CARD AUTHORIZATION (J:J!.CN, Debit, Health Savings Account, etc.)

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1 CONTRACT & CONSENT You, the client or parent/guardian of the client, do voluntarily consent and authorize me to administer psychotherapy. You are aware that the practice of psychotherapy is not an exact science and you acknowledge that no guarantees have been made as to the result of treatment. You understand that I practice under the ethical guidelines set forth by the Kentucky and my professional regulatory association. You further understand that I will make appropriate referrals for you if you have needs that I am unable to address. Insurance companies may require you to return a Coordination of Benefits form. If you do not do this, you remain responsible for the total cost of the related sessions. You understand and agree to the above fees and responsibilities and will notify me immediately of any change in your Insurance coverage. POLICY AGREEMENT Please read this important brochure and to keep it for your reference. It contains a number of important, and sometimes mandatory, notices and agreements. The Registration Form contains the signature lines for all the policies contained in this Agreement. CARD AUTHORIZATION (J:J!.CN, Debit, Health Savings Account, etc.) You understand that as a solo practitioner, I need to keep business procedures simple and straight-forward so that I may concentrate energies on helping YOu. Therefore, you are strongly urged to agree to the Card Authorization. Doing so simplifies payment of co-pays, deductibles, and no-show / late cancellation fees. COURT I LITIGATION Please understand that in litigation my role is to not make recommendations for the court or to testify concerning opinions on issues involved in the litigation. You agree to not call me as a witness in any litigation. QUESTIONS OR PROBLEMS If you have questions or problems with any of these policies, just talk with me Mike Rankin, M.A. Licensed Marriage and Family Therapist AAMFT ClinicalMember 2303 Hurstboume Village Drive, Suite WELCOME! I hope that you fmd your time in counseling to be helpful and useful. My pledge to you is to work so that you feel understood and that you meet or exceed your counseling goals and expectations. I see counseling as hosting a conversation in which you and I together talk about your life situation and see what changes you want to make to overcome obstacles. You may be in some kind of pain, dealing with suffering and going through a difficult time. I listen to clients concerning their issues and we work to fmd solutions to problems such as relationship stressors, depression, anxiety, work related issues, grief, alcohol! drug abuse, and other difficulties. These experiences of life are sometimes painful and counterproductive. We work to create new experiences for you, regain positive energies, recover and fmd your strengths and gifts, in order to meet the challenges of life, experience more rewards, and create meaning and purpose in life. Counseling may be just what you want for a period of time - giving you long-term positive results. We will work together to make this a growing experience.

2 PRIVACY POLICY Your personal health information (Pill) is used for treatment and to arrange payment for services. You have rights regarding your Pill. You have the right to look at your Pill and have one free copy. You have the right to a complete copy of this Privacy Policy. If you believe your Pill is incorrect, you can ask me to make changes. You have to make this request in writing and make sure I receive it. You must specify the reasons you want changes made. You have the right to file a complaint if you believe your privacy rights have been violated. You can file complaint with my office or with the Cabinet of Human Services. Complaints must be in writing. INSURANCE RELEASE AND ASSIGNMENT You authorize the release of any information necessary to process your insurance claims and to document treatment. You authorize and request payment of benefits directly to me. You agree that this authorization will cover all services rendered by me. You agree that a copy of your authorization may be used in lieu of the original. This Agreement states that your insurance company may place limits on the number of sessions for which they will pay. Your insurance company contracts with me for discounts off my standard fees. You remain responsible for all remaining non-covered fees such as co-pays and deductibles and any other non-contracted services that I may have provided. Your non-covered fees must be paid at the beginning of each session by cash, check, credit/debit card or Card Authorization. FINANCIAL AGREEMENT My fees are $100 for the initial session and $90 for each additional session. Co-pays and deductibles are due prior to each session. Again, if you use insurance, then I go with my contracted rate. All charges not covered by insurance remain your responsibility. All co-pay and deductible amounts are informed estimates until an Explanation of Benefits is received from your insurance. Appointments missed or canceled without 24 hours notice may result in a $60 fee. Returned checks incur a $50 fee in addition to bank fees. Court, parole, disability, CPS, or similar services are provided at the standard fee rate. The above fees are never covered by insurance. My business group works with clients to set up payments if necessary. Accounts are sent to a collection agency only when arrangements cannot be worked out. You agree for the release of any information necessary to obtain payment. MANDATORY RELEASE OF INFORMATION You acknowledge that I am obligated by law and professional regulations to report any information obtained regarding the following: Incidents of abuse or neglect upon a child, who 16 years of age or under, that have never been reported to the Cabinet for Human Services. Current incidents of abuse upon an adult that have never been reported to the Cabinet for Human Resources. Any specific threats to cause bodily harm to any identified individual(s), where there is a plan, available methods and the client refuses to take appropriate actions to not follow through with the threat. In the case of suicidal behavior, the next of kin will be notified and a mental inquest warrant may be issued. In the case of homicidal behavior the intended victim will also be notified. Any breach of a court order, specificallya restrainingorder,no-contactorderor protective order,mustbe reportedto the courts. Failure to cooperate with treatment plans ordered by court, probation,parole or Cabinetfor HumanServices.

3 Registlfation. (PLEASE PRINT) dx CLIENT LAST NAME First M.I. ----~ ~--~ May I contact you by ? IfY,print address Address City State ZIP SSN DofB Phones, Cell Home Work -~--- ~ OK to leavemessage OK to leavemessage OK to leavemessage Gender Status: Single Partnered Married Divorced Widowed EMPLOYER OR SCHOOL - RESPONSBILE PERSON (If other than client) Last Name First M.I. DofB Address City -- State ZIP SSN Date of Birth Phones, Cell Home Work'--- OK to leavemessage OK to leavernessage OK to leavemessage Gender Employer Relationship to Client IS CURRENT CONDITION RELATED TO: Auto Accident Employment Other Accident INSURANCE / EAP CO. ID # Authorization # -- SPOUSE OR PARTNER'S NAME Years Together ENfERGENCYCONTACT Phones, Cell.=--:-,Home.==--:- Work'=:---:- OK to leavemessage OK to leavemessage OK to leavemessage HOW DID YOU HEAR OF MY SERVICES HAVE YOU HAD PRIOR COUNSELING Yes No If Yes, briefly describe what was helpful about it? AGREEMENT TO POLICIES I understand and have been given a copy of the Welcome! rochure -- I agree to the Privacy Policy, Insurance Release and Assignment, Financial Agreement, Mandatory Release of Information, Contract and Consent, and Court /Litigation contained within it. Client or Responsible Party Signature Date Mike Rankin Licensed Marriage and Family Therapist AAMFT Clinical Member 2303 Hurstbourne Village Drive, Suite

4 BACKGROUND INFORMATION (page 1 of2) Dear Client: This information is beneficial to providing services to you. If you don't understand any area or any area makes you uncomfortable in any way, please bring it to my attention when we meet. Client Date of Birth Date: ~ Why are You Seeking Help? 2 Reasons for Seeking Help Now 3 Primary Care Physician and Contact Information 4 History of Mental Health Problems? Yes No Don't Know Hospitalized? Yes No Don't Know Outpatient Treatment Yes No Don't Know On Medications Yes No Don't Know History of Violence or Suicide Attempts Yes No Don't Know Thoughts about Suicide or Violence Yes No Don't Know Other Yes No Don't Know If Yes to Any, Please Tell Me More 5 Problems in Functioning? Yes No Don't Know School Yes No Don't Know Work Yes No Don't Know Family Yes No Don't Know Peers Yes No Don't Know Social Activities Yes No Don't Know Eating Yes No Don't Know Sleeping Yes No Don't Know Day-to-Day Activities Yes No Don't Know Other Yes No Don't Know If Yes to Any, Please Tell Me More 6 Current Legal, Probation, Parole Problems? Yes No Don't Know IfVes, Please Tell Me More 7 Current Medical Problems? Yes No Don't Know On Medications Yes No Don't Know Recently Hospitalized Yes No Don't Know Under Care of Health Care Professional Yes No Don't Know Other Yes No Don't Know If Yes to Any, Please Tell Me More

5 BACKGROUND INFORMATION (page 2 of2) Client: - 8 History of Medical Conditions Yes No Don't Know Drug Allergies Yes No Don't Know Tell Me More About Your Medical Conditions Alcohol Use Yes No Don't Know If Yes, Last Date Consumed 1 1 Amount Consumed What? Any Increase in Tolerance Yes No Don't Know Blackouts' Yes No Don't Know Tell Me More About Your Alcohol Use Drug Use Yes No Don't Know If Yes, Last Date Consumed 1 1 Amount Consumed What? Any Increase in Tolerance Yes No Don't Know Tell Me More About Your Drug Use 11 Chemical Dependency Treatment Yes No Don't Know If Yes, Please Tell Me More 12 Disabled Full Partial If Yes, Please Tell Me What Type and More No Don't Know ~-H-H-H-~+H)()()( H-)++DO NOT WRITE BELOW TIDS LINE -(-+()()()()()()()()( )~-(-+ 13 Strengths/ Assets 14 Preliminary Assessment 15 Preliminary Dx (s) 16 Accepted for Treatment Yes No Further Evaluation Yes No 17 If Not Accepted, Referred To and Why: 18 Initial Treatment Goals: 19 InitiaIPrognosis: 20 Other Relevant Information ---- Therapist Signature: Mike Rankin, LMFT, 2303 Hurstbourn Village Drive, rndranldn@insightbb.com

6 RELEASE OF INFORMATION Client --- DaB ---- I understand that my personal health records are protected under applicable laws and cannot be disclosed without written consent unless otherwise provided for in writing. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. This authorization shall be valid for the length of treatment with Mike Rankin or till canceled by me. I understand that I alone am responsible for any and all fees or costs that may be required by these services. Additional information concerning these fees or costs has been provided if requested by me. I hereby relieve and release the below mentioned from any and all damages, claims and causes of action arising out of, or in connection with the release of this information. I agree that a photocopy of this form may be used in lieu of the original. I am giving authorization and consent to Mike Rankin to release, obtain, and consult (by written, verbal or electronic communication) with: Doctor, Psychiatrist, etc. from Whom Information is to be Received: (Use a Separate Form for Each and Every Provider) Name Address Phone The purpose of this authorization disclosed is: Fax is for providing continuity of care. The information to be obtained or Recent History and Physical Recent Discharge Summary Psych or Neuropsych Test Results Attendance Recent Treatment Plan Current Aftercare Plan Coordination of Services Other --- Client / Responsible Party Signature Date Mike Rankin Licensed Marriage and Family Therapist AAMFT Clinical Member 2303 Hurstboume Village Drive, Suite

7 CARD AUTHORIZATION (Debit, Health Savings Account, Master Card, VISA, Discover, etc. NO AmEx) I authorize Mike Rankin to charge any co-pays, deductibles, co-insurance, bank and other fees that may become due under the Financial Agreement. This authorization shall be valid for the length of treatment with Mike Rankin or till canceled in writing by me. A copy of all charges will be given / sent to me. The following are covered under this agreement: Name (print) Name (print) CARDHOLDER Name (print) ZlP---,---:- Where card statement is sent Card Number DODD DODD DODD DODD Expiration Date DODD Month Year 3 Numbers on Back of Card ODD CARDHOLDER Signature -- Date Mike Rankin Licensed Marriage and Family Therapist AAMFT Clinical Member 2303 Hurstboume Village Drive, Suite