility staff information about how such a complaint may be filed.
12. All treatment is voluntary. There may be legal, family, or employment consequences if treatment is refused or terminated early.
13. It is our policy to charge a client for any unused service scheduled unless we have received 24-hour notice of cancellation. Please refer to our cancellation/no show policy and our financial policy for details
Signature: (reqired)
Page 3 7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com
Bright Path Counseling Center was created as a place to meet your counseling needs in a setting filled with respect,comfort, confidentiality, professionalism and personal caring. The main ingredient that makes this possible is thesuperior counseling and administrative staff that we have assembled for your needs.
With great respect, we honor your journey to healing by providing quality care in a timely fashion. We have limited space and time, therefore, every appointment time set for you is at a premium. We appreciate your returning this respect by committing to be here at your appointment time. We know you will understand the need for us to uphold the following policies:
Be On Time: Try to arrive a few minutes before your appointment so that you have the full time for your session. Therapists need to conclude your session at the appropriate time so they can complete proper closure to your session.
Not Showing Up: If you fail to be here for your appointment, please remember that this time has already been committed to you so you will be responsible to pay a No-Show Fee, regardless of your insurance carrier.
Cancellations Without 24-Hour Notice: Your appointment times cannot be filled with another client without sufficient notice. Therefore, you are still responsible for that time slot and will be charged a Late Cancellation Fee regardless of your insurance carrier. Appointments must be canceled twenty-four (24) hours of the previous business day or more in advance. For instance, Monday appointments must be canceled on Friday.
Recurring Missed Appointments: If you are an established client and you miss two appointments in a row, it shows that you are probably not committed to your counseling. Therefore, you may be discharged or placed on a clinical pause. At the discretion of the multi-disciplinary team, you will be eligible to “re-enter” the program thirty days from the discharge or pause date provided your account balance has been paid in full.
Emergency Cancellations: With a doctor’s written report, a car mechanic’s receipt, or other proper documentation, we will reschedule your appointment for the next available time that your therapist can offer and waive a missed appointment Fee.
Severe Weather: Severe weather warnings must be announced on public broadcasting systems or the Internet, in order for “weather” to be a valid reason for not showing up for your appointment or canceling less than 24 hours in advance. You must still call to cancel the appointment in order to avoid the missed appointment Fee. Please take advantage of our telehealth video and phone sessions during inclement weather!
Page 4 7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com
Bright Path schedules your counselor for one hour of time based on the appointment you have made. That is a commitment!
Bright Path charges a fee for appointments when the client either fails to show up to their appointment (No Show) or cancels their appointment less than 24 hours of the scheduled time (Late Cancel).
These fees are not reimbursed by insurance companies and are therefore accepted as part of this contract as a Non-covered Service.
These fees cover reservation of your counselor's contracted time for counseling services that could not be rendered due to your failure to show and the resulting inability to otherwise provide services to other clients during that scheduled time due to lack of adequate notification.
Bright Path's Fees are as follows:
No Show Fee: $45.00
Late Cancel Fee: $25.00
Further, Bright Path reserves the right to:
1. Pause any additional appointments for clients who have failed to show for their appointments (No Show).
2. Pause any additional appointments for clients who have either No-Showed or who have Late Canceled twice within a 30-day window.
3. Pause any additional appointments for failure to pay fees associated with this contract.
It is at the discretion of Bright Path Counseling Center when and if additional appointments can be made at our facility based on the poor attendance record or inappropriate behavior of the client at Bright Path.
Bright Path does accept Emergency Cancellations and Severe Weather as waivers for these fees as outlined in our application. Written documentation for Emergency Cancellations is expected.
Client Name (Please Print): (required)
Parent/Legal Guardian Name (Please Print):
Client signature or Parent/Legal Guardian: (required)
Date:
Page 5 7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com
I give consent for evaluation and treatment to be provided for myself by. .
I am aware that the practice of psychotherapy is not an exact science and that results cannot be guaranteed. No promises have been made to me about the results of treatment.
The risks, benefits, side effects, and alternatives of treatment as well as the consequences of non-compliance with treatment have been discussed with me and I have had the opportunity to ask questions.
I understand that I need to provide accurate information about myself to my clinician so that I will receive effective treatment. I also agree to play an active role in my treatment process.
I understand that I may terminate treatment at any time.
My signature below shows that I understand and agree with all of the above statements. I have had the opportunity to ask questions about the treatment process. If the client is a minor or has a legal guardian appointed by the court, the client’s parent or legal guardian must sign this consent.
Signature of Patient or Parent/Guardian
Printed Name
Relationship to Patient (if applicable)
Witness Signature:
Page 6 7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com
(Please Print) Name
DOB
Today’s Date
Check all that apply
Depression
YesNo
Parent-child conflict (self)
Suicidal thoughts
Parent-child conflict (spouse)
Suicidal actions
Marital - relationship issues
Anxiety / Fears / Worries/ Moody
Brother / sister issues
Panic attacks
Blended family issues
Communication issues
Nicotine abuse by family member
Anger/ Temper Issues
Eating disorder
Sexual dysfunction
Compulsive gambling
Alcohol / Other drug abuse (family)
Job / School situations / unemployed
Alcohol / Other drug abuse (self)
Legal issues
Death of a loved one
Violence in Family/Physical Abuse: Current Actual YesNo or: Threatened YesNo Who is the Victim: Abuser:
Current Sexual abuse: YesNo Victim: Abuser:
Other Current Abuse - Describe:
Violence in Family/Physical Abuse: Past Actual YesNo or: Threatened YesNo Who is the Victim: Abuser:
Past Sexual abuse: YesNo Age:
Victim: Abuser:
Other Past Abuse - Describe:
Major losses: Please List
Difficult changes: Please List
YesNo :Sleep issues
YesNo :difficulty falling asleep
YesNo :waking up in the middle of the night
YesNo :waking up too early
YesNo :sleeping too much
YesNo :nightmares
YesNo :Change in appetite
YesNo :gaining weight ( pounds)
YesNo :losing weight ( pounds)
YesNo :not hungry
YesNo :throwing up after eating
YesNo :feeling sick to my stomach
YesNo :Moody or crying more than usual
YesNo :Constipation or diarrhea
YesNo :Feeling guilty, worthless, or hopeless
YesNo :Difficulties concentrating
YesNo :Fatigue / low energy
YesNo Difficulty remembering things
YesNo :Hyper / too much energy
YesNo :Withdrawing from others
YesNo :Loss of interest in things
YesNo :Repeated actions I can’t stop
YesNo Disturbing thoughts I can’t stop
YesNo :Can’t stop washing hands/body
YesNo :People are out to get me
YesNo :People are picking on me
YesNo :Can’t stop counting or checking things
Other (please specify below)
Name of Primary Care Physician:
OK to contact? YesNo
Contact Info for PCP:
Asthma YesNo
Diabetes YesNo
Ulcers YesNo
Liver Damage YesNo
Kidney YesNo
Lupus YesNo
Stroke YesNo
Cancer YesNo
Epilepsy/Seizures YesNo
Heart YesNo
Headaches YesNo
Head Injury YesNo
Thyroid YesNo
Dementia YesNo
Addiction YesNo
Hepatitis YesNo
Hypertension YesNo
Chronic Fatigue YesNo
Multiple Sclerosis YesNo
Depression YesNo
Migraines YesNo
OB-GYN YesNo
Anxiety YesNo
Other
Any allergies or drug sensitivities?
Reason
When
What method
5. Physical Exam in last year? YesNo
Recommended? YesNo
YesNo : Schizophrenia
YesNo : Manic-Depressive Disorder
YesNo : Major depression
YesNo : Alcoholism
YesNo : Drug Abuse
Other medical:
Name of therapist or agency
Date and focus of sessions
1. Smoking (how much?)
2. Alcohol use (how much, how often?)
3. Other drug use (which, how much?)
4. How much coffee/tea/Coke/Pepsi?
5. Spiritual Identification
6. Cultural Concerns
7. Have you had any legal charges? If so, complete form below (If none, check None): None
What charges?
8. Have you had any previous (or current) CPS involvement? YesNo
9. What is the highest level of schooling you have completed?
10. Are there any guns or weapons in your house?
YesNo :Too few friends
YesNo :Enough friends
YesNo :I talk to my friends about my problems
YesNo :I don’t talk to my friends about my problems
YesNo :I am overly shy
YesNo :I find it very difficult to open up to others
YesNo :I make friends easily
YesNo :I find it hard to keep friends
YesNo :Others seem to be picking on me
YesNo :No one really seems to understand me
1.
2.
3.
4.
5.
6.
0-100%
YesNo : 1-3 sessions
YesNo : 4-6 sessions
YesNo : 7-9 sessions
YesNo : 8-12 sessions
(Please specify how many.)
Therapist Review:
(Initials)
(Date)
(Name of organization or individual)
Regarding:
Date of Birth:
For the purpose of:
(YesNo) : Coordination of treatment
(YesNo) : Referral out
(YesNo) : Insurance reimbursement
(YesNo) : Probation requirements
(YesNo) : Legal concerns
(YesNo) : Contact referral source
(YesNo) : Collateral contact
(YesNo) : Other:
Extent or nature of information to be disclosed:
(YesNo) : Psychosocial evaluation
(YesNo) : Urine drug Screen
(YesNo) : Alcohol/drug evaluation
(YesNo) : Breathalyzer results
(YesNo) : Participation in treatment
(YesNo) : Psychological testing
(YesNo) : Progress in treatment
(YesNo) : Discharge Summary
(YesNo) : Recommendations
(YesNo) : Other
Signature:
Witness:
(Please print) Your Full Name
Your Date of Birth:
Permission is hereby given to Bright Path Counseling Center and its employees to obtain information from and/or release
Name of Person to Contact:
Emergency Contact Person’s Phone Number:
Signature
Witness
On May 5, 2007, the Governor signed a new law, known as “Jonathan’s Law” (Chapter 24 of the Laws of 2007), which became effective immediately. This new law, stimulated by the tragic death of a 13-year old Jonathan Carey, while in residential care makes changes in the way in which certain notifications are made and information is shared, regarding incidents involving the health and safety of patients.
Client
Please Answer 5+12=?
