POLICIES & PAYMENT

Payment/Copayment for Services: Patients are expected to pay for services at the time they are rendered.

Insurance Reimbursement: Patients who carry an approved insurance, may have the fees for services rendered billed to their insurance company. Standard policy for cash patients is to provide you with a receipt which you may submit to your insurance company for reimbursement.

Cancellation: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours’ notice is required for the rescheduling or cancellation of that appointment. A fee of $25.00 will be charged for missed sessions without such notification.

Confidentially: All information disclosed within your sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law. Disclosure may be required under the following circumstances: where there is a reasonable suspicion of child abuse; where there is a reasonable suspicion that the patient presents a danger of violence to others or where the patient is likely to harm him or herself unless protective measures are taken. Disclosure may be required pursuant to a legal proceeding.

Receipts: Receipts are available upon request.

Emergency Procedure: If you need to contact Dr. Simms between sessions, please call and leave a voicemail message on the office phone at 951-375-4580. If your need is urgent, please don’t hesitate to go to the nearest emergency room.

By completing this form, you are agreeing to the policies listed above.

Your Full Name (required)

Your Email (required)

Today's Date & Year (required)

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/CONFIDENTIALITY

The Health Insurance Portability and Accountability Act of 1996 requires that health care providers give patients a copy of the official Notice of Privacy Practices and make a good faith effort to obtain an acknowledgement of receipt of same.

By digitally signing this form, I confirm that I have received a copy of the official Notice of Privacy Practices.

You can read our privacy document by clicking here

Your Full Name (First & Last)

Your Initials (First & Last Name Initial)

Your Email

Today's Date (Month, Day, Year)

By submitting this form, you are confirming "YES" to receipt of the official Notice of Privacy Practices.
Yes

FAMILY OUTREACH COUNSELING SERVICES CLIENT INTAKE FORM

Your Full Name

Date of Birth & Year

Occupation

Address (Street, City, State, Zip)

Your Email

Your Phone Number

Insurance Company

Copay (In US Dollars)

Number of Sessions Authorized

Referred By

Medical ID Number

Medications (please list)

Today's Date & Year

When are you seeking counseling?

TELEHEALTH CONSENT FORM

Payment/Copayment for Services: Patients are expected to pay for services at the time they are rendered.

Insurance Reimbursement: Patients who carry an approved insurance, may have the fees for services rendered billed to their insurance company. Standard policy for cash patients is to provide you with a receipt which you may submit to your insurance company for reimbursement.

Cancellation: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours’ notice is required for the rescheduling or cancellation of that appointment. A fee of $25.00 will be charged for missed sessions without such notification.

TELEHEALTH CONSENT FORM I, Enter your full name and continue to bottom of form (Patient) hereby consent to engage in Telehealth with Dr. Mary M. Simms, M.F.T, Ph.D., . I understand that Telehealth is a mode of delivering health care services, including psychotherapy, via communication technologies (e.g. Internet or phone) to facilitate diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care. By signing this form, I understand and agree to the following:

1. I have a right to confidentiality with regard to my treatment and related communications via Telehealth under the same laws that protect the confidentiality of my treatment information during in-person psychotherapy. The same mandatory and permissive exceptions to confidentiality outlined in the [Informed Consent Form or Statement of Disclosures] I received from my therapist also apply to my Telehealth services.

2. I understand that there are risks associated with participating in Telehealth including, but not limited to, the possibility, despite reasonable efforts and safeguards on the part of my therapist, that my psychotherapy sessions and transmission of my treatment information could be disrupted or distorted by technical failures and/or interrupted or accessed by unauthorized persons, and that the electronic storage of my treatment information could be accessed by unauthorized persons.

3. I understand that miscommunication between myself and my therapist may occur via Telehealth.

4. I understand that there is a risk of being overheard by persons near me and that I am responsible for using a location that is private and free from distractions or intrusions.

5. I understand that at the beginning of each Telehealth session my therapist is required to verify my full name and current location.

6. I understand that in some instances Telehealth may not be as effective or provide the same results as in-person therapy. I understand that if my therapist believes I would be better served by in-person therapy, my therapist will discuss this with me and refer me to in-person services as needed. If such services are not possible because of distance or hardship, I will be referred to other therapists who can provide such services.

7. I understand that while Telehealth has been found to be effective in treating a wide range of mental and emotional issues, there is no guarantee that Telehealth is effective for all individuals. Therefore, I understand that while I may benefit from Telehealth, results cannot be guaranteed or assured.

8. I understand that some Telehealth platforms allow for video or audio recordings and that neither I nor my therapist may record the sessions without the other party’s written permission.

9. I have discussed the fees charged for Telehealth with my therapist and agree to them [or for insurance patients: I have discussed with my therapist and agree that my therapist will bill my insurance plan for Telehealth and that any copayment is due and payable by me at the time of service.

10. I understand that my therapist will make reasonable efforts to ascertain and provide me with emergency resources in my geographic area. I further understand that my therapist may not be able to assist me in an emergency situation. If I require emergency care, I understand that I may call 911 or proceed to the nearest hospital emergency room for immediate assistance. I have read and understand the information provided above, have discussed it with my therapist, and understand that I have the right to have all my questions regarding this information answered to my satisfaction. [For conjoint or family therapy, patients may sign individual consent forms or sign the same form.]

Signature Date & Year (required)

Patient’s Printed Name Verbal Consent Obtained Therapist reviewed Telehealth Consent Form with Patient, Patient understands and agrees to the above advisements, and Patient has verbally consented to receiving psychotherapy services from Therapist via Telehealth.

(Input Full Name as Digital Signature to Agree to Above)