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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: (required)

    Date: (required)

    Witness:

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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 forty-eight (48) 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.

    Responsible Party Signature: (required)

    Date: (required)

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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 48-hour notice of cancellation. Please refer to our cancellation/no show policy and our financial policy for details.

    Responsible Party Signature:(required)

    Date: (required)

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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 48-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.

     

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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 48 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.

    Client Name (Please Print) (required) :

    Parent/Legal Guardian Name (Please Print): (required)

    Client signature or Parent/Legal Guardian: (required)

    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) NoneNone

    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) NoneNone

    When

    What method

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    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 (required):

    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:

    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.

    Client

    Date:

    Witness

    Date:

    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.

    Date:

     

    Signature (required):

    Witness:

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

    HIPAA POLICY

    We at Bright Path Counseling Center are committed to safeguarding your personal health information (PHI). PHI is any information that can identify you as an individual and your past, present, or future
    medical and/or mental health condition.

    This notice, in addition to telling you about the ways that we may use and disclose your medical
    information, also describes your rights, and the obligations that we have regarding the use and disclosure of
    medical information.

    Federal and state law require us to:

    1. )Make sure your PHI is kept private;

    2. )Give you notice of our legal duties and privacy practices with respect to your PHI; and

    3. ) Follow the terms of the notice that is currently in effect.

    Therefore, we will release your PHI only under the following circumstances:

    1. ) When you give us written consent to do so.

    2. ) When we are required by a specific court order to do so.

    We will make changes in our privacy policy only as required by law. We will notify you in advance of
    those changes, in writing.

    Privacy Compliance Officer:

    The privacy compliance officer at Bright Path is Bonnie Merkel. Please address all complaints and/or
    requests for amendments to your PHI, and/or requests for copies of your PHI, to Bonnie Merkel.

    Nonpublic Personal Information:

    Nonpublic Personal Information is the information you give your insurance company when you sign up for benefits, such as name, address, Social Security number, date of birth, etc. We will only provide that information to your insurance company (or companies) in order to verify benefits and obtain payment for services rendered. We will not disclose that information to any other entity unless 1) required to do so by court order; or 2) you give us written consent to do so.

    Psychotherapy notes:

    Psychotherapy notes have special protection under the new HIPAA regulations:

    1. ) They can only be released under a court order that shows the necessity of their release.

    2. ) Barring a court order, they can only be released when the therapist determines the release to be in your best interest.

    3. ) Psychotherapy notes will never be released without your consent, but they may not be released to an entity you authorize, if your therapist deems it to be detrimental to your treatment.

    4. ) Your insurance company may no longer pre-condition payment of benefits on the release of psychotherapy notes.

    Please note the following restrictions, and please do not ask us to violate them:

    1. ) We cannot acknowledge your presence and/or treatment at Bright Path Counseling Center without your written consent, or a court order. We cannot do so for family members, friends, employers, lawyers, government agencies, etc. If you want any of the above to act on your behalf, including the setting or changing of appointments, you must sign a written authorization.

    2. ) We cannot complete any paperwork for any local, state or federal agency, for any purpose, without your consent. We cannot provide any PHI to any insurance agency other than the one(s) reimbursing us for authorized care without your specific written authorization.

    Individual Rights:

    1. ) You have the right to inspect and/or copy your PHI, when your therapist determines that such an inspection and/or copying would not be detrimental to your physical health or personal safety, and would not cause harm to another individual. This right does not extend to psychotherapy notes, as noted above.

    2. ) You have a right, under law, to request an accounting of the instances in which we disclosed your PHI, other than disclosures made for the purpose of treatment, payment, and disclosures made with your authorization. However, at Bright Path Counseling Center, we do not make any disclosures outside of those parameters.

    3. ) You have the right to request additional restrictions on our use and disclosure of your PHI. However, the law will not permit us to honor those additional restrictions if they keep us from receiving payment for services rendered.

    Amendment:

    You have the right to request that we amend your PHI. Your request must be in writing, and it must explain why the information should be amended. We will deny your request if we did not create the information you want amended, or if we determine the current information is accurate. If we accept your request, we will make a reasonable effort to notify others, including people or organizations you name in your written request, and will include the changes in all future disclosures of your PHI. If we
    deny your request, we will provide a written explanation. You may then respond with a written statement of disagreement that will be attached to the information you want amended. You may contact Bonnie Merkel for a form to complete and return to us.

    Safeguards:

    We employ the following safeguards to insure the privacy of your PHI:

    • All of our employees sign an agreement to follow our Confidentiality guidelines.

    • All of our employees complete privacy training.

    • We have a privacy coordinator who detects and prevents security breaches.

    • All computer systems that contain personal information have security protection.

    • All physical files are kept in a double-locked storage container.

    • All of our therapy offices conform to state and federal privacy regulations with regards to construction and use.

    Questions and Complaints:

    If you want more information about our privacy practices, or feel that your privacy rights have been violated, please contact our privacy officer. You may also submit a written complaint to the Department of Health and Human Services. We will provide you with the address to file your complaint with HHS upon request.

    Please contact:

     Please Answer  


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