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Children Application

Form

ADOLESCENT/CHILD 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

Responsible Party if Minor:

Mother: Phone:
Father: Phone:
Guardian: Phone:

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 to verify my insurance coverage and to provide my insurance company with any information requested by them for the purpose of determining benefits.

Signature: Date:
Witness:

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

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7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com

Form

Financial Policy

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 over 30 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: Date:

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7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com

Form

Patient/Client Rights

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: Date:

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7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com

Form

Canceling Appointments
OR
Not Showing Up For Your Scheduled Appointments

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 the superior 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!

Reviewed With Client - Therapist Initials

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7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com

Form

NO SHOW & LATE CANCEL CONTRACT

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):
Parent/Legal Guardian Name (Please Print):
Client signature or Parent/Legal Guardian:
Date:

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7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com

Form

Informed Consent for Treatment

I give consent for evaluation and treatment to be provided for myself/my child 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 Date:
Printed Name:
Relationship to Patient (if applicable):
Witness Signature:
Date:

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7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com

Form

Background Information

PARENT – If you are completing this form for your child, the questions relate to your child. If for more than one child, you will need to complete a form for each child please.

TEEN – If you are completing this form for yourself, the questions relate to YOU.
This information will help us better understand the situations you are experiencing.
The information is confidential and will not be released without your written permission.

Name of Client: Date of Birth:
Today’s Date: Who is filling out form (relationship or self):

SITUATIONS YOU ARE HAVING

Check all that apply Check all that apply
YesNo  :Depression YesNo   :Low self-esteem
YesNo   :Suicidal thoughts YesNo   :Death of a loved one
YesNo   :Suicidal actions YesNo   :Eating disorder
YesNo   :Anxiety / Fears / Worries / Moody YesNo   :Communication issues
YesNo   :Panic attacks or Intense fears YesNo   :Parent-child conflict
YesNo   :School issues YesNo   :Legal issues
YesNo   :Alcohol / Other drug abuse (child) YesNo   :Issues with Child Protective Services (CPS)
YesNo   :Alcohol / Other drug abuse (family) YesNo   :Brother / sister issues
YesNo   :Does anyone in your household smoke? YesNo   :Blended family issues
YesNo   :Anger / Temper problems / Mean
YesNo   :Fights often / gets in many fights
YesNo   :Temper outbursts / Explosive
Prenatal Issues (detail below):
Developmental Issues (List below): Bullying or being Bullied (Describe Below):

DIFFICULTIES WITH COPING

Check all that apply Check all that apply
YesNo  :Sleep problems YesNo   :Change in appetite
  • YesNo  :difficulty falling asleep
  • YesNo   :gaining weight pounds:  
  • YesNo  :waking up in the middle of the night
  • YesNo   :losing weight pounds:  
  • YesNo  :waking up too early
  • YesNo  :not hungry
  • YesNo  :sleeping too much
  • YesNo   :throwing up after eating
  • YesNo   :nightmares
  • 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  :Problems 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)

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      :

    TRAUMA HISTORY

    Violence in Family/Physical Abuse: Current Violence in Family/Physical Abuse: Past
    Actual:    YesNo    or Threatened:   YesNo

    Who is the
    Victim:  
    Abuser:  
    Actual:   YesNo   or Threatened:   YesNo

    Who is the
    Victim:  
    Abuser:  
    Current Sexual abuse:

    Victim:  
    Abuser:  
    Past Sexual abuse:   Age:  

    Victim:  
    Abuser:  
    Other Current Abuse - Describe:
    Other Past Abuse - Describe:
    Major losses: Please List
    Difficult changes: Please List

    MEDICAL HISTORY

    Please check any of the following medical conditions that you have now or have had in the past.

    Name of Primary Care Physician:   OK to contact?:   YesNo
    Contact Info for PCP:  

    1. Chronic medical conditions / Serious illnesses (if none apply, check None) None None

    Asthma
    YesNo
    Diabetes
    YesNo
    Ulcers
    YesNo
    Liver Damage
    YesNo
    Kidney
    YesNo
    Lupus
    YesNo
    Stroke
    YesNo
    Cancer
    YesNo
    Epilepsy/Seizure
    YesNo
    Heart
    YesNo
    Headaches
    YesNo
    Head Injury
    YesNo
    Thyroid
    YesNo
    Dementia
    YesNo
    Addiction
    YesNo
    Hepatitis
    YesNo
    Hypertension
    YesNo
    Chronic Fatigue
    YesNo
    Multiple Scleros
    YesNo
    Depression
    YesNo
    Ulcers
    YesNo
    Cancer
    YesNo
    Migraines
    YesNo
    OB-GYN
    YesNo
    Anxiety
    YesNo
    Other:  
    2. Any allergies or drug sensitivities?:  
    3. Previous hospitalizations / surgeries
    Date Reason
    4. List any previous suicide attempts (If none, click None) None None
    When What method

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    7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com

    5. Current prescriptions / medications:
    6. Physical Exam in last year?  YesNo Recommended?  YesNo
    7. Family history – any major health issues or drug and/or alcohol use:
    8. In your family, has anyone ever been diagnosed and/or treated for the following (note relation):
    YesNo  :Schizophrenia
    YesNo  :Major depression
    YesNo  :Drug Abuse
    YesNo  :Manic-Depressive Disorder
    YesNo  :Alcoholism
    YesNo  :Other medical:

    CLIENT'S PREVIOUS COUNSELING

    Name of therapist or agency Date and focus of sessions

    LIFESTYLE CHOICES

    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. Have you had any legal charges? If so, complete form below (If none, check None ) None None
    Date
    6. What is the highest level of schooling you have completed?
    7. Are there any guns or weapons in your house?
    8. Spiritual Identification
    9. Are you sexually active?
    10. Do you have any questions about your sexuality? YesNo  (please check) (please check) Describe below

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    7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com

    RELATIONSHIPS

    Please use a checkmark (Ö) to indicate which of the following situations apply to you:

    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:   YesNo

    SOURCES OF STRESS

    Please list the things/events/situations that are creating stress in your life at the present time (please include significant losses and changes in your life):

    1. 4.
    2. 5.
    3. 6.

    CURRENT FUNCTIONING

    How well you are coping with things at the present time. 100% means you are coping the best you ever have:

    0-100%

    YOUR GOALS IN COUNSELING

    Please list the goals you hope to achieve in counseling. (Be as specific as you can.)

    1. 2.
    3. 4.

    HOW MANY SESSIONS DO YOU THINK YOU WILL NEED?

    (Please specify how many.)

    1-3 sessions:  
    YesNo
    4-6 sessions:  
    YesNo
    7-9 sessions:  
    YesNo
    8-12 sessions:  
    YesNo

     

    Therapist Review:     (Initials) (Date)

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    7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com

    Form

    AUTHORIZATION

    Permission is hereby given to Bright Path Counseling Center and its employees to obtain information from and/or release information to:

    (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 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 Other:  

    I understand that I may revoke this consent at any time by notifying the agency in writing, except to the extent that action has already been taken in reliance on my consent. Bright Path Counseling Center is released from all legal responsibility that may arise from this fact.

    I, the undersigned, have read the above and authorize the staff of the facility to disclose such information as herein contained.

    Date:  
    Signature: Witness:

    This authorization expires one year from its signing. A copy is as valid as the original document.

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    7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com

    Form

    EMERGENCY CONTACT RELEASE FORM

    Please sign consent for a person you would like notified in the event of an emergency.

    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 information to:

    Name of Person to Contact:
    Emergency Contact Person’s Phone Number:

    For the purpose of releasing information relating to an accident, injury or medical emergency.

    Note that in an event of an emergency no information protected under Health Insurance Portability and Accountability Act of 1996 (“HIPPA”) 45 C.F.R. pts. 160 & 164 will be disclosed to your emergency contact. I understand that I may revoke this consent at any time by notifying the agency in writing, except to the extent that action has already been taken in reliance on my consent. Bright Path Counseling Center is released from all legal responsibility that may arise from this fact.

    I, the undersigned, have read the above and authorize the staff of the facility to disclose such information as herein contained.

    Date:  
    Signature: Witness:

    This authorization expires one year from its signing. A copy is as valid as the original document.

    BACKGROUND
    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.

    You also have the right to refuse this request. If you choose not to identify an emergency contact please sign below.

    I understand by signing below I am refusing to name and give consent for a person to be notified in the event of accident or injury.

    Client Date:
    Witness Date:
     Please Answer  


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    7266 Buckley Road • N. Syracuse, NY 13212 • (315) 458-0919 • Fax: (315) 458-0954 • www.brightpathcenter.com