Place4 Counseling/Gulf Bend Center Client Information 6502 Nursery Drive Suite 104 Victoria, TX.

77904 (361) 582-5364

Patient Demographics

Chart #:____________________

SSN:_________________________

Insurance:_______________________________ Client Name:__________________________________ DOB:_______________DL#________________State:____________ Gender: Male/Female Phone:________________ Address__________________________________________ City_______________________ State __________ Zip__________ Race:________________ Preferred Language:_____________________ Student Status: Primary Phone:________________ Cell Phone:__________________ Work

____________________________ Marital Status:______________ Spouse or Guardians Name:______________________________________________________ Spouse or Guardians Address:_______________________________________________________________________________ Spouse or Guardians Contact Phone Number:_________________________ Number:___________________________ Work

Emergency Contact Name (1):____________________________ Relationship:____________ Home#:________________ Work #:_______________ Address________________________________________________ City_____________________ State ____ Zip____________ Primary Physician:_________________ Phone:______________Psychiatrist:_________________Phone:___________________

Employment & Insurance Status

Clients Employer:______________________________ Spouse/Guardian Employer:___________________________________

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Place4 Counseling/Gulf Bend Center Client Information 6502 Nursery Drive Suite 104 Victoria, TX. 77904 (361) 582-5364
Insurance Payer:__________________________ Individual ID #:____________________________ Group #:_______________ Policy Holders Name: ______________________________ SSN:_________________________ DOB:_____________________ Pol. Holders Relationship to client:________________________________Customer Service # on your card:_______________ Person Responsible for payment: ___________________________________ SSN:____________________________________ I understand that insurance benefits quoted to me by Place4 Counseling Staff are an estimation of coverage, benefits and eligibility based upon information provided at or prior to my session(s). These estimations may change based upon my individual insurance policy. I will provide Place4 staff will any updates or changes to my insurance policy. I understand that insurance may not cover some services provided and I agree to be responsible for the balance in full for services not covered. (Circle One) AGREE DISAGREE (services only provided if agreed) I hereby authorize payment under the medical insurance program be made to Place4 Counseling/Gulf Bend Center for services furnished by this provider. Additionally, I authorize said provider to release all information necessary to secure payment for services rendered and verification of insurance, which may include information concerning mental health, chemical or alcohol dependency, or AIDS. (Circle One) AGREE DISAGREE (services only provided if agreed) Signature of Person Responsible for payments: ___________________________________________ Date:_________________ Your insurance company will send you an Estimation of Benefits (EOB) after services have been rendered. If your insurance company denies any claim for services, you will receive a statement from our office. You may select how you prefer statements to be sent to you. (Please select one below) Mail Statements to: __________________________________ _____________________________ Cancellation Policy When you have an appointment scheduled at our office, that time is reserved especially for you. We understand that your time is valuable and we do everything possible to ensure that our therapists are running on time. If we have sufficient notice when you are unable to keep your appointment, we can release that time to someone else. We require a 24-hour notice if you need to reschedule or cancel your appointment. In the case of an emergency, please notify our office as soon as possible if you are unable to make your scheduled time. We thank you for your cooperation. Our policy is as follows: There will not be a charge for the first missed appointment without notice. However, if a second appointment is missed without a 24-hour notice, there will be a $50.00 charge and if a third appointment is missed without notice, a $100.00 charge. This charge will be sent to you in a statement and the balance must be paid before further sessions will be scheduled. Signature of Person Responsible for payments: ___________________________________________ Date:_________________ Email Statements to:

Consent for Services & Communication Preferences

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Place4 Counseling/Gulf Bend Center Client Information 6502 Nursery Drive Suite 104 Victoria, TX. 77904 (361) 582-5364
__________ (Initials) __________ (Initials) _________ (Initials) SERVICES: I hereby consent to services from Place4 for myself/dependent which includes intake assessment/evaluation, counseling and referrals as needed. I understand that upon completion of assessments and admission, my place4 therapist and I will develop a more detailed plan of care. The nature of the services has been explained to me and I have been given the opportunity to ask questions about the services. I understand what these services entail. CONFIDENTIALITY : I understand that any information associated with the services that I receive will be kept confidential and may only be disclosed upon my written authorization or in accordance with federal and state laws RECEIPT OF INFORMATION : I have received a copy and an explanation of Place4 services, my responsibilities and how to file a complaint/appeal. COMMUNICATION PREFERENCES: In order to keep my relationship with Place4 confidential, the best way to contact me should the need arise is noted below. I am aware that information exchanged over a cell phone and by e-mail could be intercepted by an outside party resulting in a possible confidentiality breach. I understand the benefits and risks associated with the communication preferences listed below. I wish to communicate with my provider and Place4 Staff via e-mail. I acknowledge that I have read and fully understand the risks (listed below) associated with e-mail communications between my provider and myself. I understand that all e-mails sent to me by my provider that includes any protected health information (social security, assessment results information, general condition, etc.) will be encrypted and require a password to open. I also understand that all e-mail communications will be maintained in my health record and may be reviewed by others within the organization involved in my care. In addition, I agree to the instructions outlined below. Email @ ______________________ I wish to communicate with my provider & Place4 Staff via text message . I acknowledge that I have read and fully understand the risks (listed below) associated with text message communications between my provider and myself. Text messages sent by my provider will be limited to appointment schedules/reminders. Text Message to #: _____________________________ I wish to communicate with my provider & Place4 Staff via telephone or cell phone numbers listed on this form. I authorize Place4 staff and providers to leave voicemails regarding appointment reminders and follow ups. Phone#/Cell Phone #: _________________________________ I understand that I have the right to withdraw my consent for these communication methods at any time by providing a written statement of withdrawal to Gulf Bend Center. I am aware that my withdrawal will not affect any communications that have already taken place. I have had an opportunity to review and understand the content of this consent form. By signing this consent form, I am confirming that I have been provided an explanation of the information included in this consent form and agree with the information initialed above.

__________ (Initials)

__________ (Initials)

__________ (Initials)

Client : ________________________________________________________ Date:_____________________

(Signature)

Legally Authorized Representative: _________________________________________ Date: _____________________

(Signature)

LAR Relationship to Client: ___________________________________________ Potential Risk Related to General Instructions for Sending Patient/Provider Email Email & Text Message Communications to Communications: Providers & Staff

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Place4 Counseling/Gulf Bend Center Client Information 6502 Nursery Drive Suite 104 Victoria, TX. 77904 (361) 582-5364
Emails can be altered, forwarded, intercepted, printed, and stored by others without detection. Staff other than healthcare provider may read and process emails. Loss of confidentiality when using shared computers or employers emails. Accidental routing due to wrong addresses. Vulnerability to computer hackers who could transmit information for illegitimate purposes. E-mail can be used to introduce malicious software into computer systems. An imposter can forge email. Provider cannot guarantee confidentiality of the contents of any unencrypted emails sent by client or outside entities. Use a standard, structured format with the following fields completed: Recipient/providers name. o Patient name/DOB o Subject. Limit use of email for limited communications such as: o Appointment scheduling & reminders o Non-urgent medical advice. o Use text messaging for generic appointment scheduling and reminders. Do not use email/ text messaging: for emergency or time-critical situations. to communicate regarding highly sensitive subject matter. to discuss complex subjects. All emails sent by the provider will be encrypted and require a password to open and review the contents.

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