Intake Paperwork Thank you for choosing Family Service Center as a place to receive compassionate support in coping with and navigating life’s challenges. We look forward to working with you to achieve your personal goals. We ask that you complete the enclosed intake packet by providing all requested information and documentation so we are better able to serve you, as well as orient you to FSC policies and procedures. The intake paperwork will be reviewed and collected at your first appointment. If you plan to use insurance to pay for services, please bring a copy of your insurance card. If you would like to apply for a subsidized fee, please bring documentation demonstrating financial need. The following are accepted documents:

1) W-2 or W-9 forms for all adults in the home 2) The household’s recent tax return (i.e., 1040 tax form)

Intake Packet Checklist:

☐ Client Information

☐ History/Background Information

☐ Informed Consent for Psychotherapy

☐ Insurance Declaration

☐ FSC Fee Agreement

☐ Credit Card Authorization

☐ Notice of Privacy Practices Receipt and Acknowledgement Notice

☐ FSC Notice of Privacy

☐ Bring copy of insurance, if needed

☐ Bring copy of documentation demonstrating financial need, if needed

Please contact FSC’s Office Manager, Rachel German, at 847-251-7350 with any questions or concerns.

See back for additional information

Client Information Form

FSC is a not-for-profit 501(c)(3) mental health agency serving the communities of Wilmette, Glenview, Northbrook, and Kenilworth, as well as residents of New Trier and Northfield Townships. In order to ensure that services are affordable to all community members, FSC secures financial support through grant money donated by municipalities and foundations. This funding requires FSC to report combined information about the people it serves. You will help FSC continue to secure this funding by providing the information below. Please note that client privacy is of the utmost importance to FSC. Your information is confidentially maintained and no identifying information will be shared in grant submissions. Name:

Date:

Address:

Street City State Zip code

Township:

☐ New Trier

☐ Northfield

☐ Other

Phone Number 1: Phone Number 2:

For Glenview Residents Only:

☐ Incorporated Glenview Resident

☐ Unincorporated Glenview Resident

☐ Don’t Know

Date of Birth: Gender: ☐ Female

MM/DD/YYYY ☐ Male

☐ Nonbinary

Marital Status: ☐ Single/Never Married Race/Ethnicity: ☐ African American/Black ☐ Married/Partnered ☐ American Indian/Alaska Native ☐ Divorced ☐ Asian ☐ Separated ☐ Hispanic/Latinx ☐ Widowed ☐ White/Non-Hispanic ☐ Native Hawaiian/Pacific

Islander ☐ Biracial/Multiracial

Client Information Form pg. 2

Hospital(s) at which you receive medical care, when needed:

☐ Evanston

☐ Highland Park

☐ Other

☐ Glenbrook ☐ Skokie

Highest Level of Education:

For Adult Clients ☐ High School ☐ Trade School ☐ Jr. College ☐ College ☐ Graduate School

Parent/Guardian #1 ☐ High School ☐ Trade School ☐ Jr. College ☐ College ☐ Graduate School

Parent/Guardian #2 ☐ High School ☐ Trade School ☐ Jr. College ☐ College ☐ Graduate School

Family Income: ☐ Over 180,000 ☐ 90,000 – 99,999 ☐ 45,000 - 49,999 ☐ 150,000 - 179,999 ☐ 80,000 – 89,999 ☐ 40,000 - 44,999 ☐ 130,000 - 149,999 ☐ 70,000 – 79,999 ☐ 35,000 - 39,999 ☐ 110,000 - 129,999 ☐ 60,000 – 69,999 ☐ Below 35,000 ☐ 100,000 - 109,999 ☐ 50,000 - 59,999

Number of family members dependent on income:

Adult Information Form Name:___________________________ Reason for coming today___________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ How long have you had these concerns?_______________________________________________________________ ________________________________________________________________________________________________ What things have you tried to deal with these concerns?__________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Have you had any prior therapy experience? (Please describe length of treatment and frequency of visits) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Are you thinking about hurting yourself or others? ________ Yes ________ No Please check any of the following stresses that apply to you or your family and describe:

Major relocations

__________________________________________________________________________

Job change

_______________________________________________________________________________

Deaths

_________________________________________________________________________________

__

Illnesses

_________________________________________________________________________________

_

Marital/Relational problems

_________________________________________________________________

Someone significant moving out of area

________________________________________________________

Experiencing a traumatic event

_______________________________________________________________

Witnessing a traumatic event

_________________________________________________________________

Physical or sexual abuse or

neglect_____________________________________________________________

Division of Child and Family Services (DCFS) involvement

___________________________________________

Legal Issues

_______________________________________________________________________________

Occupational History: Are you currently employed? Yes/No How long have you worked in this position?____________ Job/Type of work __________________________________________________________________________________ Medical History: Medical conditions/concerns________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Are you taking any medications on an ongoing basis? Yes/No

Name of Medication Dosage Name of prescribing physician

Medical/Psychiatric Hospitalizations: (please describe) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Family history of emotional, behavioral, psychological concerns: (including treatment) ______________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Family history of medical problems: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please indicate if you have had any history of the following problems:

Circle One Ages Describe

Asthma Yes/No

Chronic Ear Infections Yes/No

Headaches Yes/No

Hearing/Ear Problems Yes/No

Loss of Consciousness Yes/No

Nightmares Yes/No

Seizures Yes/No

Sleep Apnea/Snoring Yes/No

Surgeries Yes/No

Tics/Twitching Yes/No

Vision/Eye Problems Yes/No

Alcohol Use/Abuse Yes/No

Illicit Drug Use/Abuse Yes/No

Risky Behaviors Yes/No

Additional Information: Please list some of your personal strengths: (including family and friends) ____________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Informed Consent for Psychotherapy (adult) Page 1 of 3

Informed Consent for Psychotherapy

This document contains important information about FSC’s services and policies. Please read it carefully. Any questions can be addressed with your therapist during your first session.

A General Description of Psychotherapy: Therapy is an individualized and dynamic process focused on supporting clients in achieving personalized goals. The process varies based on a range of factors, including presenting concerns, therapeutic approaches and interventions, extenuating factors, and the therapeutic relationship between the client and therapist. Therapists will regularly communicate with clients about the therapeutic process in a collaborative manner throughout treatment. FSC staff is committed to helping clients resolve identified concerns. Benefits and Risks: Psychotherapy may result in numerous positive outcomes for clients who fully engage in the process, including a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, and increased confidence in using skills to manage stress and resolve specific problems. Despite potential positive outcomes, clients may experience uncomfortable feelings during session(s) due to the nature of discussing unpleasant aspects of life. In general, there are no guarantees as to what a client will experience throughout psychotherapy; therefore, we highly encourage clients to regularly communicate with their therapists about their experiences. Service Expectations (Individual, Couples, or Family Therapy): Therapy sessions are approximately 45 to 60 minutes in length and often occur on a weekly basis. In most cases, clients will schedule a regular day and time to meet with the therapist to establish a routine. Clients are expected to attend sessions on a consistent basis to promote positive change. Clients have the responsibility of actively engaging in the therapeutic process during session, as well as between sessions. Sessions are conducted in-person, as FSC does not provide tele-therapy or phone sessions. Initial sessions will involve an evaluation process in which the therapist gathers information about a range of topics, including background information and presenting concerns, in order to support collaborative treatment planning. During this time, the client and therapist will also engage in discussions to determine the match of the therapist’s approach and expertise with the client’s individual goals and needs. Referrals for other providers better suited to help the client will be discussed, if needed. Clients may request a change in staff, and are encouraged to discuss any questions or concerns about the recommended therapeutic approach and interventions with their therapist. Additionally, clients are able to speak with FSC’s Executive Director regarding concerns. Clients have the right to refuse and/or terminate services at any time, for any reason, and may request contact information for other providers. FSC staff is ethically obligated to terminate services and provide referral sources if they determine that current services are ineffective in meeting clients’ needs. Additionally, FSC may terminate services if clients demonstrate disengagement in the therapeutic process (i.e., inconsistent attendance, resistance to interventions, poor adherence to recommendations, lack of response to outreach calls, etc.).

Informed Consent for Psychotherapy (adult; 1/20) Page 2 of 3

Attendance: FSC highly encourages regular attendance and active participation in sessions in order to best address presenting concerns and achieve established goals. Clients are responsible for providing at least 24-hour notification of cancellation and rescheduling requests. Clients may leave a voicemail directly with their therapist or on FSC’s main number (847-251-7350) at any time, as the voicemail system notes the date and time of the call. Service termination may occur if clients repeatedly cancel sessions and/or do not provide notification prior to missing sessions. FSC recommends that clients communicate with their therapist about scheduling barriers to prevent case closure. Expectations of Clients: Clients have the responsibility to treat FSC staff and other clients with dignity and respect. Clients are also expected to protect the confidentiality of the community members receiving services at FSC. FSC reserves the right to cancel or discontinue a session if a client is suspected to be under the influence of alcohol, marijuana, or illicit substances at the time of the scheduled appointment. Clients are required to establish a safe mode of transportation to leave FSC if they arrive under the influence of alcohol, marijuana, or illicit substances. Fees and Payments: Payment is due at each session. Clients may discuss a sliding scale fee payment option with the office manager and/or therapist. Clients must provide proof of income when utilizing FSC’s sliding scale fee payment option. Clients will sign a fee agreement at the first session. Service termination or suspension may occur if the client does not make payments in a timely manner. Contacting Therapists: FSC therapists are not often immediately available by phone, and they will not answer the phone when with a client. When therapists are unavailable, clients may contact FSC’s main number and/or leave their therapist a voicemail. Therapists frequently monitor voicemail and will respond within 24 business hours. If therapists are unavailable for a prolonged period of time, they will provide clients with the contact information of another FSC staff member providing clinical coverage. Emergencies: FSC does not provide 24-hour or emergency therapy services. Should you or someone close to you require such service, the following referrals are recommended:

- 9-1-1 for emergency assistance - Local hospital emergency department - National Suicide Prevention Lifeline: 1-800-273-8255 - Help Hotline: 472-HELP (4357)

Confidentiality: Client privacy is of the utmost importance to FSC. Client information via communication and records related to services at FSC is confidentially maintained and no information will be released without clients’ written permission, with several exceptions (see below). It is important that clients discuss any questions or concerns regarding confidentiality with their therapist throughout treatment; however, formal legal advice may be needed in circumstances in which the therapist is unable to provide specific clarification or advice beyond their scope of expertise. Limits of confidentiality include:

- Client is believed to be an immediate danger to self or others (i.e., suicide, homicide) - Suspicion of a child, elderly person, or disabled person experiencing past or current abuse

and/or neglect - FSC staff receives a court order from a judge pertaining to legal proceedings - FSC staff credentials require them to receive direct supervision by a licensed FSC staff

member. Under these circumstances, supervisors are responsible for client care; therefore

Informed Consent for Psychotherapy (adult; 1/20) Page 3 of 3

they must have access to the client file and will regularly communicate with the client’s therapist.

On occasion, FSC therapists seek consultation from other professionals to support their provision of services. During consultation, therapists make every effort to avoid revealing identifying client information. Additionally, the consultant is legally and ethically bound to confidentially maintain the information. Legal Proceedings: FSC does not provide clinical services for legal proceedings, including but not limited to forensic evaluations, mediation counseling, parental custody evaluations, employee fitness for duty evaluations, and emotional support animal evaluations. Furthermore, FSC does not conduct evaluations nor provide opinions to determine liability and/or damages pertaining to personal injury legal proceedings. FSC staff will refer clients to obtain these services from other providers, if needed. FSC maintains a policy to actively avoid therapist and/or organizational involvement in any legal proceedings. Specifically, FSC requests that clients and/or clients’ legal representative(s) do not subpoena FSC client records, ask FSC staff to testify, whether in person or by affidavit, or ask FSC staff to provide letters or documentation expressing opinion pertaining to the legal proceedings. FSC staff do not render opinions within the context of legal proceedings. Although FSC maintains a policy to actively avoid involvement in any legal proceedings, a judge may require a therapist’s testimony and/or FSC records via court order. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, the therapist will provide information as needed, if appropriate consent for release of information documents are signed or a court order is provided. If the therapist is required to testify, the therapist will maintain their role as a fact witness (e.g., treatment provider) and will not provide opinions about matters outside of that role. If the client is involved in legal proceedings that require FSC staff participation, the client is responsible to pay FSC for professional time spent in relation to the legal matter at a rate of $185 per hour. Time spent may include, but not limited to, reviewing records, preparing reports, traveling, testifying, being in attendance, and other case related costs. Client/Responsible Party Acknowledgement and Acceptance of Terms: I understand that this agreement is valid during the time that I am participating in services with FSC. I have read, understand, and agree with this document’s content and have been offered a copy of the Informed Consent for Psychotherapy document. I acknowledge that I have had an opportunity to have my questions answered prior to signing this consent and participating in services. I am aware that I can terminate services at any time.

Signature of Client Date of Signature

Signature of Staff Member Date of Signature

August 2019 version

Notice of Privacy Practices Receipt and Acknowledgment of Notice

Client Name:

Date of Birth:

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Family Service Center's Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Dr. Renee Dominguez, FSC Privacy Officer, at (847)251-7350.

Signature of Client (age 12 and older) Date of Signature

Signature of Legal Guardian or Personal Representative Date of Signature

Relationship to Client

Signature of Staff Member Date of Signature

Insurance Declaration Form

Choosing to bill counseling sessions through your insurance carrier is an important decision you must

make. According to federal regulations, you may choose to pay out-of-pocket and NOT bill through

your insurance policy. Clients who choose to pay out-of-pocket are called, Self-Pay Clients. Should

this be your preference, FSC would NOT have the authorization to share your records with your

insurance company. The decision you make at the outset of services may be reversed at any time by

completing a new form and updating your file. Please note that the rates you pay for services as a

Self-Pay Client may be higher than the rates you would pay if FSC is an in network provider with

your insurance company.

I choose to be a “Self-Pay Client” at FSC. I will pay for sessions, out-of-pocket,

with cash, check, or credit card, in accordance with my signed contract for services and fee

agreement. As per my signed FSC Fee Agreement, if my FSC clinician is paneled with my

insurance company, and I elect to be a “Self-Pay Client,” I understand that I will not qualify to

receive a subsidized fee. I do not authorize FSC to share my private information with my

insurance company.

I would like to seek payment for services through my insurance company. I will be

responsible for any co-pays, co-insurance, deductible payments, or any portion of the

session fees not covered by my plan. I also understand that my FSC therapist will provide

my insurance with diagnostic information about my mental health. Diagnoses are technical

terms that describe mental health issues in terms of symptoms, severity, and duration.

I understand that if FSC is “In Network” with my company, my rates may be discounted

according to their contract with my insurance company. I understand that if FSC is “Out of

Network” with my insurance company, I will be responsible for payment to FSC and FSC will

provide me with a bill that I can submit to my insurance company so I can explore the option of

being reimbursed through my insurance company.

Signature of Client (age 12 and older) Date of Signature

Signature of Legal Guardian or Personal Representative Date of Signature

Signature of Staff Member Date of Signature

Family Service Center Fee Agreement Family Service Center Fee Policies: The fee for a therapy session at Family Service Center is $185.00. Support from local villages, townships, community organizations, and private donors, enables FSC to subsidize the fee when financial need is adequately demonstrated. Financial need can be demonstrated by providing the most recent W-2 form, pay stubs for all adults in the household, and/or by the most recent tax return. Fees are assigned on a subsidized scale based upon income and family size. Subsidized fees will be routinely reviewed (i.e., at least twice annually) and may be adjusted upwards or downwards at any time if financial circumstances change. If you have an insurance plan that FSC accepts, the expectation is that you will utilize your insurance. If you do not use your insurance, you are expected to pay the full fee (i.e., you will not qualify for the subsidized scale fee). FSC will charge your subsidized scale fee until your deductible is met. FSC will enlist its billing service, Psyquel, to verify your benefits. Verification of these benefits is not a guarantee of payment from the insurance company, but will be utilized to gauge your portion of the cost of service. If insurance does not ultimately cover the services provided, you will be responsible for payment of services. Psyquel will bill your insurance company, and your insurance company will pay Family Service Center directly. Please notify FSC immediately if there are any changes to your insurance coverage. Payments are due at the beginning of each session. Payments may be made by cash, check, or credit card. Any checks returned to FSC are subject to an additional fee of up to $25.00 to cover the bank fee that we incur. It is FSC’s practice to charge clients for professional services provided by their therapists outside of session time that is requested by you including, but not limited to, the following: report writing, telephone conversations, collaboration with other care providers, school meetings, etc. These services will be billed on a prorated basis in 15 minute increments. Appointments, Cancellation, and Termination of Services: Therapy sessions are normally 45-55 minutes in length. Consistency in keeping appointments is important to the therapy process. You are responsible for notifying the agency and/or your therapist 24 hours in advance if you will not attend a scheduled appointment. Failure to provide notification will result in a Missed Session Fee. The Missed Session Fee is equivalent to the fee assigned on the subsidized scale, independent of insurance coverage, co-pay, or co-insurance. It is important to note that insurance companies do not provide reimbursement for missed sessions. Clients who have an outstanding balance exceeding twice their fee cannot be scheduled for additional sessions until the account is paid in full or a payment plan is developed. Failure to make payments in accordance with the agreed upon plan can result in the termination of services.

I/We have read, understand, and agree to the above information.

Name of Responsible Party

Relationship to Client, if under age 18

Signature of Responsible Party Date of Signature

Signature of Staff Member Date of Signature

Subsidized Fee: Expected Copay:

Credit Card Authorization Form

Card Holder’s Name:

Print exactly as it appears on the card

Client’s Name:

Provide only if different from card holder

Card Type: ☐ M/C ☐ Visa ☐ Amex ☐ Discover

Card Number:

Expiration Date: / CVV Code:

Billing Address:

Street

City State Zip code

Card Holder’s Phone Number:

I authorize the purchase of service from Family Service Center using this credit card authorization form. This credit card information will remain on file in a protected and secured space for utilization of payment. I agree that I will indemnify and hold Family Service Center harmless against any liability pursuant to this authorization. I understand that my signature on this form will serve as an authorized signature. Lastly, I authorize Family Service Center to utilize this credit card to pay any outstanding balance on my account.

Signature of Card Holder Date of Signature