New Client. Address: City: State: Zip: Contact # s Home: Work: Social Security#: / / Date of Birth: / / Age: Name: Address: City: State: Zip:

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2 Welcome to Connections Counseling! Please complete the following forms. All information will be kept strictly confidential. Thank you for your cooperation! For Office Use Dean Auth Request Sent? Diagnosis Code: Date: Primary Counselor: New Client Returning Client Client s First Name: MI: Last Name: Address: City: State: Zip: Contact # s Home: Work: Cell: Social Security#: / / Date of Birth: / / Age: Address: Name: Address: City: State: Zip: Contact # s Home: Work: Cell: Address: Relationship to client:

3 Client Name: Date: Billing Policy & Financial Agreement Fee Schedule Service Court Eval Med Check Intake Individual Time 15min 1 hr 1 hr MD N/ /A $125 $325 $300 Psychologist $350 N/A $250 $250 Master s, CSAC $300 N/A $200 $180 Individual 30min $200 $120 $90 Family 1 hr N/ /A $250 $200 Group 1 hr - $70 / 90min - $ SAC, SAC-IT $250 N/A $175 $150 $80 $175 Same Day Payment Connections Counseling expects clients to pay for services on thee day services are rendered. Insurance Clients: All co-pay and deductible amounts are due onn the day services are rendered. Coinsurance amounts will become your responsibility after our office receivess an explanation of payment from the insurance company. Thesee amounts will be billed to you on a monthly basis. Self-Pay Clients: Payment in full will be required on the day services are rendered. If payment is not received within 30 days, our counselors will begin discharge planning and facilitate a referral for more appropriate services. Initials Financial Need If you are unable to afford services due to financial need you may contact our Office Manager at (608) ext 14 to apply for a reducedd rate. Cancellation Policy for Therapists If you need to cancel or reschedule an appointment call your primary counselor or the administrative assistant at (608) ext 10, 24 hours prior to the appointment. If you do not provide a 24 hour notice or no show for an appointment, you will be charged $80 regardless of the therapist. No Show/Late Cancel fees are the client or responsible parties responsibility and must be paid within 30 days. If a client does not pay these fees they will be given up to two sessions with their therapist to facilitate a referral and discharge planning. No Show/Late Cancel fees for psychiatrists will be billed at the regular rate of the appointment. Initials How will you be paying for services? Insurance Cash/Check Credit/Debit Card Credit/Debit Card on File Self-Payy A 10% discount will be given to all self-pay clients who: o Pay in full on the date of service. All fees not paid inn full the same day will be billed at the regular rate. o Have a credit card agreement on file to pay the balance in full every month, please contact the billing department for more information. Returned Check Policy Checks returned for insufficient funds will be charged to you at $ $50.00.

4 Responsible Party Information (If someone else takes responsibility for payment of your bill, please fill in their information here and have them sign this form. If they do not sign the form you will be held responsible for payment.) First Name: MI: Last Name: Address: City: State: Zip: Contact Information: Home: Work: Cell: Social Security#: - - Date of Birth: Employer: Relationship to Client: Insurance Information If you would like us to bill your insurance, please provide a copy of your insurance card or complete the following: Primary Insurance Company: COPY OF CARD PROVIDEDD Subscriber or ID#: Group/File #: Full Name of Policy Holder: Date of Birth: Employer: Relationship to Client: Is referral/pre-authorization required? Yes No Has pre-authorization been obtained: Yes No Secondary Insurance Company: COPY OF CARD PROVIDEDD Subscriber or ID#: Group/File #: Full Name of Policy Holder: Date of Birth: Employer: Relationship to Client: Is referral/pre-authorization required? Yes No Has pre-authorization been obtained: Yes No Financial Agreem ent and Commercial Assignment of Benefits: You are responsible for your entire bill. However, we will submit claims to your health insurance company as a courtesy too you. We suggest that before your first appointment, you make sure that you understand the Alcohol and Other Drug Abuse(AODA) and Mental Health benefits provided by your insurance plan. You should understand the amounts of your co-payments (the portion of the charge your insurance company expects you to pay) and deductibles (the amount your insurance company requires you to pay before the benefits begin). Youu should be aware of plan restrictions and benefit limits. Many insurance plans require pre-authorization for AODA/Mental Health services. Some insurance plans place restrictions on the type of services covered and/or on the frequency or r number of appointments covered. You must let ourr billing departmentt and your therapist know about these requirements and restrictions before your first appointment. I authorize the release of information by Connections Counseling, LLC; ; to the extent that disclosure of my medical records is necessary for billing, collection or payment of claims. I release Connections Counseling, LLC from all legal responsibility or liability that may arise from this act. I assign benefits to Connections Counseling, LLC, for charges incurred by eligible persons covered under my current or subsequent plan. Reimbursement is subject to eligibility and plan limitations. I agree by my signature below that photocopies of this authorization may be used in insurance claims and the "Signature on File" may be used in lieu of my actual signature thereon. I have been informed of the charges for treatment and agree to be directly responsible for payment of all charges which insurance will not pay. I fully understand the above and will comply with these expectations. By signing below, I am stating that I have received, read and understand the above policies and hereby agree to them: Client s Signature Date Responsible Party Date

5 Client s Name: Intake Date: Primary Therapist: Client Rights & Informed Consent PLEASE READ BELOW AND SIGN. THANK YOU! Client Rights Specialist, Inc. Maria Hanson, JD P.O. Box Madison, WI (608) Therapy cannot be defined in simple terms. I understand it varies depending on the personalities of the therapist and the particular issues I bring forward. I understand, in order for therapy to be most successful, it calls for a very active effort on my part. Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. I understand this creates safety to take risks and provides the support to become empowered to change. I understand that all information shared with the therapists at Connections Counseling is confidential and no information will be released without my consent. In all other circumstances, consent to release information is given through written authorization. I further understand there are specific and limited exceptions to this confidentiality: when a specific statutory exception applies or a duty to warn exists. Connections Counseling is a certified outpatient drug/alcohol and mental health clinic. In my best interest, I understand that I may be required to participate in random urine drug screens. This may be further explored in individual sessions. I understand that while psychotherapy and/or medication, may provide significant benefits, it may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings, or may lead to the recall of troubling memories. However, the purpose of therapy is to alleviate problems and symptoms I present. I further understand it is the therapist s responsibility to suggest alternative treatment modes and will assist in referrals when appropriate and necessary. I understand that I have the right to withdraw informed consent at any time in writing. Otherwise this consent will be valid for 15 months. If I have any questions regarding this consent form or about the services offered at Connections Counseling, I may discuss such with my therapist. Also available if requested, is a pamphlet explaining your rights and the grievance procedure available to you. Please ask your therapist or the office if you would like a copy. I have read the above information and have been notified of my rights and grievance procedure available to me. My therapist has also informed me of the cost of treatment. I hereby give my informed consent to receive treatment. Date CLIENT SIGNATURE Date GUARDIAN SIGNATURE (if client is under 14 years of age) Date THERAPIST SIGNATURE

6 CONNECTIONS COUNSELING, LLC 5005 University Avenue, Suite 100, Madison, WI (608) FAX (608) NOTICE OF PRIVACY PRACTICES Effective Date: July 15, 2003 DUTIES OF PROVIDER Connections Counseling, LLC (CC) is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices. CC is required to abide by the terms of this Notice as may be amended periodically. THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice is required by regulations established under federal law, the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accounting Act of 1996 (HIPAA). This notice is intended to inform you of your rights regarding records that Connections Counseling is required to keep on the service that you obtain from us and the other obligations CC has and ways that CC may use or disclose your protected health information. The Privacy Rule is lengthy and extremely complex. This Notice cannot be a complete and accurate account of the contents of the Privacy Rule or State Laws that apply to the matters described here. If you have questions about these matters, please discuss them with your therapist before making any sensitive disclosures or ask to contact the Connections Counseling Director. Information that you disclose in order to obtain services from CC will generally not be re-disclosed to anyone else without your consent. CC, however, may use your health information, that is, information that constitutes protected health information as defined by the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), for the purposes of providing you services, obtaining payment for your care, and conducting health care operations. CC has established a policy to guard you against unnecessary disclosure of your health information. THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED: TO PROVIDE THERAPY: When your CC therapist plans to be out of town or otherwise unavailable to deal with crisis that you may experience, they may brief their backup therapist on the nature of your situation so that you will receive better care should you need it. SUPERVISION: State of Wisconsin regulations require supervision for some therapists, who may review your health information with their supervising psychologist or psychiatrist. Such review will be documented in your confidential file. TO OBTAIN PAYMENT: While CC will not seek reimbursement for services from insurance or third party payers without your consent, the process of obtaining such payment may involve disclosure. CC may need to obtain prior approval from you insurer and may need to explain to the insurer your need for health care and the services that will be provided to you. CC may include your health care information in invoices to collect payment from third parties for the care that you receive from CC. For example, CC may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or CC. In most cases, what is used is simply a numerical code for what you are working on with your CC therapist and the dates of service. Some managed care plans require more descriptive information for them to agree to reimburse. A form may need to be filled out by your therapist and mailed or faxed to the provider. Some payers, such as Worker s Compensation, require copies of session notes in order to reimburse. Such third party payers are generally subject to the provisions of the HIPAA. It is your choice, however, to use a third party payer versus paying for CC services yourself. Please discuss your situation with your therapist as it applies to your disclosure. If CC is collecting payment from you, CC has a right to bill you if need be and use collection agencies or other means as necessary and to disclose what is needed for that purpose. You have the right to request the address where we bill you and phone numbers where you consent for us to call you if needed to reschedule appointments. ACCREDITATION AND COMPLIANCE REQUIREMENTS: In order to be certified by the State of Wisconsin, CC must comply with onsite reviews to insure compliance with State Regulations. Such reviews involve a small random sampling of client files by a State auditor who is bound by confidentiality requirements of HIPAA. Managed care companies may also perform onsite inspections of records for their clients. To assure compliance with such rules, CC therapists conduct periodic internal audits of each other s client files. WHEN LEGALLY REQUIRED: CC will disclose your health information when it is required to do so by any State, Federal, or Local Law. TO REPORT ABUSE, NEGLECT, OR DOMESTIC VIOLENCE: CC therapists are required to notify government authorities if they believe a client who is a minor is the victim of abuse or neglect. CC will only disclose abuse, neglect, or domestic violence between adults when the client agrees to the disclosure or when specifically required or authorized by law. TO PREVENT INJURY: CC may, consistent with applicable law and ethical standards of conduct, disclose your health information if they, in good faith, believe that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety, or to the health and safety of the public. IN CONNECTION WITH JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: As permitted or required by State law, CC may disclose your health information in the course of any judicial or administrative proceeding in response to a court or administrative order. CC may also disclose in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, 1

7 but only when reasonable efforts have been made to tell you about the request or to obtain an order protecting your health information. FOR LAW ENFORCEMENT PURPOSES: As permitted or required by State law, CC may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime. FOR SPECIFIED GOVERNMENT FUNCTIONS: In certain circumstances, the Federal regulations authorize CC to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody. AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION Other than is stated above, CC will not disclose your health information without your written or verbal authorization. Verbal authorizations may be used if the disclosure you request has a time frame or other practical consideration that favors it. Verbal consents will be recorded in your CC file. If your representative authorizes CC to use or disclose your health information, you may revoke that authorization in writing at any time. YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION RIGHT TO REQUEST RESTRICTIONS: You have the right to request restrictions or limitations on CC s uses or disclosures of protected health information about you for therapy, payment or health operations. CC is not legally required to agree to your request. Should you wish to make such a request, please inform your therapist, who will give you a form for making the request. RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request that CC communicate with you about confidential matters through specific channels, in a certain way or at a certain location. For example, you may ask that CC only contact you at home, or only by mail. CC will not ask you the reason for the request, and, while not obligated to do so, will accommodate reasonable requests. RIGHT TO INSPECT AND COPY: You have a right to inspect and copy certain parts of your records, which includes records on your health information and billing records, but not notes that are kept by your therapist for his or her own use. If you request a copy of the information, CC may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. CC may only restrict your request to inspect and copy if there is a reason to believe that access would be harmful to you. RIGHT TO AMEND: If you believe that your health information records are incorrect or incomplete, you or your representative have the right to request that CC amend your records. That request may be made as long as the information is retained by CC. A request for amendment of the records must be made in writing to your CC therapist or the CC Director, stating the reasons you believe the record is incomplete or in error and needs to be amended. CC may deny the request if it is not in writing or does not include a reason for the amendment. The request may also be denied if your health information records were not created by CC, if the records you are requesting are not part of CC s records, if the health information you wish to amend is not part of the health information that you or your representative are permitted to inspect and copy, or if, in the opinion of CC, the records containing your health information are accurate and complete. RIGHT TO AN ACCOUNTING OF DISCLOSURES: A record of disclosures will be kept in your CC file. You or your representative have a right to request an accounting of disclosures of your protected health information made by CC. The request for accounting must be made in writing to your CC therapist or the CC Director. The accounting per any 12-month period will be given without charge. Subsequent accounting requests may be subject to a reasonable cost based fee. RIGHT TO A PAPER COPY OF DISCLOSURES: You or your representatives have a right to a separate paper copy of this Notice at any time even if you or your representative may have received the Notice previously. To obtain a separate copy, please contact the CC Clinic Manager. RIGHT TO COMPLAIN: If you believe that your privacy rights have been violated, you or your representatives have the right to express complaints to CC and to the US Secretary of Health and Human Services. Any complaints to CC should be made in writing to the CC Director. CC encourages you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint. AMENDMENTS TO THIS NOTICE: CC reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all health information that it maintains. Each version of the Notice will have an effective date on the first page. I have received and read the Notice of Privacy Practices from Connections Counseling, LLC, understand my rights under HIPAA, and will contact Connections at (608) with any questions regarding my privacy rights. Client Name (please print) X Client Signature Date X Guardian Signature Date (if Client is under 18 years of age) Witness Signature Date 2

8 Client Follow-up Authorization Client Name: I understand that Connections Counseling would like to conduct two confidential followups after my therapy has ended. The initial follow-up would occur in about two months, and the second in about six to eight months. The follow-ups would be in the form of a discrete mailing, or if I so choose, by a confidential telephone interview. I understand that the purpose of these follow-ups is to gather information on the effectiveness of the treatment program and to find ways to improve it. It has also been explained to me that the follow-ups will be solely for the purpose of getting information about how I am getting along and will be of no immediate benefit to me. I understand that my ratings and/or answers will be kept strictly confidential and the information will be used only to help evaluate Connections Counseling s services. It has been explained to me that I can refuse to participate or later withdraw my consent to participate with no adverse consequences to me, and that this consent will expire in two years from the date of my signature. This authorization, however, is subject to revocation at any time. Any information that has been provided up until written withdrawal of this consent can be used for the intended purpose. Having been informed of the above request, Connections Counseling may contact me/us for the: Initial follow-up Agree Do Not Agree 6-8 month follow-up Agree Do Not Agree For the 6-8 month follow-up, I/we prefer a: Mailed Survey Telephone (your phone number) Best time to Call Client s Signature Date Date Parent/Legal Guardian s Signature (if client is a minor)

9 Name: DOB: Date: Primary Therapist: Personal History The following are questions asked of all persons beginning service at Connections Counseling, LLC. The information you provide will assist your therapist in getting to know you as quickly as possible. Please answer ALL questions as completely as possible. Your answers are UconfidentialU and will not be shared with anyone outside the clinic without your written consent. What brings you to Connections? Please list any difficulties with being able to attend treatment (transportation, childcare, etc). 1. General Information Currently in school? Yes Full Time Part Time No Currently employed? Yes Full Time Part Time No With whom do you live? How would you describe you racial/ethnic background? (Optional) Do you have any personal spiritual or religious beliefs? (Optional) Yes No If yes, please describe 2. Crime and Criminal Justice If you have received any charges please fill out the box below. Date Charge Outcome/Consequence Do you have an attorney? If so, who? PLEASE NOTE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations (42 C.F.R. Part 2) prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. See Rule 2.32(A). C:\Users\JK-77\Desktop\2010 pre-pdf form Personal History Packet.docx

10 If you are currently on supervision, probation or parole, please explain and provide the name of the Social Worker/Probation /Parole Officer: 3. Social Connectedness Please list any family history of mental health issues or substance use: Name Relation to you Issue Please list those people you consider part of your support system: Name Relationship Age Closeness to individual (1 not close 5 very close) 4. Physical Health Who is your primary care physician? Please list any physical or dental conditions that concern you. Have you ever experienced a head injury? Yes No If yes, please explain. Please list any known allergies. Please list all medications you are currently taking and who prescribes them. Have you ever been hospitalized? Yes No If yes, please explain. PLEASE NOTE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations (42 C.F.R. Part 2) prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. See Rule 2.32(A). C:\Users\JK-77\Desktop\2010 pre-pdf form Personal History Packet.docx

11 Alcohol and other drug use is a risk factor for having a communicable disease (such as sexually transmitted diseases [STDs], human immunodeficiency virus [HIV], hepatitis B or C, or tuberculosis [TB]. Would you like the counselor to provide you with information on communicable diseases? Yes No 5. Past Treatment History Please note any mental health and substance abuse treatment services you have received, including counseling, crisis, psychiatric evaluation, prescription for medications or hospitalizations, assessment, classes, detox, outpatient and inpatient services or self-help groups Dates Issue Treatment Provider/Hospital Outcome 6. Mental Health Using the scale below, please identify any behaviors and/or symptoms that you are or have been concerned about in the last 3 months: (1 = minimal to 5 = major) Anger Anxiety Compulsive Actions Depression Disorientation Distractions Eating Disorder Fatigue Gambling Addiction Hallucinations Hopelessness Impulsive Internet Addiction Irritability Judgment Errors Loneliness Memory Loss Mood Swings Obsessive Thoughts Panic Attacks Phobias/fear Poor Hygiene Sexual Addiction Sexual Difficulties Recurring Thoughts Sleeping Problems Suicidal Thoughts Worrying Other Have you ever been diagnosed with a mental health issue? If so, what: Please describe your history of any traumatic experiences (some examples of traumatic experiences may include: physical abuse, sexual abuse, emotional abuse, violence, neglect, divorce, death of a loved one, abortion, natural disaster, war, etc.) Include information as victim, perpetrator, or affected family member: PLEASE NOTE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations (42 C.F.R. Part 2) prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. See Rule 2.32(A). C:\Users\JK-77\Desktop\2010 pre-pdf form Personal History Packet.docx

12 6. Substance Abuse Drug Classes Past Concern? Current Concern? Alcohol Uppers Cannabis Cocaine Hallucinogens Inhalants Nicotine Opiates PCP Benzos Synthetic Drugs How many days have you used this month? How do you use? (smoke, iv, snort) How much do you use? If you use substances, what do you like best about using alcohol or others drugs? How long have you been using? If you use substances, what do you like least about using alcohol or others drugs? What is the longest period of time you have abstained from all alcohol and drug use? What were the circumstances? 8. Goals for Treatment What do you hope to gain from participating in services at Connections Counseling? What strengths do you possess that would help you reach these goals? What might get in the way of you reaching these goals? Is there anything else that would be helpful to know about you? Do you wish to make a request to see a Psychiatrist? Yes No If yes, please explain. Client Signature & Date PLEASE NOTE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations (42 C.F.R. Part 2) prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose. See Rule 2.32(A). C:\Users\JK-77\Desktop\2010 pre-pdf form Personal History Packet.docx