Directions for Forms:

1) Please complete Form 1 to the extent you feel comfortable. Your information is kept confidential and helps us prepare for your first session.

2) After reading Forms 2-4, please complete the consent boxes and submit.

3) For questions or concerns, contact Suzanne, our practice manager, at 252-215-9011. She will also contact you prior to your first appointment to assist with insurance benefits as needed.

Form 1

New Client Intake

New Client Intake (Secure and Confidential Submission)

FORM 2

Client Rights To Treatment and PHI

Client Rights to Treatment

• I understand that my involvement in treatment at TFWC is completely voluntary.
• I have a right to receive high-quality service, to be treated with respect and courtesy, and to be served without discrimination.
• I have a right to medical and emergency medical care whenever necessary.
• I understand that I have the right to decline to participant with any intervention at any time, including medication, and I may decline to answer questions at any time. I have a right to discuss my services with staff to identify if it is working, and express questions or complaints if needed. I may also request a change of staff within the agency, and if not available or reasonable, I may ask for an outside referral without retaliation by staff/Agency.
• I understand that I may terminate treatment with my therapist or TFWC at any time without retaliation from Agency/staff.
• I understand that I may file a grievance for misconduct to the local LME (Trillium Health Resources) or licensure board.
• I understand that my information will be kept private and confidential, with exception to legal/ethical obligation to report safety concerns (danger to self or others), order by the court, or subpoena.
• I may have access to my records by written request to the active therapist or doctor.

(In accordance with GS 122C-51, it is the policy of the State to assure basic human rights to each client of a facility. These rights include the right to dignity, privacy, humane care, and freedom from mental and physical abuse, neglect, and exploitation. Each facility shall assure to each client the right to live as normally as possible while receiving care and treatment.

It is further the policy of this State that each client who is admitted to and is receiving services from a facility has the right to treatment, including access to medical care and habilitation, regardless of age or degree of mental illness, developmental disabilities, or substance abuse. Each client has the right to an individualized written treatment or habilitation plan setting forth a program to maximize the development or restoration of his capabilities)

Client Rights with Release of Protected Health Information (PHI)

• I understand that signing any consent to release PHI at TFWC is voluntary.
• I understand that I have the right to revoke any authorization at any time by sending written notification to the office address listed at the top of this form.
• I understand that my revocation will not be effective to the extent that action has been taken in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
• I understand that my mental health provider may not condition psychological/psychiatric services upon my signing an authorization unless these services are provided to me for the purpose of creating health information for a third party.
• I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of this information and no longer protected by the HIPPA Privacy Rule. I understand that TFWC is not liable for any third-party disclosure of PHI pursuant to any authorization.
• I understand that the authorization to release PHI does not authorize my mental health provider to discuss my health information or medical care with anyone other than the person/agency specified on my release form.
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Please check boxes below and send to confirm understanding of the rights to treatment and PHI.

Form 3

Appointment Agreement

Cancellations and Missed Appointments

We at The Family Wellness Center, PLLC are committed to providing you with quality services. Your appointment time has been specifically reserved for you. We ask that you notify us if you are unable to keep the scheduled appointment with at least 24-hour notice. When adequate notice is not given it is difficult to fill your designated appointment time. A $75.00 charge is assessed to you for notice under 24-hours, or for failure to show for a scheduled therapist appointment. The fee is required before scheduling further appointments. Services may be discontinued after two consecutive late cancellations or missed appointments.

Please check box below and send to consent to Appointments Agreement.

Form 4

Fee Schedule & Insurance Billing Authorization

Clinician Charges:

Level of Care Evaluation     $ 200.00 (self-pay)

Clinical Assessment            $ 160.00

Therapy Session                 $ 140.00

Crisis Consult                      $ 240.00

Group (60-90 min)               $  40.00

Phone Consult                     $  40.00

Missed Appointment            $  75.00

Court Involvement:

Records Submission            $    60.00 per diem

Subpoena/Appearance        $1200.00 per diem

Insurance Billing Authorization

(*FWC will bill your insurance for you. Please expect a call from the practice manager to review your benefits).

By completing the form below, I understand the charges for services rendered and that insurance authorization for services is my responsibility and required prior to the initial visit, or any unmanaged visits. I agree to be solely responsible for my portion of the financial investment by paying all co-payments or pre-deductible amounts by check or cash prior to each session. The Family Wellness Center will bill my insurance company for the remaining payment of services rendered to me. I understand that The Family Wellness Center has a contracted rate for reimbursement with my insurance company and that I will not be charged for the adjusted amount. I acknowledge that all reimbursements will be paid directly to The Family Wellness Center. If for whatever reason my insurance fails to reimburse The Family Wellness Center for the contracted charges, I am solely responsible for the balance. I understand that it is my responsibility to notify The Family Wellness Center about any changes to my insurance coverage prior to receiving any services.

Please check boxes below and send to consent to Fees and Insurance Billing.