New Client Packet

JORDAN WEST FAMILY COUNSELING SERVICE AGREEMENT
PATIENT INFORMATION
Name*

First NameInitialLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home/Mobile Phone*
Please enter a valid phone number.
Social Security Number*
Birth date*

MonthDayYear
Date
Age*
Sex*

MaleFemale
Marital Status*

SingleMarriedWidowedDivorced
Who is your Employer?
Job / Occupation
Whom may we thank for referring you?
In case of emergency, who should be notified?*
Emergency Phone Number
Please enter a valid phone number.

RESPONSIBLE PARTY
Relationship to Patient
Other Relationship to Patient
Name*

First NameInitialLast Name
Birth date*

MonthDayYear
Date
Social Security Number*
Address (if different from patient’s)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Person Responsible Employed by
Occupation
Business Address
Business Phone
Please enter a valid phone number.

PRIMARY INSURANCE
Relationship to Patient*
Other Relationship to Patient
Insurance Subscriber Name*
Birth date*

MonthDayYear
Date
Social Security Number*
Address (if different from patient’s)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Subscriber Employed by
Business Phone
Please enter a valid phone number.
Insurance Company Name*
Insurance ID Number
Plan ID Number
Is patient covered by additional insurance?*

YesNo
If yes, is the policy listed above primary?

Employee Assistance Program (EAP)
Is patient covered by an EAP?*

YesNo
If yes, what is the EAP Company?

CompanyPhone Number
Address (if different from patient’s)

Street Address

Street Address Line 2

CityState

Zip Code
Authorization Number

Other Payment Source
Clergy*

YesNo
If yes, Clergy name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Other than listed above?*

Yesno
If yes, source name
Phone Number
Please enter a valid phone number.

ASSIGNMENT AND RELEASE
I, the undersigned, certify that I (or my dependent) have insurance coverage with Insurance Company * and assign directly to my provider all insurance benefits otherwise payable to me for services rendered. I understand that I am ultimately responsible for all charges accumulated. I hereby authorize Jordan West Family Counseling to release all information necessary to secure the payment of benefits, and authorize the use of this signature on all insurance submissions. I give permission for treatment of myself/my dependent to my assigned provider.
Signature*

Clear
I give permission for treatment of myself/my dependent to my assigned provider.
Signature*

Clear
Relationship to Patient*
Other Relationship to Patient
Date

MonthDayYear
Date

Notice of Client Rights and Grievance Policy
Jordan West Family Counseling Client’s Rights
- Welcome to Jordan West Family Counseling
- We hope that we can give you the kind of support and help that you are looking for
When you receive services from Jordan West Family Counselling you the following rights:
- You have the right to receive high quality service
- You have the right to be treated with respect and dignity in a humane service environment that affords reasonable protection from harm and affords reasonable privacy.
- You have the right to be provided services in a setting under conditions that are least restrictive to your liberty, that are least intrusive to you and that provide for the greatest degree of independence.
- You have the right to receive no services without informed voluntary consent except as permitted by law.
- You have the right participate and to have other persons of your choice participate in the planning and provision of services with your
  consent.
- You have the right to refuse services, including any specific procedure without suffering punitive consequences. If adverse consequences are expected to result from such refusal, that fact must be explained verbally to you and if appropriate, to your guardian.
- You have the right to not be involuntarily terminated or transferred from services without prior notice, notification of available sources of necessary continued services and exercise of a grievance procedure.
- You have the right to communicate privately with any public or private rights protection program or rights advocate.
- You have the right to execute a declaration of mental health treatment.
- You, and your guardian, if appropriate, have the right to be informed in writing of any fees that may be charged.
- No person will be denied treatment or discriminated against on the basis of age except in cases where program criteria for service or staff skill restrict the service to specific age groups.
- Treatment provided is non-discriminatory and sensitive to differences of race, color, creed, sex, handicap, national origin or duration of residence.
- You have the right to lodge a grievance if you feel any of these rights have been violated.
This is what we ask from you:
- Treat the staff and others at Jordan West Family Counselling with courtesy and respect
- Let Jordan West Family Counselling know 24 hours before if you cannot come to an appointment.
Client Grievance

Jordan West Family Counseling (JWFC) is committed to providing the best possible conditions where clients may receive quality treatment and
care without prejudice or fear. Clients are made aware that he/she has the right to discuss any dissatisfaction with services by contacting the
Clinical Director at 801-566-0749.
If a client feels our service to them can be improved, or a client feels his or her rights as clients have been disregarded, we urge that client first
discuss those concerns with the treating therapist. If the client feels that the treating therapist does not adequately address those concerns, we
encourage the client to use the following grievance procedure.
A grievance means a dispute between a client and a JWFC Provider about how to interpret or apply the client rights described in the Patient
Rights and Responsibilities.
- The client needs to submit the grievance as soon as possible after the date of the event grieved, in writing to the treating therapist. The treating therapist will consult with JWFC Clinical Director and will respond to the client in writing within ten days of the date of receiving the grievance. (note: If grievance is related to alleged abuse or neglect immediate response maybe warranted.)
- If the client is not satisfied with the response from the treating therapist, or does not receive a response, the client may request review by the clinical director. This request must be made in writing and must be delivered within 30 days from date of the incident complained about. A grievance form is available for this purpose. The clinical director will investigate the facts and will respond to the client in writing within ten days after the date of receiving the client's request for review.
- If the client is not satisfied with the response from the clinical director, or if the client does not receive a response from the clinical
  director within 10 days, the client may request review by the grievance panel. The client will sign a release of information in order for the
  grievance panel to review and give a response.
The grievance panel is composed of the Board of Directors of JWFC. This request must be made in writing and must be delivered to the Grievance panel of Jordan West Family Counseling within ten days of the date the client received or should have received the Clinical Director's response.

The Grievance Panel will review the grievance, the facts (including records Jordan West Family Counseling), and the relief sought. The grievance panel may but is not required to hold a meeting. If a meeting is held, the client must appear personally and not by a representative (if under age of 18 a parent or guardian may be representative for client).

The grievance panel will respond to the client no later than 90 days after the President receives the request for review. A member of the grievance panel will inform the client by letter the panel's findings and final decision
The undersigned has received the Client Rights and Grievance Policy of Jordan West Family Counseling*

Clear

Patient Financial and Fee Agreement
Your insurance will be billed standard rates based upon the CPT (current procedural terminology) code. You will be responsible for co-pays, co-insurance, late cancelation, missed appointment fees or deductibles as directed by your insurance company at the time of service.

An appointment is a reservation for time with a counselor. Out of courtesy and respect for your counselor please contact Jordan West Family Counseling if you need to cancel an appointment. If an appointment is missed, without notifying Jordan West Family Counseling, a fee of $50.00 will be assessed. If an appointment is cancelled less than 24 hour prior to the appointment a fee of $50.00 will be assessed.

Due to insurance carriers’ tardiness in regards to service claims submitted by providers, please read the following information:
- If your insurance company does not respond in a timely fashion a “Statement” will be released to you. Upon receipt of the “Statement” we suggest that you contact your insurance carrier and request that they process your claim.
- Should you receive any correspondence from your insurance company in regards to your services in this office, you must respond to that correspondence immediately, in order to have the claim processed and paid.
- Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay a fixed allowance for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance at the time of service.
- Jordan West Family Counseling will only bill the Primary Insurance. You will need to bill your Secondary Insurance. Documentation can be provided if it is required. You will be required to pay any co-payment or co-insurance at the time of service. Secondary insurance is not a substitute for co-payments/co-insurance.
Patient’s or authorized person’s signature: I authorize the release of any medical, behavioral health or other information necessary to process my insurance claim.

Insured’s or authorized person’s signature: I authorize payment of medical, behavioral health benefits to the provider for services. I fully understand that, regardless of insurance coverage, I am legally responsible for all fees due. I further understand Jordan West Family Counseling’s missed appointment and late cancellation policy

Patient’s authorized person’s signature: I acknowledge if an appointment is cancelled less than 24 hours prior to the appointment or the appointment is missed a fee $50.00 will be assessed.
Relationship to Patient*
Other Relationship to Patient
Date

MonthDayYear
Date
Patient Name*
Authorized Person
Signature*

Clear
Returned checks will be assessed a $30.00 fee. Please note that unless your appointment is cancelled with a 24hour notice, latecancellation fees will apply. Delinquent accounts are subject to referral to collection agencies.If your account is referred to a collection agency the balance will be charged 35%collection fee. Interest will be assessed at a rate of 1% per annumwill apply for balances over 60 days old Any questions regarding financial issues may be directed to the Office Manager.

Release of Confidential Mental Health Information
Client Name*

First NameInitialLast Name
Social Security Number*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Disclosure of Mental Health Information: Your mental health information and communication of that information is essential to your treatment. We prefer to speak directly with each patient but we understand that other individuals of family members may have knowledge of and be assisting in your treatment and progress. Please, list the individual(s) who we are authorized to discuss your treatment/progress with. (NOTE: We cannot discuss your treatment/progress with others, including parents, spouse, other family members, caseworkers, attorney general, Guardian Ad Litem, Judge, or court clerks unless they are listed below.)
Authorized person 1

Name of the personRelationship to Patient
Authorized person 2

Name of the personRelationship to Patient
Confidential Communication: Communication between Jordan West Family Counseling and you, the client is critical to your well-being. Please list the phone number(s) where we can reach you, your parent(s) or guardian.
Contact Information 1

Name of PersonPhone NumberRelationship to Patient
Contact Information 2

Name of PersonPhone NumberRelationship to Patient
Contact Information 3

Name of PersonPhone NumberRelationship to Patient
Permissions: Children over the age of 12 will be given consent for a counselor / Jordan West Family Counseling to communicate with parent(s) regarding their progress. In cases of an "in custody" client, permission will be given to communicate with foster parent(s), caseworker(s), Guardian Ad Litem, Attorney General or Judge. In addition, clients who are court referred into treatment will give consent to communicate with probation officers, Judge(s) and court clerks in order to send updates, treatment progress, treatment summaries, and treatment termination.
Relationship to Patient*
Other Relationship to Patient
Date

MonthDayYear
Date
Signature: I hereby authorize the use or disclosure of my personal mental health information as described above . If patient is under the age of 18 a parent or guardian may sign that consent to disclose information.*

First NameInitialLast Name
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Note: This restriction applies only to mental health treatment provided by Jordan West Family Counseling. Other providers involved in your treatment may require you to complete a separate request for restriction. Either you, or Jordan West Family Counseling to may terminate this restriction by completing the following.
This agreement is terminated as of
Patient Name
Signature

Clear
Relationship to Patient*
Other Relationship to Patient
Date

MonthDayYear
Date

Appointment Reminders
Jordan West Family Counseling utilizes an auto reminder tool to improve the service we offer to you, the customer. This service allows Jordan West Family Counseling to communicate electronically with mobile devices (cellular phones), landline phones and e-mail accounts.

Despite this being a service offered to you we still put you in ‘the driver’s seat’, by enabling you to start and stop any further messages anytime you want. This service requires no purchase or fee to participate in the service, standard messaging and data fees may apply. Check your mobile plan for more details.

I agree to participate in this messaging service to have voice calls, text message or e-mail reminders sent, which relieves Jordan West Family Counseling of confidentially liability due to HIPPA compliance issues as you, the patient, are choosing the source of contact.

It is our belief that only you will be the person reading your email address. I understand that other members of my family may access messages left on my e-mail address. By signing this form, I agree to relieve Jordan West Family Counseling of any liability for this contact.

Your reminder call will come around 6:00 pm and no later than 8:00 pm the day prior to your appointment. If you need to cancel your appointment, please, contact Jordan West Family Counseling office 24 hours in advance to avoid a late cancellation or no show fee of $50.00.

The message that may be delivered is as follows: “John/Mary this important reminder is to let you know it is time for your appointment with (name of therapist)”.
Please indicate only one method of call reminders that you would prefer.*

Voice Phone CallText Message (SMS)Email messageNo Reminder Calls / Messages. Please ask your counselor for a reminder card for your next appointment.
Phone Number (no text message)
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email Address:
example@example.com
Please initial that you understand you will NOT receive a reminder for your future appointments:

Clear
Patient Name*

First NameInitialLast Name
Patient or Guardian Signature*

Clear
Date

MonthDayYear
Date

Notice of Privacy Practices For Protected Health Information
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This office is required to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices. This office will not use or disclose your health information except as described in this Notice. If you consent, the office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, medical history, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes are:
- A provider or assistant obtains treatment information about you and records it in a health record.
- During the course of your treatment, the provider determines he/she will need to consult with another specialist in the area. He/she will obtain your signed authorization before sharing information with such specialists to obtain his/her input.
- Referral information may be forwarded to Diagnostic Testing Labs for further treatment or testing where the provider will want results of such treatment or testing reported bock to him/her.
- If the provider is a specialist, your health information and progress may be reported back to your primary care provider or referring provider, upon receipt of your written authorization.
Example of use of your health information for payment purposes:
- We submit requests health information from us regarding medical care given. We will provide information to them about you and the care given. For example, a bill sent to your health insurance company may include information that identifies your diagnosis, and the procedures and supplies used.
Example of use of your health information for health care operations:
- We obtain services from our insurers or other business associates (an individual or entity under contract with us to perform or assist us in a function or activity that necessitates the use or disclosure of health information) such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical transcription, medical review, legal services, and insurance. We will share health information about you with our insurers or other business associates as necessary to obtain these services. We require our insurers and other business associates to protect the confidentiality of your health information.
YOUR HEALTH INFORMATION RIGHTS

The health and billing records we maintain are the physical property of the treating provider. The information in it, however, belongs to you. You have the right to:
- Request a restriction on certain uses and disclousres of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted as required by law:
- Obtain a paper copy of the Notice of Privacy Practices for Protected Health information ("Notice") by making a request at our office.
- Request that you be allowed to inspect and copy your billing record - you may exercise this right by delivering the request in writing to our office;
- Obtain an accounting of disclosures of your health information as required to be maintained by law, upon request. An accounting will not include internal uses of information for treatment, payment, operations, or disclosures made to you; and
- Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.
You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and health care operations purposes.

Notice of Privacy Practices For Protected Health Information, Continued
OUR RESPONSIBILITIES

This office is required to:
- Maintain the privacy of your health information required by law;
- Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
- Abide by the terms of this Notice;
- Notify you if we cannot accommodate a requested restriction or request; and
- Accommodate your reasonable requests regarding methods to communicate health information with you. We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy or our "Notice" or by visiting our office and picking up a copy.
TO REQUEST INFORMATION OR FILE A COMPLAINT

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Betty Owen at 801-566-0749. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Betty Owen. You may also file a complaint by mailing it to the Department of Health and Human Services. We cannot, and will not, require you to waive the right to file a complaint with the Department of Health and Human Services (HHS) as a condition of receiving treatment from the office. Likewise, we cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.
OTHER DISCLOSURES AND USES

Notification of Family/Friends: Our office does NOT disclose protected health information or any other information to family members.

Appointment Reminders and Treatment Information: We may contact you and/or leave a message on your telephone answering machine to provide you with appointment reminders, lab results, prescription information, or billing information.

Workers Compensation: If you are seeking compensation through Workers Compensation, we may disclose your health information to the extent necessary to comply with laws relating to Workers Compensation.

Abuse, Neglect & Domestic Violence: We may disclose your health information to public authorities as allowed by law to report abuse, neglect, or domestic violence.

Law Enforcement: We may disclose your health information for law enforcement purposes as required by law, such as when required by a court order; for identification of a victim of a crime if certain protective requirements are met; to report a crime in emergencies; and other appropriate situations as permitted by law.

Judicial/Administrative Proceedings: We may disclose your health information in the course of any judicial or administrative proceeding as allowed or required by law or as directed by a proper court order or in response to a subpoena, discovery request or other lawful process if certain specific requirements are met. To avert a serious threat to health or safely, we may disclose your health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

Other Uses: Any other uses and disclosures of your health information besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.

HIPAA requires that we make the Notice of Privacy Practices available to you. We ask that you sign and date this form. When you sign and date this form you are agreeing that you were given a copy of the Notice of Privacy Practices. You are not agreeing to what the notice says.
Relationship to Patient*
Other Relationship to Patient
Date

MonthDayYear
Date
The undersigned has received the Privacy Policy of Jordan West Family Counseling*

First NameInitialLast
Signature*

Clear

JORDAN WEST FAMILY COUNSELING SERVICE AGREEMENT

PATIENT INFORMATION

RESPONSIBLE PARTY

PRIMARY INSURANCE

Employee Assistance Program (EAP)

Other Payment Source

ASSIGNMENT AND RELEASE

Notice of Client Rights and Grievance Policy

Patient Financial and Fee Agreement

Release of Confidential Mental Health Information

Appointment Reminders

Notice of Privacy Practices For Protected Health Information

Notice of Privacy Practices For Protected Health Information, Continued

Mental Health Family History

Please answer these questions to the best of your ability

Problem Inventory