CLIENT FORMS

	Required Forms     Client Fact Sheet Client Application Financial Policy Insurance Benefit Form Service Agreement - Signature Page HIPAA Privacy Notice - Signature Page Physician Release Form
	HIPAA and Service Agreement     HIPAA Privacy Notice Service Agreement Service Agreement Appendixes
	Optional Forms     School Release Form Release of Information Multiple Attendees Form Adolescent Confidentiality Form Adult Information Form Child Information Form

• To the right, in the top box, are the Required Forms for the first appointment.
• Please print out each form separately.
• Each form needs to be completed and brought to the first session
• For the HIPAA and Service Agreement we only need you to provide us with a copy of the signature page (for each form). However, please read these documents carefully prior to your appointment.
• When you come to the first session please bring a copy of your insurance card.
• Please complete and sign the Physician Release Form so we can coordinate care with your doctor (while this is not required, most insurance companies request that we coordinate care with your physician).

HIPAA PRIVACY NOTICE & SERVICE AGREEMENT

• The HIPPA Privacy Notice and Service Agreement (including Appendixes) are very important documents.
• The HIPAA Privacy Notice explains guidelines for confidentiality.
• The Service Agreement and Appendixes detail Centers for Family Change’s policies.
• Please read these forms prior to your first appointment.
• If you have any questions be, sure to raise them with your therapist.

OPTIONAL FORMS

• Complete the Adult Information Form, for adult clients
• Complete the Child Information Form, if the client is a child or teenager.
• Please complete the School Release Form if the client is a student and you would like your therapist to talk to school personnel.
• Please complete the Release of Information form to allow us to obtain records from previous therapists (be sure to list the clinician’s name and phone number).
• Complete the Multiple Attendees form if you are likely to involve your spouse or partner in your therapy sessions.
• Complete the Adolescent Confidentiality Form if the client is a child, 12-17, who is likely to have individual sessions.
• If you have questions about any of these forms you can discuss them with your therapist at the first appointment.

PAYMENT INFORMATION

Payment is required at the time of service. For the first session the fee is $175.00 and for following sessions the fee is $150.00. However, if you are using your insurance your fee will most likely be discounted. Please discuss this with your therapist.

Your Centers for Family Change therapist accepts cash or checks. We expect payment at time of service for co-pays, co-insurance and/or deductibles. We will bill your insurance for their portion of the fee.

PAYING BY CREDIT CARD

You can now pay your Centers for Family Change bill by credit card (currently only available in our Oakbrook office). Please talk with your therapist about how you can utilize this option.