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Joanne Jones, MSW, M.A.Licensed Marriage & Family TherapistINSURANCE CLIENT INTAKE FORMToday’s Date:Client(Last Name)(First Name)Date of BirthSpouse(Last Name)(First Name)Date of BirthClient AddressStreetCityStateZip CodeClient Cell Phone #Client Work #Client Home Number #Spouse Cell Phone #Spouse Work #Spouse Home Number #Relationship Status:MarriedName of InsuranceSubscriber ID#SeparatedDivorcedPartneredName of Subscriber or Policy HolderSocial Security #In a RelationshipSingleDate of Birth of SubscriberAuthorization ## of Sessions AuthorizedNote: If your EAP provider is different than your mental health insurance provider, you must includeyour social security number above in order for me to bill your EAP.Please check if it is okay to contact you on:Home PhoneIs it okay to send mail to your home?YesNoWork PhoneCell PhoneName and contact information of Primary Care Physician:Are you taking psychotropic medication(s)?If Yes, please describe:Anti-depressantAnti-psychoticMedications monitored by:PsychiatristYesNoMood StabilizerOtherAnti-AnxietyDon’t KnowPrimary Care PhysicianARNPPsychostimulantOtherDescribe why you are seeking help:2200 - 112th Avenue NE, Suite 120, Bellevue, WA 98004 (425) 455-9907 joanne@joannestherapy.comPage 1 of 8
Joanne Jones, MSW, M.A.Licensed Marriage & Family TherapistINSURANCE CLIENT INTAKE FORMWhen were you last examined by a physician?List any major health problems for which you currently receive treatment:List any medications you are now taking:Medication NameDosageStart DateEnd DateDescribe your reason(s) for seeking treatment at this time. Include when the problem started:Have you ever received mental health or substance abuse treatment of any kind before?NoYes (please provide additional information below)Provider NameReason for seeking helpStart DateEnd DatePlease indicate past problems with a “P” and current problems with a Obsessions/CompulsionsTraumaChronic IllnessChronic PainLonelinessEating or Weight ProblemAbuse/VictimizationDomestic ViolenceManic EpisodesLegal MattersMarriage/Relationship IssuesSexuality/Sexuality IssuesFamily ConflictBehavioral ating a drug/alcohol habitEliminating another habit(i.e. overspending, gambling)Please indicate how the problems are affecting the following areas of your hool PerformanceFriendshipsFinancial SituationPhysical Health2200 - 112th Avenue NE, Suite 120, Bellevue, WA 98004 (425) 455-9907 NotApplicableN/Ajoanne@joannestherapy.comPage 2 of 8
Joanne Jones, MSW, M.A.Licensed Marriage & Family TherapistINSURANCE CLIENT DISCLOSURE STATEMENTWashington Licensed MFT Number: LF00001118Counselor’s Name: Joanne JonesType of Counseling Provided: Individual, Couples, and Family TherapyMethods and Techniques Used: Family Systems Therapy, Structural, and Solution- Focused TherapyEducation, Training, Experience: Licensed Marriage and Family TherapistChemical Dependency ProfessionalClinical Member of AAMFT and WAMFTFamily and Adolescent Therapist, Starting OverMaster of Arts, Marriage & Family Therapy, Pacific Lutheran UniversityMontlake Family Therapy TrainingMaster of Social Work, University of WashingtonBachelor of Arts in Psychology with Addiction Studies SpecialtyFEESThe fee for the first session (intake) is 150.00 and thereafter each individual session is 110.00, eachcouple or family session is 125.00. Most insurance companies do not cover family or maritalcounseling. You are also responsible for meeting your deductible and co-payments. If for any reasonyour insurance does not cover the therapy session(s), you are responsible for the fee.Intervention sessions are 175.00 per session and are not covered by insurance.Payment or co-payment for the session is to be made at the beginning of each session in the form of cash,check, or credit card. If you are unable to pay at the time of your session, we will discuss possiblepayment options. If you pay by check and your check is returned from the bank, I require cash or moneyorder payment for the unpaid session and any bank fees to be made prior to any subsequent sessions.It is your responsibility to follow-up with your insurance company promptly to inform them you areattending therapy with Joanne Jones, LMFT. If you do not obtain authorization for the session(s),you will be responsible for the session fee(s).(INITIAL)Appointments cancelled with less than 24 hours notice will be billed to you.(INITIAL)Unpaid accounts 90 days past due are turned over to Collections.(INITIAL)2200 - 112th Avenue NE, Suite 120, Bellevue, WA 98004 (425) 455-9907 joanne@joannestherapy.comPage 3 of 8
Joanne Jones, MSW, M.A.Licensed Marriage & Family TherapistINSURANCE CLIENT DISCLOSURE STATEMENTCONFIDENTIALITYAll information discussed in therapy is CONFIDENTIAL. No information is communicated to othersoutside of the session without your signed consent. However, I am required by Washington State law torelease confidential information in selected situations. If I believe you may be physically or sexuallyabusing or neglecting a minor child or vulnerable adult or developmentally disabled person, or if youreport information to me about the possible abuse or neglect of such a person, I am required by law toreport it. If I believe you are likely to do harm to yourself or to another person, I must also take steps toprotect you and/or the other person. Written records of your sessions are kept in a locked file cabinet.Client Disclosure Statement“Counselors practicing counseling for a fee must be licensed or registered with the Department of Healthfor the protection of the public health and safety. Registration of an individual with the department doesnot include recognition of any practice standards, nor necessarily implies the effectiveness of anytreatment.”The purpose of the Counselor Credentialing Act (Chapter 18.19 RCW) is: (A) To provide protection forpublic health and safety; and (B) To empower the citizens of the State of Washington by providing acomplaint process against those counselors who would commit acts of unprofessional conduct.I am not qualified to do parenting evaluations nor am I an expert witness. Should you be involvedin legal matters, I will not go to court. However, I can refer you to a qualified professional to assistyou if needed.CONSENT TO TREATMENTI/we have read, understand and agree to the information above.Client SignatureDateClient SignatureDateJoanne Jones, LMFTDate2200 - 112th Avenue NE, Suite 120, Bellevue, WA 98004 (425) 455-9907 joanne@joannestherapy.comPage 4 of 8
Joanne Jones, MSW, M.A.Licensed Marriage & Family TherapistINSURANCE INFORMATIONClient’s Name Date of BirthClient’s Insurance IDRelation to Subscriber:SelfSpouseChildOther(Client) Are You:EmployedStudentUnemployedName of InsuranceGroup or Policy #Claims Address:Is authorization required prior to attending therapy?YesNoYou may need to call and let the insurance company know that you are seeing me to get the sessionsauthorized.Authorization # (if required): # of sessions coveredIf you are not the insured policy holder fill out the following information:Name of SubscriberSubscriber ID Subscriber’s Date of BirthSubscriber’s AddressSubscriber’s EmployerIf there is a secondary insurance fill out the following information:Name of the Insured PersonName of Secondary Insurance Group or Policy #Insured Person’s ID # Insured Person’s Date of BirthAddress of Insured PersonEmployer of Insured Person2200 - 112th Avenue NE, Suite 120, Bellevue, WA 98004 (425) 455-9907 joanne@joannestherapy.comPage 5 of 8
Joanne Jones, MSW, M.A.Licensed Marriage & Family TherapistINSURANCE RELEASE OF INFORMATIONI, , authorize Joanne Jones to release and obtaininformation pertaining to my client records to insurance provider to bill insurance for mentalhealth benefits for me.Name and address of insurance provider with whom information is to be exchanged:Specific type of information to be disclosed: participation in therapy, billing for services and clinicalupdates as required by insurance carrier.Client SignatureDateClient SignatureDateJoanne Jones, LMFTDateThe information which is being disclosed from records whose confidentiality is protected by lawprohibits disclosure without the specific consent of the person to whom it pertains.2200 - 112th Avenue NE, Suite 120, Bellevue, WA 98004 (425) 455-9907 joanne@joannestherapy.comPage 6 of 8
Joanne Jones, MSW, M.A.Licensed Marriage & Family TherapistEMAIL & TEXT MESSAGE AUTHORIZATION FORMEmail Address(es) to Send Appointment Reminders to:ORPhone Number(s) to Text Message Appointment Reminders to:Email Address(es) to Send Statements to:It is important to be aware that email communication can be relatively easily accessed by unauthorizedpeople and hence can compromise the privacy and confidentiality of such communication. Emails, inparticular, are vulnerable to such unauthorized access due to the fact that servers have unlimited anddirect access to all emails that go through them. Please notify me if you decide to avoid or limit, in anyway, the use of email. Unless I hear from you otherwise, I will continue to communicate with you viaemail when necessary or appropriate.Statements will be sent from jessica@joannestherapy.com by my Administrative Assistant, JessicaBarrett.By signing below I authorize Joanne Jones and Jessica Barrett to email my statements and appointmentreminders. I also authorize Joanne Jones to send appointment reminders by text message.I understand that appointments cancelled with less than 24 hours notice will be billed directly tome.Client SignatureDateClient SignatureDateJoanne Jones, LMFTDate2200 - 112th Avenue NE, Suite 120, Bellevue, WA 98004 (425) 455-9907 joanne@joannestherapy.comPage 7 of 8
Joanne Jones, MSW, M.A.Licensed Marriage & Family TherapistACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESBy my signature below, I, , acknowledge that I havereceived a copy of the Notice of Privacy Practices from Joanne Jones.Client/Parent/Guardian SignatureDateIf this acknowledgement is signed by a personal representative on behalf of the client, complete thefollowing:Personal Representative’s NameRelationship to ClientFor Office Use OnlyI attempted to obtain written acknowledgment of receipt of my Notice of Privacy Practices, butacknowledgement could not be obtained because:Individual refused to sign.Communications barriers prohibited obtaining the acknowledgement.An emergency situation prevented me from obtaining acknowledgement.Other (please specify)This form will be retained in your medical record. This form is educational only, does not constitutelegal advice, and covers only federal, not state law.2200 - 112th Avenue NE, Suite 120, Bellevue, WA 98004 (425) 455-9907 joanne@joannestherapy.comPage 8 of 8
Joanne Jones, MSW, M.A. Licensed Marriage & Family Therapist 2200 - 112th Avenue NE, Suite 120, Bellevue, WA 98004 (425) 455-9907 joanne@joannestherapy.com Page 6 of 8 INSURANCE RELEASE OF INFORMATION I, _, authorize Joanne Jones to release and obtain information pertaining to my client records to insurance provider to bill insurance for mental
