New Client Registration Form

New Client Registration Form - Adult

This registration document contains all the forms that must be completed before your first appointment is scheduled. All information is confidential and protected by HIPAA
Thank you for your interest in receiving counseling services at JFS Desert, choosing to work with our clinicians on your behavioral health goals. It’s important that you understand the following points:

1. JFS Desert is a non-sectarian, nonprofit organization that will be providing you or your family members with professional clinical counseling.

2. Receipt of JFS Desert counseling services is confidential, and your identity will be protected by the agency.

3. To facilitate the sharing of medical information with your physician (and anyone else of your choosing), you will be asked to sign a Release of Information form.

4. JFS Desert staff does not prescribe medication of any kind.

5. Although JFS therapists can diagnose various mental health disorders, including ADHD, JFS therapists do not do psychological or psychiatric evaluations for educational, program placement, or medication management purposes.

6. JFS Desert is not affiliated with the court system; however, JFS may provide mental health services to court-ordered clients. Please note that JFS is not “court-ordered” to provide those services.

7. JFS provides individual, family, and/or group therapy. “Couples” therapy is not currently provided. JFS reserves the right to review individual requests for couples therapy but is under no obligation to provide it.

8. All parents of minor clients must be available for the entire initial session (in-person or via Telecare), and a parent or guardian must be in the JFS lobby while minor clients are being provided in-person services.

9. During your assessment and throughout your treatment, you will be asked to complete a screening tool. A screening tool is a brief questionnaire to check your mood. The answers provide helpful clinical information and are used to authorize additional sessions.

10. If a client presents with suicidal or homicidal thoughts, that client may be seen on a weekly basis for a brief period. Once stable, that client may be scheduled every other week.

11. JFS provides an after-hours answering service but not a therapist on-call. During a mental health emergency, please call 911 or go to the nearest emergency room. Messages received after hours are returned on the next business day.

12. JFS does not offer standing scheduled appointments. Clients are encouraged to keep 2 appointments scheduled at any one time.

13. Your professional clinician is trained to help you learn to cope differently, communicate differently, or manage your emotions more efficiently. The development of a therapeutic relationship will begin to form at your first session. This can take several sessions to truly develop. This is true for individuals, children, couples, and seniors. Should you discover you are not comfortable with your clinician and wish to make a change in providers, please discuss this with your clinician. Your current clinician will be happy to assist with a change of clinicians.

14. JFS case managers assist clients to get connected to available benefits such as Calfresh, Section 8 housing vouchers, and United Lift applications while also offering emergency financial assistance for necessities such as overdue rent and utilities, food, and medications. Please ask your therapist or any JFS staff person about connecting to a JFS case manager.

Should you have any subsequent questions, please feel free to ask your clinician, and again... welcome to JFS Desert.
To acknowledge your receipt of the above information, please initial the box below.*

Client Information
Client Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender*
Preferred Pronoun
Preferred Language
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cellphone Number*
Cellphone Provider*
Would you like to receive JFS notifications by text? Example: Appointment reminders.*

AcceptDecline
E-mail*
example@example.com
Would you like to receive notifications and communications by email? Examples: Appointment reminders, Zoom link, and requests from JFS office staff.*

AcceptDecline
Emergency Contact Name*

First NameLast Name
Relationship to Client
Emergency Contact's Phone Number*
Please enter a valid phone number.
Demographics

This information is voluntary and we appreciate you providing as much information as possible as it helps JFS continue to provide services.
Ethnicity
Race
Sexual Orientation
Marital Status
Estimated Annual Household Income
Number of People in Household
Are You Head of Household?
Are You A Veteran?
Are You Disabled?
Religion
Medical Information
Family Doctor Name
Family Doctor Phone Number
Other Mental Health Treatment(s)?
If Yes with Whom and When:
Do You Have an Advanced Health Care Directive?
Medication Currently Being Taken:
State Client's Reasons for Service:*
How Did You Learn About JFS?

Consent to Treatment
I consent and agree voluntarily to receive services from Jewish Family Service of the Desert (JFS). These services may include, but are not limited to, diagnostic assessments, individual, group, and/ or family therapy and consultations and referrals to other behavioral health professionals
Please initial each item below to acknowledge you have read and understood the terms.
I understand that by consenting to treatment, personal health information may be exchanged in a limited way for treatment, payment and healthcare operations purposes, only.*
I understand that I have the right to terminate treatment at any time. I also understand that I have the right to refuse to implement any recommendations, psychological interventions, or any treatment procedures. *
I understand that I am expected to benefit from treatment, but there is no implied or expressed guarantee that I will. *
I understand that JFS is an outpatient clinic and uses an after-hours answering service when the office is closed at night, holidays and weekends. I understand that in the event of a psychiatric emergency, I will be directed by the answering service to call 911.*
I understand that JFS therapists are mandated reporters andconfidentiality may be broken to report child, elder or Dependant abuse,expressed threats of violence toward an ascertainable victim, detailed planningor concrete sign of future suicide attempts*
I understand that confidentiality may be broken if there is asubpoena request from legal and administrative institutions.*
I understand that I must be in California to receivetelehealth services from a JFS therapist. I will cancel my appointment 24 hoursin advance if traveling outside California.*
Office Based Services
You have requested to receive counseling services in the JFS Palm Springs office, and we are proud to be able to offer these services. In making this request and in signing below, you agree to abide by all JFS safety protocols. Further, you agree to do the following:
- Bring an appropriate mask/face shield to each counseling session and/or to drop off completed paperwork;
- Adhere to all posted safety precautions, including 6’ social distancing, frequent use of sanitation items, and not entering the office if you, a person accompanying you, or anyone with whom you spent the 24 hours immediately prior to your appointment are showing any signs or symptoms of exposure to COVID-19. A list of these symptoms will be posted;
- Abide by the decisions of JFS staff related to access to the JFS office;
- Provide truthful and accurate information related to health and safety questions; and
- To stay home if you or a person accompanying you feels ill. Note: You can complete your session via telecare if you have completed a consent to receive telecare services and notice is provided within two (2) hours of your scheduled session start time.
By initializing below, you agree to be provided with in-person counseling sessions at the JFS Palm Springs office, and you agree to abide by all stated and/or posted guidelines.
Initials*

Consent to Participate in Telecare Counseling Sessions
1.    PURPOSE. The purpose of this form is to obtain your consent to participate in telecare counseling with a Jewish Family Service of the Desert (JFS) Licensed Therapist.

2.    NATURE OF TELECARE COUNSELING. Telecare involves the use of audio, video, or other electronic communications to interact with you, consult with your Therapist, and/or review your medical information for the purpose of diagnosis, therapy, follow-up, and/or education. During your telecare counseling, details of your medical history and personal health information may be discussed.

3.    RISKS, BENEFITS. The benefits of telecare include having access to a Licensed Clinician for therapy without having to travel outside of your home or local health care community.

4.    A potential risk of telecare is that, in rare circumstances, security protocols could fail causing a breach of patient privacy. You may decline telecare services if you so wish.

5.    PROTECTED HEALTH INFORMATION AND RECORDS. All laws concerning patient access to medical records and copies of medical records apply to telecare. Dissemination of any patient identifiable images or information from the session or other entities shall not occur without your consent.

6.    CONFIDENTIALITY. To the best of the therapist’s and agency’s ability, all existing confidentiality protections under federal HIPAA and California law apply.

7.    RIGHTS. You may withhold or withdraw your consent to telecare at any time before and/or during the session without affecting your right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.

My health care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered.
I Agree to Telecare Sessions*

YesNo, I decline
I have selected the option above correctly*

Telehealth Norms
1. Camera must be on.

2. No drug or substance use (including vapes) prior to or during your session.

3. No driving.

4. No eating during session.

5. Wear appropriate clothing that you'd wear to an in-person visit.

6. Treat the session like an in-person appointment, eliminate distractions and refrain from other activities.

7. No phone calls or texting during your session.
Signature*

Clear
Date*

MonthDayYear
Date

Payment Policy and Fee Agreement
Please initial each item below to acknowledge you have read and understood the terms.
I understand payment is due at the time of each date of service (DOS) and can be made by cash, check or credit card.*
I authorize JFS Desert to charge the credit card that I have provided; I understand that JFS will charge the card for each service completed and will email a receipt for the transaction. I will not receive a notification prior to the charge unless the amount agreed below changes.*
I understand JFS also accepts reimbursement from many third party payers, including Medicare and Medi-Cal. JFS may assist me in the completion of the necessary insurance forms to facilitate collection of benefits. However, I understand that I am ultimately responsible for all charges not covered by my insurance.
I understand that I must notify JFS when I change insurance plans or HMO providers as this change can modify or interrupt my mental health benefits. Failure to do so may result in requiring me to assume responsibility for payment of my counseling until a new authorization for treatment is approved.
I understand I may be charged $25.00 when an appointment is cancelled with less than 24 hours advance notice, or when I have failed to keep the appointment.*
I understand and agree that 2 or more late cancellations or “no shows” within three (3) months may be cause to discontinue services. See “Cancellation & Late Cancellation Policy Reminder Notice” on this form.*
I have read, understand and agree to the JFS fee policy, and I agree to pay whatever amount my insurance responsibility is, including but not limited to the copay. I agree to allow JFS to collect copays at the date of service or anytime thereafter.*

Proof of Income / Affidavit Letter
I am providing this affidavit to verify my income and:*

I am providing supporting documentation, or:I have no other documents available.
I receive (gross amount) $
The frequency of pay is
I last received this amount on
I understand that this information is subject to verification by JFS of the Desert. I certify that the information presented in this letter is true and correct to the best of my knowledge and belief.*

Client Acknowledgement of JFS Counseling, Cancellation and Late Cancellation Policy
Our goal is to provide quality counseling in a timely manner. In order to do so we have a 24-hour cancellation policy. The policy enables us to better utilize available appointments for our clients in need of therapy.

Cancellation of an Appointment

We recognize that schedules sometimes change. If you must cancel your appointment, we require that you please call at least 24 hours before your appointment. Appointments are in high demand. Your early cancellation gives others the possibility of meeting with their therapist. During evenings, weekends, and/or holidays, you can call our main number, (760) 325-4088, and leave a message with the answering service or email us at appointments@jfsdesert.org

Late Cancellations

Cancellations made less than 24 hours before an appointment are considered a late cancellation. A fee of $25 may be charged if applicable. Excessive late cancellations may be cause to discontinue services.

No-Show Policy

A client is considered a “no-show” if they do not call or email the office to cancel the session, nor arrive for the session. No-shows are inconvenient for both clients who need to schedule appointments and office staff and therapists who work hard to prepare for your visit. The late cancellation fee of $25 may apply. After two (2) “no-shows” within three (3) months, services may be discontinued at the agency’s discretion.

Counseling Policy

On your first visit to JFS your clinician will review the counseling process and begin to collect data, which will aid in the development of your treatment plan; this plan will be reviewed with you upon completion.
I have read, understand and agree to the JFS Counseling, Cancellation, and Late Cancellation Policy.*

Notice of Privacy Practices Summary Notice
Jewish Family Service of the Desert (JFS) keeps medical information about you.

This information is personal and private. We need to use this information in several ways:
- Conduct, plan and direct your treatment, which may be reviewed at agency clinical meetings.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and professional certification.
Under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information (PHI). These rights are:
- Review the complete notice of privacy practices prior to signing this agreement.
- Right of access to inspect and copy information in my file.
- Right to amend information in my file.
- Right to an accounting of disclosures made about information in my file.
- Right to request restrictions on how my information is used. I understand JFS is not required to agree to my request.
- Right to request the way in which information about me is shared.
- Right to copy of this notice.
- The right to file a complaint regarding privacy with the Secretary of Health and Human Services toll-free at 877-696-6775. If I have any questions regarding my privacy rights I can contact the JFS privacy official at 760-325-4088.
NOTICE TO CLIENTS

The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors. You may contact the Board online at www.bbs.ca.gov or by calling (916) 574-7830.
I have read, understand and agree to the JFS Notice of Privacy Practices Summary Notice above.*

Signatures
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear
Please upload photo ID and proof of income

Cancelof
Should be Empty:

New Client Registration Form - Adult

Consent to Treatment

Office Based Services

Consent to Participate in Telecare Counseling Sessions

Telehealth Norms

Payment Policy and Fee Agreement

Proof of Income / Affidavit Letter

Client Acknowledgement of JFS Counseling, Cancellation and Late Cancellation Policy

Authorization to Disclose and/or Obtain Information

Notice of Privacy Practices Summary Notice

Signatures