Online Intake Form | Omaha NE | Envision Counseling Center LLC

New Client Intake Forms

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Consent to Treatment and Client Rights and Responsibilities
The undersigned requests and agrees to clinical therapy services. These services include but are not limited to: individual, family, couples, conjoint, marital, group and animal assisted counseling. In addition, I grant authority to my therapist to engage in professional consultation and/or emergency telephone responses necessary for my treatment.
If you experience a medical or psychiatric emergency, call 911 or go to your nearest emergency room.
Confidentiality Policy
Envision Counseling Center, LLC will give information to others only with my written consent with exception of the following: The law requires a report to be made if there is reason to believe that a child has been abused, a client threatens to harm him or herself, or another person.
Client Rights:
As a client you have the right to privacy, to be treated with respect, make decisions about your care and treatment plan, get information in a way that you can understand, and refuse treatment that you do not want.
Client Responsibilities:
Clients are responsible for giving us complete information about your health so we can better assist you. Please follow the treatment plan that you develop with your therapist, and attend appointments on time. All unpaid charges are the client’s responsibility.
Consent to Treatment
Acknowledgement*
- I acknowledge entering my name below is equivalent to a handwritten signature.
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY

Financial Agreement and Office Policy Notification
Thank you for choosing Envision Counseling Center, LCC as your service provider. We are pleased to have the opportunity to help you reach your therapeutic goals. In order to better assist you, we have policies in place regarding attendance and services not covered by insurance.
Payment is expected the time of service. This may be your self-pay, co-pay, co-insurance, or deductible amount. If you are unable to pay at time of service, the appointment can be re scheduled.
Please notify us as soon as possible if there are any changes in your insurance or payer coverage, policy number or employment. Failure to do so may result in claim denial. The client or responsible party is responsible for any charges not covered by insurance or third party payers.
There are some services you may want your therapist to provide that are not covered by insurance. These include but are not limited to: sessions held via phone or other non-face to face therapy, duplication of your medical records, court ordered or other legally related services, and other types of therapy or evaluation not covered by your insurance. Please ask your therapist for information on these fees.
Your therapist sets aside a specific appointment time exclusively for you. We require 24 hours notice for cancellations. This allows us to serve other individuals that require urgent appointments. We realize that true emergencies do happen, and such cases will be taken into consideration. Failure to provide 24 hour notification, or no-showing will result in a $25.00 fee to be paid by your next appointment. Three no-shows or late cancellations within a 90 day period will result in termination of services.
Parents or other care givers must be present in the waiting room with children under 10, and with children that require supervision. Please do not eat in the waiting room.
We request that you silence your cell phones in session and refrain from using them in the waiting room, as this may be disruptive to others. Thank you for your cooperation.
Acknowledgement*
- I acknowledge entering my initials and name below is equivalent to a handwritten signature.
Please initial here to acknowledge your understanding of our late cancellation fee.*
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY

Assignment of Insurance Benefits and Authorization to Release Information to Payers
I hereby authorize and request my insurance company, EAP, and/or Medicare and Medicaid to make payments directly to Envision Counseling Center, LLC for services rendered. I also authorize Envision Counseling Center, LLC to release any information pertinent to services rendered to any authorized representative ofmy insurance company, EAP and/or Medicare and Medicaid.
Acknowledgement*
- I acknowledge entering my initials and name below is equivalent to a handwritten signature.
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY

I acknowledge that I have been offered a copy of Envision Counseling Center LLC’s Notice of Privacy Practices form.
Acknowledgement*
- I acknowledge entering my initials and name below is equivalent to a handwritten signature.
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY