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Nicholas Stelzner, LPC2419 W. State St. STE 8Boise, ID 83702(208) 724-5507Client InformationClient’s Name:Date of Birth:Home Telephone #:Social Security #:Address:Parent Information (please fill out if your child is a minor)Parent’s Name:Date of Birth:Home Telephone #:Social Security #:Address:Work Phone:Insurance Information: (This section must be completely filled out.)Insured’s Name (as it appears on insurance card):Employer:Insured’s Home Telephone #:Health Plan Name:Insured’s Address:ID #:Insured’s Date of Birth:Group #:Insured’s Social Security #:Telephone # for plan information:Assignment of Insurance BenefitsI hereby request and authorize payment to Nicholas Stelzner, LPC for my visits.In making this assignment, I understand and agree any unpaid balance not covered by this policy will be paid by me.I further agree that any balance remaining of the proceeds of this policy, after all charges for this service are paid,may be applied to any other indebtedness for prior services rendered to me or any other person or whom I am legallyobligated.Additionally, I hereby authorize Nicholas Stelzner, LPC and his administrative biller to release copies of mycounseling records, for any and/or all of my visits, as requested by my insurance carrier to my insurance carrier forpayment of services.Client’s Signature:Date:
f u l c r u m 6 2 4 Informed Consent for Therapy ServicesCOUNSELOR-CLIENT SERVICE AGREEMENTThis document contains important information about my professionalservices and business policies. It also contains summary informationabout the Health Insurance Portability and Accountability Act (HIPAA),a federal law that provides privacy protections and patient rights aboutthe use and disclosure of your Protected Health Information (PHI) forthe purposes of treatment, payment, and health care operations.Although these documents are long and sometimes complex, it is veryimportant that you understand them. When you sign this document, itwill also represent an agreement between us. We can discuss anyquestions you have when you sign them or at any time in the future.COUNSELING SERVICESCounseling is a relationship between people that works in part because ofclearly defined rights and responsibilities held by each person. As a clientin counseling, you have certain rights and responsibilities that areimportant for you to understand. There are also legal limitations to thoserights that you should be aware of. I, as your counselor, havecorresponding responsibilities to you. These rights and responsibilitiesare described in the following sections.Counseling has both benefits and risks. Risks may include experiencinguncomfortable feelings, such as sadness, guilt, anxiety, anger,frustration, loneliness and helplessness, because the process ofcounseling often requires discussing the unpleasant aspects of your life.However, counseling has been shown to have benefits for individualsNicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 who undertake it. The therapeutic process often leads to a significantreduction in feelings of distress, increased satisfaction in interpersonalrelationships, greater personal awareness and insight, increased skills formanaging stress and resolutions to specific problems. But, there are noguarantees about what will happen. Counseling requires a very activeeffort on your part. In order to be most successful, you will have to workon things we discuss outside of sessions.The first session(s) might involve but are not limited to; involve acomprehensive evaluation and discussion of your needs. By the end ofthat process, we will be able to offer you some initial impressions of whatour work might include. At that point, we will discuss your treatmentgoals and create an initial treatment plan. You should evaluate thisinformation and make your own assessment about whether you feelcomfortable working with me. If you have questions about myprocedures, we should discuss them whenever they arise. If your doubtspersist, I will be happy to help you set up a meeting with another mentalhealth professional for a second opinion.Welcome to my practice, FULCRUM 624 LLC. A little about Fulcrum624 LLC and me. I have been in the mental health field since 2000,working as a number of titles, duties and responsibilities. I received myMaster’s in Mental Health/Counseling from Idaho State University in2014. I completed both my undergraduate degrees in psychology, whileplaying sports at the College of Southern Idaho and Lewis-Clark StateCollege and after as a professional athlete. I am a Licensed ProfessionalCounselor, Habilitative Interventionist, Behavioral Interventionist,Consultant, Sports and Performance Counselor, mental developmentNicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 enhancement, evaluator/assessor and have been fortunate enough towork under other various titles in the mental health field. I come from aneclectic approach. I believe that each process is unique and thereforeshould be customized to meet your therapeutic needs. I alsoemploy/implement natural setting approaches as we see fit andnecessary. I work with adolescents, adults, couples, groups/teams, andfamilies. I look forward to assisting with your enhancement and overalltherapeutic process.APPOINTMENTSAppointments will ordinarily be 45-50 minutes in duration, once perweek at a time we agree on, although some sessions may be more or lessfrequent as needed. The time scheduled for your appointment is assignedto you and you alone. If you need to cancel or reschedule a session, I askthat you provide me with 24 hours notice. If you miss a session withoutcanceling, or cancel with less than 24-hour notice, my policy is to collectthe amount of your co-payment (unless we both agree that you wereunable to attend due to circumstances beyond your control). It isimportant to note that insurance companies do not providereimbursement for cancelled sessions; thus, you will be responsible forthe portion of the fee as described above. If it is possible, I will try to findanother time to reschedule the appointment. In addition, you areresponsible for coming to your session on time; if you are late, yourappointment will still need to end on time.Nicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 PROFESSIONAL FEESThe standard fee for the initial intake is and each subsequent session is . You are responsible for paying at the time of your session unless priorarrangements have been made. Payment must be made by; card, checkor cash. Any checks returned to my office are subject to an additional feeof up to 25.00 to cover the bank fee that I incur. If you refuse to payyour debt, I reserve the right to use an attorney or collection agency tosecure payment.In addition to weekly appointments, it is my practice to charge thisamount on a prorated basis (I will break down the hourly cost) for otherprofessional services that you may require such as report writing,telephone conversations that last longer than 15 minutes, attendance atmeetings or consultations which you have requested, or the timerequired to perform any other service which you may request of me. Ifyou anticipate becoming involved in a court case, I recommend that wediscuss this fully before you waive your right to confidentiality. If yourcase requires my participation, you will be expected to pay for theprofessional time required even if another party compels me to testify.INSURANCEIn order for us to set realistic treatment goals and priorities, it isimportant to evaluate what resources you have available to pay for yourtreatment. If you have a health insurance policy, it will usually providesome coverage for mental health treatment. With your permission, mybilling service and I will assist you to the extent possible in filing claimsand ascertaining information about your coverage, but you areNicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 responsible for knowing your coverage and for letting me know if/whenyour coverage changes.Due to the rising costs of health care, insurance benefits haveincreasingly become more complex. It is sometimes difficult todetermine exactly how much mental health coverage is available.Managed Health Care plans such as HMOs and PPOs often requireadvance authorization, without which they may refuse to providereimbursement for mental health services. These plans are often limitedto short-term treatment approaches designed to work out specificproblems that interfere with a person’s usual level of functioning. It maybe necessary to seek approval for more therapy after a certain number ofsessions. While a lot can be accomplished in short-term therapy, somepatients feel that they need more services after insurance benefits end.Some managed-care plans will not allow me to provide services to youonce your benefits end. If this is the case, I will do my best to findanother provider who will help you continue your counseling andtherapeutic process.You should also be aware that most insurance companies require you toauthorize me to provide them with a clinical diagnosis. (Diagnoses aretechnical terms that describe the nature of your problems and whetherthey are short-term or long-term problems. All diagnoses come from abook entitled the DSM-V. There is a copy in my office and I will be gladto let you see it to learn more about your diagnosis, if applicable.).Sometimes I have to provide additional clinical information such astreatment plans or summaries, or copies of the entire record (in rarecases). This information will become part of the insurance company filesand will probably be stored in a computer. Though all insuranceNicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 companies claim to keep such information confidential, I have no controlover what they do with it once it is in their hands. In some cases, theymay share the information with a national medical informationdatabank. I will provide you with a copy of any report I submit, if yourequest it. By signing this Agreement, you agree that I can providerequested information to your carrier if you plan to pay with insurance.In addition, if you plan to use your insurance, authorization from theinsurance company may be required before they will cover therapy fees.If you did not obtain authorization and it is required, you may beresponsible for full payment of the fee. Many policies leave a percentageof the fee (which is called co-insurance) or a flat dollar amount (referredto as a co-payment ) to be covered by the patient. Either amount is to bepaid at the time of the visit by check or cash. In addition, some insurancecompanies also have a deductible, which is an out-of-pocket amount thatmust be paid by the patient before the insurance companies are willingto begin paying any amount for services. This will typically mean thatyou will be responsible to pay for initial sessions with me until yourdeductible has been met; the deductible amount may also need to be metat the start of each calendar year. Once we have all of the informationabout your insurance coverage, we will discuss what we can reasonablyexpect to accomplish with the benefits that are available and what willhappen if coverage ends before you feel ready to end your sessions. It isimportant to remember that you always have the right to pay for myservices yourself to avoid the problems described above, unlessprohibited by my provider contract.If I am not a participating provider for your insurance plan, I will supplyyou with a receipt of payment for services, which you can submit to yourNicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 insurance company for reimbursement. Please note that not allinsurance companies reimburse for out-of-network providers. If youprefer to use a participating provider, I will refer you to a colleague.PROFESSIONAL RECORDSI am required to keep appropriate records of the services that I provide.Your records are maintained in a secure, locked location in the office. Ikeep brief records noting that you were here, your reasons for seekingtherapy, the goals and progress we set for treatment, your diagnosis,topics we discussed, your medical, social, and treatment history, recordsI receive from other providers, copies of records I send to others, andyour billing records. Except in unusual circumstances that involvedanger to yourself, you have the right to a copy of your file. Because theseare professional records, they may be misinterpreted and/or upsetting tountrained readers. For this reason, I recommend that you initiallyreview them with me, or have them forwarded to another mental healthprofessional to discuss the contents. If I refuse your request for access toyour records, you have a right to have my decision reviewed by anothermental health professional, which I will discuss with you upon yourrequest. You also have the right to request that a copy of your file bemade available to any other health care provider at your written request.CONFIDENTIALITYMy policies about confidentiality, as well as other information about yourprivacy rights, are fully described in a separate document entitled Noticeof Privacy Practices. You have been provided with a copy of thatNicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 document and we have discussed those issues. Please remember that youmay reopen the conversation at any time during our work together.PARENTS & MINORSWhile privacy in therapy is crucial to successful progress; parentalinvolvement can also be essential. Other communication will require thechild’s agreement, unless I feel there is a safety concern (see also abovesection on Confidentiality for exceptions), in which case I will makeevery effort to notify the child of my intention to disclose informationahead of time and make every effort to handle any objections that areraised. [See sample Adolescent Consent Form, to be signed by bothadolescent and parent(s).]CONTACTING MEI am often not immediately available by telephone. My phone number forFulcrum 624 LLC is (208) 724-5507. I do not answer my phone when Iam with clients or otherwise unavailable. At these times, you may leave amessage on my confidential voice mail and your call will be returned assoon as possible, but it may take a day or two for non-urgent matters. If,for any number of unseen reasons, you do not hear from me or I amunable to reach you, and you feel you cannot wait for a return call or ifyou feel unable to keep yourself safe, 1) contact your physician, 2) call 911and ask to speak to the mental health worker on call, or 3) go to yournearest emergency room. I will make every attempt to inform you inadvance of planned absences, and provide you with the name and phonenumber of the mental health professional covering my practice. I will beopen to communicating via email, however, please be aware of theNicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 limitations of confidentiality using this forum of communication. I willnot conduct sessions via email but will be open to discussingappointments this way.SOCIAL MEDIA I do not participate with requests from clients orprevious clients through social media. In doing so, it is a dualrelationship and jeopardizes confidentiality.OTHER RIGHTSIf you are unhappy with what is happening in therapy, I hope you willtalk with me so that I can respond to your concerns. Such comments willbe taken seriously, validated and handled with care and respect. You mayalso request that I refer you to another therapist and are free to endtherapy at any time. You have the right to considerate, safe andrespectful care, without discrimination as to race, ethnicity, color,gender, sexual orientation, age, religion, national origin, or source ofpayment. You have the right to ask questions about any aspects oftherapy and about my specific training and experience. You have theright to expect that I will not have social or sexual relationships withclients or with former clients.Nicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 While this is a unique relationship, it is a professional one and it is mypolicy to maintain only a professional relationship with you. This meansthat I cannot accept gifts or invitations, or engage in a business orpersonal/virtual relationship with you. If I see you in public, I will protectyour confidentiality by acknowledging you only if you approach me first.These guidelines exist to ensure the quality of your care.As required by the Idaho Bureau of Occupational Licenses (IBOL) andIdaho Licensing Board of Professional Counselors and Marriage and FamilyTherapists, I must clearly state to you that sexual intimacy is neverappropriate with a client and should be reported to the board immediately.IBOL can be contacted at: 700 W. State St., Boise, ID 83702, (208)3343233 or ibol@ibol.idaho.gov."Nicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 CONSENT TO COUNSELINGYour signature below indicates that you have read this Agreement andthe Notice of Privacy Practices and agree to the terms.Signature of Patient or Personal RepresentativePrinted Name of Patient or Personal RepresentativeDateNicholas Stelzner LPC, NCC:Nicholas A. Stelzner, LPC, NCC, HI, BI208.724.5507fulcrum624@gmail.comSports Performance CounselingMental Development . Mental Counseling . Consulting . Habilitative Intervention . Behavioral Intervention . ASD Specialist
f u l c r u m 6 2 4 Idaho Counseling Licensing BoardThe Idaho Counseling Licensing Board has the general responsibility ofregulating the practice of licensed professional counselors. The licensure ofany individual under the licensing laws of Idaho does not imply orconstitute neither an endorsement of that counselor nor guaranteeeffectiveness of treatment. The Idaho Counselor Licensing Board, throughthe Idaho Bureau of Occupational Licenses, Owyhee Plaza, 1109 MainStreet, Suite 220, Boise, Idaho 83702-5642, is responsible for licensure ofcounselors within the state of Idaho.Any unethical and unprofessional conduct should be reported to the aboveCounseling Licensing Board.N
Master’s in Mental Health/Counseling from Idaho State University in 2014. I completed both my undergraduate degrees in psychology, while playing sports at the College of Southern Idaho and Lewis-Clark State College and after as a professional athlete. I am a Licensed Professional Counselor, Habilitative Interventionist, Behavioral .
