Crossroads Counseling Center

www.crossroadslink.com

Adult Intake (complete form below) Child/Adolescent Intake (Click here)

Required fields are marked with *

Date * / MM / DD YYYY
Therapist's Name
Counselor Gender Preferred Male Female Either
Location Preferred Brandon Clinton Ridgeland
Why You Are Seeking Counseling? Anger Management Anxiety/ Depression Chemical Dependency Sexual Disorder Grief Marital Play Therapy Child/Adolescent Intake (Click here) Other (Please describe)
How Did You Hear About Us? Personal Friend Insurance Company List Website Phone Book Ad Doctor Church
Which church?
Which Pastor?
Doctor's Name
Other
Client's Personal Data
Name * First Last
Gender Female Male
Birth Date / MM / DD YYYY
SS#
Home Phone * - (###) - ### ####
Work Phone - (###) - ### ####
Cell Phone * - (###) - ### ####
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email
Can a voice mail message be left for you on the above phone numbers? *
Marital Status Married Single Separated Divorced
Client's occupation
Employed by
Please list the name(s) of anyone with whom you would like your therapist to communicate regarding your therapy
Insurance Information
It is important that you thoroughly complete this form and provide a copy of both sides of your insurance card(s). Thank you.
Primary Insurance Information (The primary is the policy holder)
Name of the Insured First Last
Primary's Date of Birth / MM / DD YYYY
SS#
Gender Female Male
Primary's Address (if different from above)
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone - (###) - ### ####
Mobile Phone - (###) - ### ####
Work Phone - (###) - ### ####
Employer of Insured
Address of Employer
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Insurance Co.
Policy #
Group #
Relationship to the Primary Insured
Is client a dependent child? Yes No
Marital Status Married Single Other
Do You Have Secondary Insurance? Yes No
Name of the Insured First Last
Date of Birth / MM / DD YYYY
SS#
Gender Female Male
Employer of the Insured
Work Phone - (###) - ### ####
Insurance Co.
Policy #
Group #
I authorize the release of any medical or other information necessary to process an insurance claim. I understand that CCC will diligently attempt to get accurate information regarding my mental health insurance benefits. I will not hold CCC liable for insurance nonpayment due to misquoted benefits. I ackowledge I am responsible to know and understand my benefits plan. CCC will fine my insurance claims for me as a courtesy. I am ultimately responsible for all charges my insurance company does not pay, except for contracted network provider discounts that may apply. I also request assigned benefits be paid to CCC and/or the provider indicated above. * Yes
Fees and Payment Information
Fee: The initial session fee is $135. Charges vary as per different type services rendered such as individual therapy, family therapy, psychiatric interview, testing, and group therapy. Your therapist will discuss these charges before services are rendered. (LINK HERE)
Insurance

Please make your insurance card available for photocopying.

All CCC counselors are providers for Blue Cross Blue Shield of Mississippi.

Three counselors are TriCare certified.

For other insurance companies, your counselor provides a receipt for you to personally file.

You are responsible for paying the entire fee for the first three sessions until payment is firmly established with the insurance provider. Any monies reimbursed by the insurance provider that are more than your payment for the first three sessions will be reimbursed immediately upon receipt. Once payment from insurance is established, you will only be responsible for the co-pay.

Remember, your health insurance is a contract between you and your insurer. Therefore, you alone are responsible for payment regardless of what your insurance company pays.

Some plans require pre-authorization. It is your responsibility to engage this process with your insurance company:

1. Is Crossroads a provider? (Refer to "Crossroads Counseling Center,""Rankin County Baptist Association DBA Crossroads Counseling Center," or the name of your assigned counselor.)
2. What are my mental health benefits? (not simply "counseling")
3. Do I have a deductible, and how much is it? How much have I already paid toward my deductible?
Appointment Cancellation Policy

Twenty-four (24) hour notification is an expected courtesy to the therapist who is reserving time for you and to other clients who are waiting to schedule appointments. You must give a 24-advance notice for cancelled appointments. The advance notice is standard in our profession. If you are more than 15 minutes late for your appointment, it is considered a missed appointment, and you will be responsible for the fees for that session.

If you miss or fail to cancel an appointment within 24-hours, you will be charged the entire session fee. Insurance plans do not pay for such charges.

Confidentiality

Crossroads Counseling Center, CCC, takes confidentiality seriously, and we desire to provide an environment in which our clients may place their trust and confidence. Your therapist will keep all information regarding your identity, evaluation, treatment, and related records in confidence. However, there are several exceptions in which we will break confidentiality:
Mandated reporting of physical or sexual abuse of a child or vulnerable adult

Diagnosis, written treatment plans, and dates of service will be shared with your insurance company for collection of payments and continuation of therapy

Threats of suicide or homicide

When written consent is obtained from you to release information

Information necessary for supervision or consultation

Information released as outlined in the HIPAA Notice of Privacy Practice

Information in the course of therapy with a minor dependant which clinically requires disclosure to their parent or legal guardian. (A verbal explanation for disclosure will be made to the minor child during session.)

Other as required by law, court order, or in the event of litigation.

Your consent at the end of this document indicates consent to use your personal health information for routine practices according to the law for treatment, payment, and health care operations. You may revoke this consent in writing at any time, except to the extent that CCC has taken action relying on this consent.

Communication and Technology

There is ongoing advancement of technology and expansive means of communication (e.g. email, text messaging, twittering, social networking sites, etc.). The most secure exchange of confidential information is face to face. Crossroads Counseling Center prioritizes confidentiality and therefore desires to avoid communication via means in which your identity cannot be verified or in which others may be exposed to the confidential information sent by the therapist. However, Crossroads understands that you may prefer to exchange information via email or text messaging to communicate with your therapist.
I understand and agree that if I choose to communicate with my counselor through email and/ or text messaging, my therapist will not be held liable for exposure of confidential information. * Yes
Emergencies

CCC is not equipped to handle emergencies. If you have an emergency, please call 911 and/or go to your nearest emergency room.

Consent for Professional Services Agreement

I voluntarily agree to participate in the assessment and counseling as offered by Crossroads Counseling Center. I acknowledge that no guarantees have been made to me regarding the outcome of my therapy. I understand my rights and responsibilities as stated in this document.

I acknowledge receipt of this document and all the information contained in this document along with the HIPAA Privacy Practices. I agree that my therapist may withdraw and will not be obligated to provide counseling services if I fail to abide by the terms specified in this document. If applicable, I give consent as the parent or guardian of a minor dependant for counseling services to be provided to the minor listed above. If applicable, I authorize Crossroads Counseling Center to submit my counseling sessions (or sessions for a covered minor dependant) to my insurance company for payment of services. Additionally, I authorize my insurance carrier to submit payment of benefits and services directly to Crossroads Counseling Center.
I certify that I am not under a legal disability that prevents me from understanding the terms of this agreement, and I accept all the terms and conditions as herein stated. * Yes
HIPAA Notice of Privacy Practices
Crossroads Counseling Center
www.crossroadslink.com

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

This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected Health Information" is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your therapist, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing mental health care services to you, to pay your health care bills, to support the operation of the therapist's practice, and any other use required by law.

TREATMENT: We will use and disclose your protected health information to provide, coordinate, or manage your mental health care and any related service. This includes the coordination or management of your mental health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

PAYMENT: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for psychological testing or a hospital stay may require that your relevant protected health information be disclosed to your health plan to obtain approval for the psychological testing or hospital admission.

HEALTHCARE OPERATIONS: We may use or disclose, as needed, your protected health information in order to support the business activities of your therapist's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your therapist. We may also call you by name in the waiting room when your therapist is ready to see you.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law; public health issues as required by law; communicable diseases; health oversight; abuse or neglect; food and drug administration requirements; legal proceedings; law enforcement; coroners, funeral directors, and organ donation; research; criminal activity; military activity and national security; workers' compensation; inmates; required uses and disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization at any time in writing, except to the extent that your therapist or the therapist's practice has taken action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS

The following is a statement of rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under Federal Law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restrictions to apply.
Your provider is not required to agree to a restriction that you may request. If your provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another healthcare professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You may have the right to have your provider amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. We reserve the right to change the terms of the notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice becomes effective on or before April 14, 2003.
I have received a copy of my privacy rights under the Health Insurance Portability Act and the HIPPA notice (LINK HERE). I agree to all of these policies and I understand that I may contact this office to make any changes I require. * Yes

Crossroads Counseling Center

Client's Personal Data

Insurance Information
It is important that you thoroughly complete this form and provide a copy of both sides of your insurance card(s). Thank you.

Primary Insurance Information (The primary is the policy holder)

Fees and Payment Information
Fee: The initial session fee is $135. Charges vary as per different type services rendered such as individual therapy, family therapy, psychiatric interview, testing, and group therapy. Your therapist will discuss these charges before services are rendered. (LINK HERE)

Crossroads Counseling Center

Client's Personal Data

Insurance Information It is important that you thoroughly complete this form and provide a copy of both sides of your insurance card(s). Thank you.

Primary Insurance Information (The primary is the policy holder)

Fees and Payment Information Fee: The initial session fee is $135. Charges vary as per different type services rendered such as individual therapy, family therapy, psychiatric interview, testing, and group therapy. Your therapist will discuss these charges before services are rendered. (LINK HERE)

Insurance Information
It is important that you thoroughly complete this form and provide a copy of both sides of your insurance card(s). Thank you.

Fees and Payment Information
Fee: The initial session fee is $135. Charges vary as per different type services rendered such as individual therapy, family therapy, psychiatric interview, testing, and group therapy. Your therapist will discuss these charges before services are rendered. (LINK HERE)