The Family Wellness Center, PLLC
1035 C Director Ct, Greenville NC 27858
The Family Wellness Center
Child Behavioral and Family Therapy
Child-Adult ADHD Evaluation and Treatment
Couple and Marital Therapy
Serving Greenville, Washington, and surrounding areas
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
(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)
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.
End of Forms. Thank you.