Personal Growth Better Quality of Life Reduced Stress Important Signatures Client First Name:* Client Last Name:* Date of Birth* MM slash DD slash YYYY Parent/Guardian (for Minors) or Spouse/Partner (for Couple’s Counseling): FINANCIAL POLICY/MISSED APPOINTMENT POLICY* My signature below indicates that I have been provided a copy of CenterLife’s Financial Policy. I acknowledge that I am responsible for any payments not billable and/or covered by insurance. I have made payment arrangements with a credit/debit card on file and/or other payment options made available to me for services rendered by CenterLife Counseling. In compliance with health insurance contracts, CenterLife Counseling cannot waive co-pays or co-insurance amounts. NOTICE OF PRIVACY PRACTICES* My signature below indicates that I have been provided with a copy of the HIPAA Omnibus Notice of Privacy Practices. I understand that all medical records are kept confidential unless a separate release of information form is signed by me, authorizing the release of these medical records. I hereby authorize CenterLife Counseling to release my medical records to my insurance company for the purpose of processing my insurance claims. This authorization shall remain in effect as long as charges are being submitted for insurance claims processing or as long as dictated by payer. ASSIGNMENT OF BENEFITS* I hereby authorize direct payment to CenterLife Counseling of any medical benefits otherwise payable to me for services provided by a Mental Health Professional affiliated with CenterLife Counseling. CONTACT INFORMATION* CenterLife Counseling considers your e-mail and other contact information to be confidential. We will not disclose or sell any of your contact information to outside parties or entities. APPOINTMENT REMINDERS & FILLING CANCELLED APPOINTMENTSDo NOT check all 3 boxes. The third one voids the first two. I hereby authorize CenterLife Counseling to send appointment reminders via email and/or text. I hereby give consent to be notified via email and/or text of appointment openings with my therapist. I elect to opt out of all email and/or text communication with CenterLife Counseling. Email Address Cell NumberCell Carrier My signature confirms that I have received these forms and that I have been given the opportunity to ask questions about them.HiddenSignature ConfirmationMy signature confirms that I have received these forms and that I have been given the opportunity to ask questions about them.Signature of Client or Personal Representative* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY HiddenSignatureIf Signed by a Personal RepresentativeIf Signed by a Personal RepresentativeRelationship to client HiddenSignatureSignature of TherapistNameThis field is for validation purposes and should be left unchanged. Δ
