Client Intake Form

Stacy Light, MA, LPC, NBCC, TYMT

"*" indicates required fields

Step 1 of 10

Client Information

First Name*

Last Name*

Street Address*

City*

State*

Zip Code*

Date of Birth*

Social Security Number*

Email Address*

Home Phone*

Work Phone

Cell Phone

Can you be contacted at work?*

Yes

Can you be contacted at home?*

Yes

Who may I thank for referring you?

Cancellation Policy

Your appointment time is reserved for you. If you cancel it, you must call 24 hours before your scheduled time to avoid a MISSED APPOINTMENT FEE. Late cancellations (less than 24 hours before your appointment) will be charged the full price of your session. If you do not call to cancel, the fee is $100.00.

Cancel with more than 24 hours: NO FEE*

Cancel with more than 24 hours: NO FEE

Cancel with less than 24 hours: FULL PRICE*

Cancel with less than 24 hours: FULL PRICE

Cancel without notice: $100.00*

Cancel without notice: $100.00

Insurance does not cover these fees.*

Insurance does not cover these fees.

Saturday appointments require a 48-hour cancellation notice, and Sunday appointments require a 72-hour notice. Late cancellations (less than 48 or 72 hours before your appointment) incur a $60.00 charge. If you do not call to cancel, the fee is $100.00.

Initial*

Please do not send an email or text if you have to cancel or change your appointment. Please call and, if necessary, leave a voicemail.

Preparation of Written Documents
Preparation of reports, clinical summaries, and letters requested by you or your legal representative will require a fee based on the time spent preparing them. The minimum fee is $25.00 for reports based on a preparation time of 15 minutes or less increments.

Court Appearances, Other Appearances, and Travel Time
Court appearances and all other appearances, including travel time, will be billed at the customary hourly rate of $110.00.

Termination of Therapy
When you are ready to leave therapy, it is customary to have a final session to wrap things up. Sometimes, people get nervous about therapy just when it is becoming most selective. I’m going to ask you not to quit therapy by leaving a phone message or sending an email. Please do it in person. If you have not had a termination session, your case is considered closed thirty days after the last contact.

I have read and understand the above information and agree to these policies. I understand that I am responsible for all charges, regardless of insurance coverage.

Patient Signature (Guardian, If Minor)*

Date*

Information Policy

Confidentiality
The privacy of your therapy is of utmost importance. There are times, however, when information must be shared with others. These times are:

If you threaten to harm yourself or someone else.
If you abuse a minor.
Insurance: A medical or psychiatric diagnosis is required to justify payment.
Managed Care: All HMOs, POS, and some PPOs and EAPs require a detailed treatment plan before authorizing additional sessions beyond the original authorization.

A typical treatment plan may contain:

A statement of the problem for which you sought treatment
Your psychiatric diagnosis
Your symptoms to justify the psychiatric diagnosis
Your drug and alcohol use
Your history of previous mental health treatment
Your current medications
Your treatment goals
The methods we will be using to help you achieve your goals
Your progress made toward those goals

Some managed care plans require the therapist to inform primary care physicians of treatment.

Who is your primary care physician?

Fees and Payment
A full session is 50 minutes. The fee for the first session is $125.00, and follow-up sessions are $110.00. I will bill your insurance company for you as a courtesy. You are responsible for obtaining the authorization number, number of sessions, unpaid deductible amount, and co-pay/co-insurance amount before the first session. You are also responsible for the counseling sessions if the insurance provider does not pay. Payments and co-payments must be made at the time of service. I accept checks or cash. Upon request, I can provide you with a receipt that you may use for insurance reimbursement. For minor children, the parent bringing the child in for treatment will be held responsible for the payment at the time of service. THERE ARE NO EXCEPTIONS TO THIS POLICY. You will be charged an interest fee of 15% on a balance that is 50 days old. If an account is turned over for collection, you agree to pay the court, attorney, and collection fees. If you are a member of a managed care program, co-payment and/or deductible amounts must be made at the time of service. You are responsible for providing any insurance updates or changes before services are rendered.