Client Intake Form

Please complete all 8 forms.

    • 1

      Patient Information

    • 2

      Physician & Referral Information

    • 3

      Responsible Party (Guarantor) Information

    • 4

      Emergency Contact Information

    • 5

      Obtain/Release of Information

    • 6

      Informed Consent and Agreement for Counseling

    • 7

      Notice of Privacy Practice

    • 8

      Telebehavioral Health Informed Consent

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    Patient Information

    Client Intake Form

    PATIENT INFORMATION

    Please select a therapist:

    I am/We are interested in:

    Patient Status:

    First Name:

    Last Name:

    Nickname/AKA:

    Email:

    Date of Birth:

    Phone – Home:

    Phone – Cell:

    Phone – Work:

    Gender:

    Relationship Status:

    Street Address:

    Address Line 2 (optional):

    City:

    State:

    Zip Code:

    Race (optional):

    Language (other than English):

    Employment Status:

    Employer:

    Employer Phone:

    PHYSICIAN REFERRAL INFORMATION


    How did you hear about us?
    BillboardEmployerFamily MemberFriendHealth Fair EventInsuranceMagazineMailNewsPhysicianRadioTelevisionWebsiteYellow PagesOther

    RESPONSIBLE PARTY (GUARANTOR) INFORMATION

    Relationship to Patient (if self, skip to next page):




    Address:





    Phone Number:




    Employment Status:

    Active Duty MilitaryChildDisabledEmployed Full-TimeEmployed Part-TimeHomemakerNot EmployedRetiredSelf EmployedStudent Full-TimeStudent Part-TimeOther


    EMERGENCY CONTACT INFORMATION


    Phone Number:



    Address:





    AUTHORIZATION TO OBTAIN/RELEASE INFORMATION

    This form when completed and signed by you authorizes Penllyn Counseling Associates LLC to obtain/release protected information from the identified party designated.

    I authorize and give my permission for Penllyn Counseling Associates LLC to obtain/release information personal, medical and or psychotherapy notes.
    Check those that apply:
    PersonalMedicalPsychotherapy

    This authorization shall remain in effect until I am no longer a client of Penllyn Counseling Associates LLC.

    I have the right to revoke this authorization, in writing, at any time by sending such written notification to Penllyn Counseling Associates LLC. However, my revocation will not be effective to the extent that Penllyn Counseling Associates LLC has taken action in reliance on the authorization.

    I understand that my sessions with Penllyn Counseling Associates LLC are not contingent upon my agreement to sign this authorization.

    I understand that information used for Penllyn Counseling Associates LLC to the authorization may be subject to re-disclosure by the recipient of my information and no longer protected by the HIPAA Privacy Act.


    I have been informed that I may revoke this authorization (except to the extent that has been taken in reliance thereon) by written or oral communication to Penllyn Counseling Associates LLC. I understand that this authorization is voluntary. I have also been informed of my right, subject to Section 7100.11.3 of the regulations promulgated under the Mental Health Procedures Act of 1976, to inspect the information to be obtained. Furthermore, I consent to the disclosure of information, if any, relation to my drug or alcohol abuse or dependency provided that disclosure is limited, pursuant to Section 8 of the Pennsylvania Drug and Alcohol Abuse Control Act of 1972, to 1) medical personnel for the purpose of diagnosis and treatment, and 22) government or other officials exclusively for the purpose of obtaining benefits due me as a result of my drug or alcohol abuse or dependency. I certify that this form has been fully explained to me and that I understand it. I know I may have a copy of this authorization.

    Signature of Client


    Electronic Signature:


    Penllyn Counseling Associates LLC

    589 Skippack Pike, Suite 303, Blue Bell, PA 19422

    NPI #1952047987

    Informed Consent Form

    Penllyn Counseling Associates (PCA) welcomes you!

    Introduction

    This document outlines the important details regarding the psychological services we offer in our private practice. Please read this information carefully and ask any questions you may have before signing below. By signing this form, you acknowledge that you have read and understood this information and that you have had all your questions answered. If you elect to use your insurance benefits, as described in the section below called Insurance Reimbursement, then by signing this form you are also giving me and PCA permission to share your information with your insurance company.


    The Pennsylvania and New Jersey license numbers of the providers within Penllyn Counseling Associates:

    • Judith Kurtis LCSW - PA CW018543, NJ 44SC05555400

    • Rachael Rosenfeld LCSW - PA CW019016, NJ 44SC06242700


    Services Offered

    • PCA provides individual therapy for adults (ages 18+) and children (under 18) experiencing a variety of challenges, including anxiety, depression, relationship issues, communication breakdown.

    • PCA utilizes cognitive-behavioral therapy, mindfulness-based therapies, solution- oriented therapy, and psychodynamic therapy.

    • PCA does not offer, e.g., medication management, court-ordered evaluations, return to work letters, animal support letters.


    Evaluation

    • The first few sessions will involve an evaluation of your needs. This evaluation typically lasts 1-2 sessions.

    • Following initial evaluation, we will discuss if the therapist is the right therapist for you and will offer a treatment plan.

    • The therapist will refer you to another therapist if someone else is better suited.


    Psychotherapy

    • Psychotherapy is a collaborative effort that requires active participation from you.

    • The approach used will vary depending on your needs and it may involve discussing uncomfortable topics.

    • There are no guarantees about the outcome of therapy, but studies have shown psychotherapy to be helpful to those who undergo it.


    Benefits and Risks of Therapy

    • Therapy requires a significant investment of time, money, and energy. Therapy can be a helpful and effective way to address emotional and behavioral difficulties.

    • Potential benefits of therapy include improved mood, reduced stress, better coping skills, and enhanced relationships.

    • However, therapy can also involve some emotional discomfort as you explore challenging issues.

    • Throughout any therapy sessions, you are encouraged to ask questions. Also, feel free to seek a second opinion at any time.


    Confidentiality

    • All information discussed in therapy sessions will be kept confidential, unless you give us written permission to share such information, with some exceptions as outlined below:

    • The therapist may be required by law to report suspected abuse or neglect, for example regarding children, elders, or disabled adults. PCA may also be required to disclose information if compelled by a court order.

    • If the therapist believes you may harm yourself or others, the therapist may need to take steps to ensure your safety or the safety of others.

    • The therapist may consult with other professionals about your case to help provide you with appropriate care. If a consultation occurs, every effort will be taken to avoid revealing information that could identify you to maintain your privacy.

    • If you use your insurance benefits, PCA must share clinical information about you as described in the Insurance Reimbursement section below at the request of your insurance company.

  • If you are concerned about confidentiality in any situation, please bring it to our attention.


    Fees

    • All billing, copays, deductibles are managed by Philadelphia Medical Billing - https://www.pmbill.com/.

    • Sessions are typically [30, 45 or 50] minutes long.

    • There is a cancellation fee of $60 for cancellations with less than 48 hours' notice.


    Additional Fees

    • Additional services, including the list below, will be billed at rate per hour.

    • Report writing

    • Telephone conversations at your request

    • Attendance at meetings with other professionals per your request

    • Preparation of records or treatment summaries

    • Time spent performing any other service you may request of PCA and to which PCA agrees

  • Legal Matters

    • You are responsible for professional time if legal matters require PCA participation, even if the therapist or records are subpoenaed.

    • PCA’s fee for legal preparation and attendance at proceedings is $120.00 per hour and is adjusted based on time and codes.


    Insurance Reimbursement

    • Understanding your insurance coverage is important for setting realistic treatment goals.

    • Your insurer may require authorization before providing reimbursement and may limit the number of sessions that are covered by insurance. Should you request more
      sessions beyond your insurance coverage, you would be responsible for the total amount of those sessions.

    • PCA recommends contacting your insurance company directly and in advance of our first session to understand your specific mental health coverage benefits and any
      limitations or pre-authorization requirements.

    • If you are using EAP benefits, please contact your Benefits Administrator for this information:

    • The EAP authorization code

    • How many sessions are authorized

    • The starting and ending date

    • Your insurance information will still be needed to be able to continue therapy seamlessly beyond the number of authorized sessions.

  • Most insurance companies, including Medicare, require a diagnosis to provide coverage and may request additional clinical information (treatment plans, progress
    notes, etc.). When you sign this form, you are giving us permission to share your information with your insurance company to seek payment for your covered services.

  • Choosing not to use your insurance for some or all your care. You have the right to pay for services yourself to avoid these limitations and potential privacy concerns associated with using your insurance.


    • Your Rights

    • You have the right to participate actively in your treatment and make informed decisions about your care.

    • You have the right to ask questions and request clarification at any time.

    • You have the right to terminate therapy at any time.

    • You have the right to seek a second opinion.

    • You have the right to access your treatment records, with some exceptions. Please let us know if you would like to discuss.


    Contacting Us

    • When you contact PCA, you are welcome to leave a message or text or email, and PCA will return your call, text or email promptly.

    • If you require immediate help and you have not connected with PCA, call 911 or call 988.

    • In case of an extended absence on our part, your therapist will provide you with contact information of a colleague who may be able to provide you with services.


    Our Responsibilities

    • PCA is committed to providing you with competent and ethical psychological care.

    • PCA will respect your privacy and confidentiality.

    • Your therapist will discuss the limitations of their expertise and refer you to another provider if necessary.


    Agreement
    I agree and consent to participate in behavioral health care services offered and provided at/ by Penllyn Counseling Associates LLC, a behavioral healthcare provider.

    By signing below, you acknowledge that you have read and understood this Informed Consent for Treatment document, that you have had all your questions answered to your satisfaction, and you consent to the release of information described above. You agree to participate in therapy voluntarily.

    I have read and understand the above policies




    Patient (Legal Guardian) Electronic Signature:

    NOTICE OF PRIVACY PRACTICES

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

    Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your
    PHI.

    I am required are required by law to maintain the privacy of PHI and to provide you with notice of legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on my website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

    HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

    For Treatment: Your PHI may be used and disclosed by those who are involved in your care for them purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. I may disclose PHI to any other consultant only with your authorization.


    For Payment: I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.


    For Health Care Operations: I may use or disclose, as needed, your PHI in order to support my business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.


    Required by Law: Under the law, I must disclose your PHI to you upon your request. In addition, I must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.


    Without Authorization: Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations. As a social worker licensed in this state and as a member of the National Association of Social Workers,it is my practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the
    NASW Code of Ethics and HIPAA.


    Child Abuse or Neglect: I may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.


    Judicial and Administrative Proceedings: I may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.


    Deceased Patients: I may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.


    Medical Emergencies: I may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. I will do my best to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.


    Family Involvement in Care: I may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.


    Health Oversight: If required, I may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.


    Law Enforcement: I may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.


    Specialized Government Functions: I may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious
    harm.


    Public Health: If required, I may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.


    Public Safety: I may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.


    Research: PHI may only be disclosed after a special approval process or with your authorization.


    Fundraising: I may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.


    Verbal Permission: I may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.


    With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

    Your Rights Regarding Your PHI:

    You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to Penllyn Counseling Associates LLC.

    • Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.

    • Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, youmay ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.

    • Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

    • Right to Request Restrictions. You have the right to request a restriction or limitation on theuse or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

    • Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.

    • Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

    • Right to a Copy of this Notice. You have the right to a copy of this notice.


    If you believe we have violated your privacy rights, you have the right to file a complaint in writing to Penllyn Counseling Associates LLC or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. I will not retaliate against you for filing a complaint.

    Signature of Client

    Signature of Parent, Guardian, or Personal Representative*

    Refusal of Acknowledgement

    Client Refuses to Acknowledge Receipt

    Telebehavioral Health Informed Consent

    Introduction of Telebehavioral Health:

    As a client or patient receiving behavioral services through telebehavioral health technologies, I understand:

    • Telebehavioral health is the delivery of behavioral health services using interactive technologies (use of audio, video or other electronic communications) between a practitioner and a client/patient who are not in the same physical location.

    • The interactive technologies used in telebehavioral health incorporate network and software security protocols to protect the confidentiality of client/patient information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

    Software Security Protocols:

    Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.

    Benefits & Limitations:

    This service is provided by technology (including but not limited to video, phone, text, apps and email) and may not involve direct face to face communication. There are benefits and limitations to this service.

    Technology Requirements:

    I will need access to, and familiarity with, the appropriate technology in order to participate in the service provided.

    Exchange of Information:

    The exchange of information will not be direct and any paperwork exchanged will likely be provided through electronic means or through postal delivery.

    During my telebehavioral health consultation, details of my medical history and personal health information may be discussed with myself or other behavioral health care professionals through the use of interactive video, audio or other telecommunications technology.

    Local Practitioners:

    If a need for direct, in-person services arises, it is my responsibility to contact practitioners in my area such as:

    ,
    ,
    or

    or to contact my behavioral practitioner’s office for an in-person appointment or my primary care physician if my behavioral practitioner is unavailable. I understand that an opening may not be immediately available in either office.

    Self-Termination:

    I may decline any telebehavioral health services at any time without jeopardizing my access to future care, services, and benefits.

    Risks of Technology:

    These services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties.

    Modification Plan:

    My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies we have agreed upon today, and modify our plan as needed.

    Emergency Protocol:

    In emergencies, in the event of disruption of service, or for routine or administrative reasons, it may be necessary to communicate by other means:

    In emergency situations

    Should service be disrupted:

    For other communication:

    Communications

    My practitioner may utilize alternative means of communication in the circumstance where regular communications methods are down

    My practitioner will respond to communications and routine messages within the day of receiving the message.

    Client Communication:

    It is my responsibility to maintain privacy on the client end of communication. Insurance companies, those authorized by the client, and those permitted by law may also have access to records or communications.

    I will take the following precautions to ensure that my communications are directed only to my psychologist or other designated individuals:


    Storage

    My communication exchanged with my practitioner will be stored in the following manner:

    Laws & Standards:

    The laws and professional standards that apply to in-person behavioral services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.

    Confirmation of Agreement:


    Signature:

    Please remember to text pics to 215-292-8437: Front and back of all insurance cards, except prescription cards.