Intake Form

  1. Notice of Privacy Practices 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 

MY PLEDGE REGARDING HEALTH INFORMATION: We understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information that we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to: Make sure that protected health information (“PHI”) that identifies you is kept private. Give you this notice of our legal duties and privacy practices with respect to health information. Follow the terms of the notice that is currently in effect. We can change the terms of this Notice, and such changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website. 

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s Personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We may also disclose your protected health information for the treatment activities of any healthcare provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed healthcare provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition. Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other healthcare providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between healthcare providers and referrals of a patient for health care from one health care provider to another. Lawsuits and Disputes: If you are involved in a lawsuit, We may disclose health information in response to a court or administrative order. We may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. 

CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION: Psychotherapy Notes. We do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: a. for our use in treating you. b. For our use in training or supervising 

mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c. For our use in defending ourselves in legal proceedings instituted by you. d. For use by the Secretary of Health and Human Services to investigate our compliance with HIPAA. e. Required by law and the use or disclosure is limited to the Requirements of such law. Required bylaw for certain health oversight activities pertaining to the originator of the psychotherapy notes. Required by a coroner who is performing duties authorized bylaw. h. Required to help avert a serious threat to the health and safety of others. Marketing Purposes. As a psychotherapist, we will not use or disclose your PHI for marketing purposes. Sale of PHI. As a psychotherapist, we will not sell your PHI in the regular course of our business. 

CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, We can use and disclose your PHI without your Authorization for the following reasons: When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety. For health oversight activities, including audits and investigations. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so. For law enforcement purposes, including reporting crimes occurring on my premises. To coroners or medical examiners, when such individuals are performing duties authorized bylaw. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions. For workers’ compensation purposes. Although our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws. Appointment reminders and health related benefits or services may use and disclose your PHI to contact you to remind you that you have an appointment with me. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that We offer. 

CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT. Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations. 

YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI: The Right to Request Limits on Uses and Disclosures of your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we may say “no” if we believe it would affect your health care. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of- pocket in full. The Right to Choose How We Send PHI to You. You have the right to ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and we will agree to all reasonable requests. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that we have about you. We will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and we may charge a reasonable, cost based fee for doing so. 

The Right to Get a List of the Disclosures We Have Made: You have the right to request a list of instances in which we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we will give you will include disclosures made in the last six years unless you request a shorter time. We 

will provide the list to you at no charge, but if you make more than one request in the same year, we will charge you a reasonable cost based fee for each additional request. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that We correct the existing information or add the missing information. We may say “no” to your request, but we will tell you why in writing within 60 days of receiving your request. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by-mail. And, even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it. EFFECTIVE DATE OF THIS NOTICE This notice went into effect on September 20, 2013 Acknowledgement of Receipt of Privacy Notice under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices. 

  1. Informed Consent for Psychotherapy 

Informed Consent 

Welcome to Transformative Growth Counseling. This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us. 

PSYCHOLOGICAL SERVICES 

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you bring forward. There are many different methods that maybe use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. This is also inclusive of couples and families. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. Our first few sessions will involve an evaluation of your needs (or the needs of the couple/family/child) and history. By the end of the initial evaluation, will be able to offer you some first impressions of what our work will include. You should evaluate this information along with your own opinions of whether you feel comfortable working with us. If you have questions about our procedures, we should discuss them whenever they arise. If your doubts persist, will be happy to help you set up a meeting with another mental health professional for a second opinion. 

Treatment Sessions 

Sessions are 50 minutes long for individuals, most couples, and youth. We normally conduct an evaluation-style interview that will last 2-3 sessions. During this time, we can both decide if we are the best person to provide the services you need in order to meet your treatment goals. If psychotherapy continues, we will usually schedule one 50-minute session (one “appointment hour” equals 50 minutes’ duration) per week at a time we agree on, although some sessions maybe longer, as needed or as agreed upon by both parties. Children under the age of 12, typically have shorter sessions due to the immaturity of the child. This varies by age; the typical 3 year old may only be able to participate in 25-30 minutes of therapy, where as an 8 year old may have no problem going on for 45-50 minutes. Once an appointment is scheduled, you will be expected to pay for the session, unless you provide 24 hours [1 DAY] advance notice of cancellation. Failure to provide 24 hours-notice will result in a $50 missed appointment fee. An appointment cannot be rescheduled until this fee is paid; insurance doesn’t cover that fee. 

Payments & Insurance: 

You will be expected to pay for each session on the same day services are provided. If you have insurance, we will file a claim on your behalf. If your account has a balance due, the therapist reserves the right to cancel your appointment until your account is paid in full. If your account has not been paid for more than 30 days, and arrangements for payment have not been agreed upon, Transformative Growth Counseling reserves the right to terminate treatment and refer you to other providers. We may use the option of using legal means to secure the payment from you for the balance due, once it is more than 30 days past due. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary to collect payment from you, its costs will be included in the claim.] In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. 

Insurance – Only applicable if using insurance for services. 

INSURANCE REIMBURSEMENT: In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. TGC will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of agreed fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. We feel it is necessary to clear confusion, we will be willing to call the companion on your behalf. Due to the rising costs of healthcare, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to Short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. [Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your psychotherapy.] You should also be aware that most insurance companies require you to **allow* us to provide them with a clinical diagnosis. Sometimes we have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, We have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it. We understand that using your insurance we are aware that such information may be provided to them. We will try to keep that information limited to the minimum necessary. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above [unless prohibited by contract]. 

Professional Records 

The laws and standards of our profession require that we keep treatment records. You may request to receive a copy of medical records (attendance, treatment plan). We do not release psychotherapy notes. The law does not require us to release notes directly to you or others, even at your request, because these are professional records – they can be misinterpreted and/or upsetting to untrained reader, including yourself. For example, we do not release records directly to attorneys, without a court order because they are not trained in reading clinical notes – just as we as counselors, are not trained to interpret their legal writings. By signing this you are agreeing to us keeping your files secure. You consent to your therapist recording sessions as a form of notes as needed. Your identification is always completely confidential. Patients will be charged a professional fee of $125 per hour (because this is not therapy but document/paperwork) for anytime spent in preparing information or medical record requests, and when in reviewing them in our presence. 

MINORS 

If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records if you are at risk of self-harm or harming others. It is our policy to request an agreement from parents that they agree to give up access to your records. If they agree, we will provide them only with general information about our work together, unless we feel there is a high risk that you will seriously harm yourself or someone else. In this case, we 

will notify them of the concern. We will also provide them with a summary of your treatment when it is complete. Before giving them any information, we will discuss the matter with you, if possible, and do our best to handle any objections you may have with what we am prepared to discuss. We strive to have conversations about minors, with minors present. 

Interns/Practicum/Residents in Psychology In addition to providing counseling, TGC also believes in providing learning opportunities for future and current, therapists and psychologists. We refer to our clinical training as “practicum” or “internship” in the field of Psychology and Social Work. Much like a medical residency, interns/practicum counselors have already completed many years of schooling and many hours of training, (including a bachelor’s degree) before entering the field at the Master’s or PhD level. What this means for all clients: From time to time, your therapist may ask if it’s ok to bring back an intern to observe or to record sessions, with your permission. Observation or recording will not affect your confidentiality; all people at TGC are bound by confidentiality rules. In addition, you are NOT obligated to say yes to an additional observer or session recordings. You can refuse before, and change your mind at any time during the session with your therapist. If you are working with someone on practicum as your counselor, they are supervised by either Cassie Whitfield, LCW, Director of Student Training, Or Jessica Norman, LCPC, Clinical Director, as well as the Clinical Director at their perspective university. The therapeutic work you do with your counselor will be reviewed with their clinical supervisor – this benefits you as there two highly skilled professionals working together to bring you the best care possible. Confidentiality 

CONFIDENTIALITY: In general, the privacy of all communications between a patient and therapist, is protected by law, and we can only release information about our work to others with your written permission. But there are a few exceptions: In most legal proceedings, you have the right to prevent us from providing any information about your treatment to others, including attorneys. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order our testimony if he/she determines that the issues demand it. There are some situations in which we are legally obligated to take action to protect others from harm, even if have to reveal some information about a patient’s treatment. For example, if we believe that a child [elderly person, or disabled person] is being abused, I must file a report with the appropriate state agency. If we believe that a patient is threatening serious bodily harm to another, we are required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself or is under the influence of alcohol or drugs, to the point the counselor feels in their professional judgment, would put people in harm’s way, we may be obligated to seek help from the police, or obtain hospitalization for you, or to contact family members or others who can help provide protection. These situations have rarely occurred in our practice. If similar situation occurs, we will make every effort to fully discuss it with you before taking any action. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our first meeting. We will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and we are not an attorney. If we see each other accidentally outside of the therapy office, we will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us, and we do not wish to jeopardize your privacy. However, if you acknowledge us first, we will be more than happy to speak briefly with you, but we feel it is most appropriate not to engage in any lengthy discussions in public or outside of the therapy office. 

Contacting Your Therapist 

Clinical staff at TGC are usually not immediately available by telephone. We recommend you contact your therapist directly by phone or email regarding appointments, scheduling and treatment. While we are conducting counseling sessions throughout the day, we will not answer the phone when we are with another client, just as we won’t answer the phone while you are working together. We do take emails 24/7, and will reply to you regardless of phone or email contact, within 24 hours except weekends and holidays. Saturday and Sunday email will be returned on Monday at the latest. Outside topics related to scheduling and appointments, therapists are NOT available by text or other SMS applications; clinical or 

private matters put in texts/SMS will not be answered. When a therapist is unavailable, the telephone is answered by voicemail which is confidential and secured. We will make every effort to return your call within 24 hours of when you made it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. If you are unable to reach us and feel that you can’t wait for us to return your call, contact your family physician or go to the nearest emergency room. If we will be unavailable for an extended time, we will provide you with notice of this, and the name of colleague or resource to contact in case of crisis or offer you online therapy in the meantime (e.g. travel). 

Social Media 

Counselor and Staff personal facebook and other social media accounts are forbidden from “friending” or following clients until 2 years after treatment ends with your therapist. However, you can follow and friend TGC on Facebook at www.facebook.com/TransformativeGrowth 

TERMINATION: Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. We may terminate treatment after appropriate discussion with you, and may offer a termination process if it is determined that the psychotherapy is not being effectively used or if you are in default on payment. We will not terminate the therapeutic relationship without first discussing the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, we will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source. Should you fail to schedule an appointment for three consecutive weeks, unless other notice or arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.

4. Payment & Insurance 

If you did not provide this to our front desk yet, please enter your insurance and payment information. 

Important information about your insurance: If you have any questions or issues about your billing, please contact Dr. Jessica Norman, Clinical Director. We bill as a group; not as individual providers. We may show up in a variety of ways for services, such as: Transformative Growth Counseling; TGC. At times, supervising provider names listed (Jessica Norman and Cassie Whitfield). Because we are a nonprofit, what your insurance EOB reflects may be more than you actually actually owe. Please contact us if you have questions; we will work with you, to ensure claims are not rejected by insurance. 

Your information is confidentially and securely stored in accordance to HIPPA. However, If you’d rather give your payment information in an alternative format you can call intake at: 630-423-6010, or use this portal to enter it in the client demographic section. 

Payment: Please enter the payment information you would like to use for copay, deductible or session fees. Payment is due at time of services. If your card is declined or not valid, you may have more than one charge in a week, when your information is updated or your card is not declined.

  1. Insurance Billing 

Insurance Basics – What You Need to Know: Your therapist will conduct a variety of services while working with you, both during and in between sessions. This included conducting and writing assessments and treatment plans, clinical evaluations, preparing and giving psychometric testing and determining results; preparation session documents and reports, last minute/crisis appointments, and following up throughout the week, where indicated. Typically speaking, insurance companies only require your copay when you have therapy sessions in person or by phone. Other services, such as testing, clinical documentation, etc, typically have no copay due by you. If you have co-insurance, you may have portion of those services due. If in the process of our work together we discover gaps in coverage or additional co- insurances due by you, this will be discussed with you prior to ancillary services being rendered. If you have questions about this, please contact our office. Therapists do not handle insurance or billing questions. Contact us at: 630-423- 6010. 

Insurance Benefits are only a quote 

Insurance: Every plan is truly different. However, in an effort to help alleviate financial stress, we need your help! First, it is every consumers duty to know their own insurance plan and coverage, before seeking treatment. As providers, we will obtain a quote from your insurance carrier, but it is ONLY a quote. Secondly, If your claim report comes back different than what you or our provider system quoted to us, or you’ve lost coverage, have not met your deductible or have services that are not covered, you will be responsible for the amount not covered by insurance. Deductibles: It is the consumer’s duty to track their deductible and it’s progress. You will need to notify our office when you’ve hit your deductible, if any, so we can adjust your amount to copay/co-insurance, if any. 

  1. Cancellations 

Regarding Appointments and Cancellations: 

If you would like to cancel or reschedule your appointment, we have three easy ways to do this: 1. Contact your therapist directly by phone or email. 2. Call our mainline & leave a voice message. 3. Reply 2 to your text reminder. All other replies (besides 1 to confirm, or 2 to cancel) are not received or read. Please book your appointments with careful consideration of when you are available. 

If less than 24 hours notice is given when cancelling an appointment, a $50 fee will be charged. The fee must be paid to make another appointment.