Hard Copies of Clinical Intake Documents
Download these 3 PDF documents complete or keep them for your own records.
Information, Authorization and Informed Consent
File Size: 10805 kb
File Type: pdf
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Telehealth Addendum
File Size: 48 kb
File Type: pdf
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READ ONLY: HIPAA Client Notification of Privacy Rights
File Size: 223 kb
File Type: pdf
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    Clinical Intake and Personal Data
    Please complete Client Intake and Personal Data fields provided below.
    Please give the following info for each person that currently lives in your home, including yourself.
    List NAME, AGE, & RELATIONSHIP TO YOURSELF
    Who may we contact in the event of an emergency?

    Payment Information

    All credit card information provided below is for the sole purpose of payment for services provided by Hayne Steen, LMHC at Elbow Tree Christian Counseling, LLC for mental health counseling, spiritual direction, or life coaching.

    Professional Disclosure Statement and Counseling Agreement

    NATURE OF COUNSELING

    My goal for you in counseling is to help identify your childhood wounds, faulty thinking, and unhealthy behavioral and relational patterns and to walk beside you in the healing process. Unfortunately there are no “quick fixes” in counseling only hard work in the form of sessions, homework assignments, writing, reading, learning tools and techniques, and attending workshops when appropriate. As a Christian counseling practice we are committed to help your spiritual life develop and enable you to understand Biblical truth and apply it to your life.

    CONFIDENTIALITY
    We respect the information you share with us and how difficult it can be to open up. I may review “un- identifying details” of your case with other counseling professionals whom I consult with in order to help you in the best way possible. Our conversations and our written/taped records will be kept confidential and are protected by law, with a few exceptions, which are for your own protection: (1) when we believe that you intend to harm yourself or another person (2) when we believe a child or elderly person has been - or will be - abused or neglected and (3) when there is domestic violence in the home. In rare circumstances, Professional Counselors can be ordered by a judge to release information. Otherwise, we will not tell anyone else about your treatment, diagnosis, history, or even that you are a client without your full knowledge, and usually with a signed Release of Information Form. A copy of the HIPAA (Health Insurance Portability and Accountability Act) Patient Notification of Privacy Rights will be made available to you. Signing at the end of this disclosure will indicate that you have had an opportunity to review and understand this (HIPAA) document.

    We are committed to staying on the leading edge with regard protecting your confidentiality and Private Health Information (PHI). Therefore, we will deliver all PHI securely to our clients. I understand that utilizing a communication stream like email or text messaging could jeopardize the confidentiality of my PHI.

    COUNSELING RELATIONSHIP
    During the time of your treatment we will meet regularly for 50-minute sessions. Ours is a professional relationship and must be respected by both sides. There may be opportunity for us to run into each other in a social context i.e. church, the grocery store or school etc. Let’s both keep our professional relationship in mind at this time. To protect you, I’ll tend to avoid initiating with you in public. However, you always have the freedom to initiate with me. Please feel free to discuss this with me at any time when this happens. My goal is to make you comfortable with our professional relationship and best meet your needs as a client.

    SCHEDULING AND LENGTH OF SESSIONS
    Sessions are 50 minutes long. I will schedule our sessions per mutual agreement, as time is available. If you call the main ETCC phone number, you will usually have to leave a message, but my desire is to call you back as soon as possible. Because, I operate on an appointment basis only, I may not be able to handle urgent emergencies that may arise with clients. If your situation is out of control and can not wait on an appointment, it is important that you contact 911 or your local emergency services. If you are unable to keep an appointment, please call/email/text me no less than 24 hours prior to your appointment. You may leave me a message if you need to. Cancellations made inside that 24 hour window will result in you being responsible for paying the full cost of the session that you missed. Of course, this policy does not apply to emergencies. Because of my participation in two different networks of providers who participate in disaster response (one local and one international), from time to time, I may ask you to consider rescheduling a standing appointment(s). I would appreciate your sensitivity, flexibility and grace in this area.

    FEES/METHODS OF PAYMENT
    The fee throughout the month of April 2020 will be $60 per 50 minute session as a way to offer some relief to all of our existing clients as well as prospective clients. (Ends 4/30/2020)

    The standard fee is $100.00 per 50 minute session. I ask for payment at the time of service, and do not engage in billing for clients. Cash, personal checks and most credit/debit/HSA cards are acceptable for payment. For credit/debit/HSA cards, there will be a $3 convenience fee. I will provide you with a receipt upon request, for fees paid if you desire. There will be a $25 fee for returned checks. I am also willing to help you seek financial support from your local church and your family to help with the cost of counseling. If you are involved in litigation and I am required to be involved in your case (travel time, preparation, attendance at court, letters) I will charge you a fee of $200/hour (pre-paid).

    BILLING/INSURANCE REIMBURSEMENT
    I am a board certified “Licensed Mental Health Counselor” (#MH16012) in the state of Florida which will allow me to provide you with viable insurance receipts and clinical diagnosis. I am currently not listed on any insurance panels.

    COMPLAINT PROCEDURES
    If you are dissatisfied with any aspect of our work, please inform me, Hayne Steen, owner of ETCC in Saint Augustine, immediately. This will make our work together more efficient and effective. If a problem arises requiring a legal remedy to solve, the client agrees to solve all problems through the means above or independent mediation and not pursue formal litigation. Complaints should also be registered with the Florida Board of Health at Department of Health, 4052 Bald Cypress Way, Bin C75 Tallahassee, Florida 32399-3260 or 850-245-4339.

    APPROPRIATE REFERRALS
    I am qualified to meet the needs of the vast majority of the people who come to see me. If I cannot help you, I will try my best to refer you to another appropriate professional in the community to meet your needs.

    If you have any questions, please feel free to ask me. Once you have read and understood this statement, please sign and date. Thank you for choosing this practice to meet your needs.

    Telehealth Addendum [revised April 15, 2020]

    This is to be used in conjunction with, but does not replace, the Information, Authorization & Informed Consent for Treatment document that is required of all clients prior to starting therapy services. You may find a current version of the initial Authorization document on your therapist’s web page.

    TELEHEALTH
    If telehealth services are necessary or requested, I hereby consent to engaging in telehealth as a part of Elbow Tree Christian Counseling, LLC as part of my psychotherapy. I understand that “telehealth” includes the practice of diagnosis, treatment, goal setting, referral to resources, skills training, and psychoeducation through the use of internet-based video-conferencing. Telehealth psychotherapy may include psychological health care delivery, consultation, coaching, and/or counseling. Telehealth psychotherapy will occur primarily through interactive audio, video, email, texting and telephone communications.

    Confidentiality: I understand that the current laws that protect privacy and confidentiality also apply to telehealth. Any exceptions to confidentiality are described in the Authorization document. I understand that no permanent video or voice recordings will be made or kept from telehealth sessions. I agree not to record or store video conference sessions.

    Technology: I understand that I may need to download an application and/or software to use this platform if my therapist requires it. I also need to have a broadband Internet connection or a smartphone device with a good cellular connection.

    Risks: I understand telehealth carries risks, including but not limited to: a) technological failures such as unclear video, loss of sound, poor connection or loss of connection; b) nonverbal cues are less readily perceivable to both therapist and client; c) limits to confidentiality. At Elbow Tree Christian Counseling, we use HIPAA compliant and encrypted technology for a) sending and receiving email; b) performing audio and video sessions and c) creating and storing client records. Under certain circumstances, we may use unsecured technology for a) scheduling communications; b) to navigate emergent or crisis situations or c) when Federal Emergency Protocols are in place and services need to be delivered when HIPAA compliant systems are overwhelmed or unavailable.

    Financial Obligations: Fees associated with telehealth appointments are payable by credit or debit card only and reflect my current regular session fee. If a superbill is desired to file for out-of-network benefits with my insurance company, I am responsible for contacting my insurance company to determine my coverage for telehealth services.

    By signing below, I am indicating that I have reviewed the “Telehealth” policy and agree to its terms and I acknowledge that my clinician reviewed all aspects of this authorization for treatment and informed consent. I understand that I may ask questions at any time regarding any aspect of this Authorization and agree to abide by its terms during our professional relationship. I acknowledge a hard copy of this Authorization has been made available to me    .