Client Clinical Intake and Billing Information

in order for us to best serve you we need to have quite a bit of information prior to your first appointment. When you hit "SUBMIT" at the end of this form, the data will be transmitted through a secure, HIPAA compliant system to our office where your therapist can review it with you in session. 


Please complete and submit this form so we can schedule your first appointment. You'll also read and sign an additional form in our waiting room giving us informed consent, but you won't have to supply any of the information in this form (except your identifying info). We CANNOT start an intake session without these materials completed and the consent document signed. Give yourself about 20 to 30 minutes to complete this form. In order to preserve your privacy you'll have to finish this form in one sitting because it cannot be saved and is not filed until you hit submit. If you need to stop and continue later, please save the form by hitting the button below:



 
Client Name: Gender:
Nickname: Marital Status:
Date of Birth: Employment:
Address 1: Is client a minor? Yes     No 
Address 2:  Occupation: 
City/State/Zip:    
Mobile Phone:      
Home Phone:    
Work Phone:    
Other Phone:    
Preferred Phone:    
Email Address:    
Caregiver 1
(for minors):
Caregiver 2
(for minors):
In Case of Emergency:  
 
  

Fees

We try hard to make services affordable for families and will work closely with you to keep your account current. We offer interest-free payment plans for clients who place a credit card number on file at our office. However, we also retain a bill collection agency for outstanding accounts that become delinquent. Please read each of the following paragraphs to assure your understanding of our billing procedure and ask your intake therapist if you have any questions about these procedures. You will be asked to check a box after each statement.

For independently licensed staff our usual and customary hourly fee is $150 for intakes and $120 for ongoing psychotherapy of 45 minutes in length. Your insurance company may have contracted a different rate for your therapy. Your copay and deductible may range from 100% of the cost of the sessions to no cost at all depending your plan. You will want to talk to your insurance company before your first session to find out what they will and won't pay. In addition to regular therapy and medication appointments, we charge for other professional services by the quarter hour. These include report writing, telephone conversations, attendance live or by video at meetings with other professionals you have requested and authorized us to attend, preparation of records or treatment summaries, and time spent performing any other service you may request. We usually do not charge for email and texting (see media policy below) unless you require a heavier than average use of these services. If you become involved in any legal proceedings that require the participation of our staff, you will be expected to pay for our professional time even if the staff member is called to testify by another party. 

FPS charges a flat fee of $50 for all missed appointments or late cancelations. A missed appointment is any appointment not canceled. A late cancel is any appointment not canceled with 24 hours prior notice. Fees for missed or late-canceled appointments due to legitimate emergencies will usually be waived. If you cancel more than a third of your appointments or reschedule more than half your appointments, even if they are not late-canceled or late rescheduled, FPS staff may discuss terminating your case.  Medication management and psychotherapy require consistent attendance and we typically have a list of people wanting to get in. We can't help you if you're not here on a consistent basis. While such termination is extremely rare, we do include it in our informed consent for such cases.

 
Clients must pay all costs for services that are not paid by an insurance carrier. While we try to verify insurance benefits before your treatment begins, you are ultimately responsible for knowing what will and won't be paid for. Though we rarely file a collections action, we reserve the right to do so if your account becomes past due and you have not placed a credit or debit card on file to make regular payments. By signing this document, you are releasing Family Psychological Services, LLC to provide necessary information to its designated collection agency. If you move or relocate without making arrangements with Family Psychological Services, LLC for future billing, you may be subject to immediate collection action. If you write us a check and it is returned, a $30 fee will be added to your account. 

 I have read the above statement about fees, collection, and billing, I understand them and I agree.
 I need to discuss the above statement
 with a therapist at intake before I agree.

Guarantors (People Who Pay Your Bill)

If you are over the age of 18 and have a parent or other individual guaranteeing your bill we must have the guarantors billing information, he or she must agree to a payment arrangement, or you must present a credit card in your name with an authorization to bill the card. If you request the bill be sent to your guarantor, you are agreeing that your billing information will be shared with him or her. Be aware that if the guarantor does not pay the bill, you will be ultimately responsible for its payment and subject to collections. Please provide the contact information for your guarantor if he or she is not the insurance policyholder noted above.


Divorced Parents Presenting A Child

If you are a divorced parent presenting your child for treatment, by signing this document you are agreeing that you alone will be responsible for the bill, regardless of any court orders that may be in place. We will supply receipts for all services you purchase at this office so you can turn those in to the child’s other parent for full or partial payment, but you are ultimately responsible for any payments incurred, unless you obtain a guarantor statement from the child’s other parent. By checking this box you are agreeing to this stipulation. If your ex-spouse contacts this office and puts a credit card on file to split charges, we will honor that card for half the charges after insurance. However, you remain responsible for the bill if the non-presenting parent does not honor that agreement.

 I am an adult client and thus not affected by this statement.
 I am not a divorced parent and thus not affected by this statement.
 I am a divorced parent presenting a child for therapy. I have read the above statement and I agree to pay all costs associated with my child's treatment.


Paying Charges Not Covered By Insurance

You are ultimately responsible for your charges whether you pay cash or whether you are using insurance. Insurance clients nearly always incur copays, coinsurance, and deductible. Because insurance policies now vary so greatly and initial benefit disclosures from insurance companies do not guarantee payment, we require all clients to place a credit or debit card on file at our office to cover costs at time of service or within the scope of a payment plan agreed upon between you and FPS. FPS is authorized to charge Health Savings and Flex Benefits cards for services rendered in the covered year. The card number you provide will be transmitted through our HIPAA compliant email system (FPSSecure.com secured by LuxSci.com) and will be stored in a HIPAA compliant billing program (TherapyNotes LLC) both of which are password protected and can only be accessed from one of our computers. By signing this document, you are authorizing us to bill your credit card for all services not otherwise covered or, with prior approval, you may set up a flat-rate monthly payment plan which charges your card either on the 15th or the 30th of the month for an amount stated below.  

 I have read the above statement about placing my credit card on and I authorize Family Psychological Services charge services not covered by insurance (FPS does not accept into service anyone who does not have a viable form of payment on file). 

 I certify that I am currently on KanCare and will not owe a copay‚Äč or other insurance charge.
 

Name:  This is a flex benefits or health savings card active thru 
Credit Card Number: Type of Card:  Visa       MasterCard      Discover
Billing Address:
Expiration Date: CCV (Security) Code: 
   


This authorization will remain in force and effect until my account is closed or until Family Psychological Services, LLC Inc. has received written notification from me of its termination, in such time and such manner as to afford Family Psychological Services, LLC Inc. a reasonable opportunity to act on that request. I understand that if I cancel this agreement without making another payment arrangement my account will be considered delinquent and may be referred for collection action.

Electronically sign in the square below using your finger (touch screen) or a mouse or trackpad before you submit it. If you've never done this before, it's a bit of an awkward process and your signature won't look great, but it is a valid legal signature. You only get one chance, so do your best. This is NOT the signature for the entire document. Just the credit card authorization. 
 

Statements

Clients who request them can receive a statement of billing for tax or reimbursement purposes. We can give you a paper statement in the office at any time. If you want to receive a statement and don't want to come by the office, we prefer to email using our HIPAA compliant email system (FPSSecure.com) which we have found to be more reliable since many of our clients move during college or in career transition but leave their emails the same. You will need to set up a password when you receive the email to access that information. We will also send statements by US Postal if requested to do so. Please accept at least one of the following:

 Send my statements by secure email to this address: 
 Send my statements by US Postal to the address below (if you are a student, please us a permanent address:
 


Insurance Billing

Clients, who qualify by diagnosis and wish to do so, may choose to have their treatment costs reimbursed by a medical insurance carrier. By contract, we must bill your insurance company directly. By completing this form you authorize us to provide to your carrier whatever information is required to assure reimbursement for services we may render. Typically, this will include diagnosis, but some insurance companies like Blue Cross and Blue Shield of Kansas ask for more extensive information like treatment plans, goals and objectives. In fact, we have found it best to presume that when you elect to use insurance, your entire record is open to review. Insurance companies are bound by Federal laws guiding confidentiality, but Family Psychological Services, LLC cannot be responsible for any information once it is released to your insurance company or any use to which that company might submit it. To learn more about your insurance company’s policies on privacy and billing, contact them directly. Some clients prefer to avoid the exposure of private information and choose to pay cash instead of using insurance benefits, particularly when they have a high deductible plan. Please talk with the office manager if you prefer this option. We do not offer payment plans for clients who opt out of insurance.

Send Your Insurance Card. If you want us to bill your insurance we strongly encourage you to send a picture of your insurance card to carriepoemba@fpssecure.com so we can review it before your appointment. This email is HIPAA-compliant and encrypted so your health information is secure. If you do not bring the information by the time of your first appointment, you will be considered a self-paying (cash) client until the card can be presented and we will bill you full fee for the session. 

Medicare and KanCare (Medicaid). We do not accept any form of Medicare as primary or secondary insurance. Several of our providers accept KanCare (Medicaid) for children and adolescents within their scope of practice. At this time we do not see Medicare or Medicaid clients for medication management but our staff will work with other prescribers on your case as necessary.

Relationship and Sex Therapy. Treatment which is primarily intended to improve sexual functioning or relationships is not deemed to be "medically necessary" by insurance companies and thus those services are not covered. The exception to this rule is when these forms of treatment are used to treat other diagnosable conditions, like ADHD, anxiety, depression, etc. In these cases, insurance companies understand that involving family members, partners, and friends may improve outcomes for the identified individual client. Family Psychological Services strongly prefers to work this way. This is not, however, martial or relationship therapy, but what we refer to as a "conjoint therapy process" intended to treat one of the family members for conditions that may also have relational and sexual components. In most cases, partner participation can provide valuable treatment options, but the chart must be open on the identified and diagnosed client, the partner considered a "collateral" in that process, and the conjoint therapy must address the individual client's treatment goals.

Be aware that these limitations are not policies of Family Psychological Services, but requirements of insurance company contracts. Providers who bill for a marital-only or sex therapy (as opposed to conjoint services for an identified and properly diagnosed mental health condition) are doing so in violation of their insurance contract. Please feel free to discuss with our office the details if your case as far as insurance is concerned. Sometimes we can determine if your situation would or would not be billable through insurance.

Court Ordered Treatment. Insurance may or may not reimburse for any court-ordered treatments. Contact your insurance company to find out if this is covered on your policy and please provide us with a written statement to that effect before your intake session. This is also true of divorce or coparenting therapy that is not initiated in response to a specific mental health concern. Many times children and adults are having significant mental health problems adjusting to the divorce. Those situations are typically reimbursable by insurance because we can demonstrate "medical necessity" in terms of behavior, thought, and emotion related to the divorce. However, coparenting therapy, supervised therapy with parent and child to reintegrate their relationship, and any forensic service related to divorce is NEVER reimbursable. Under no circumstances will insurance or KanCare reimburse for court-ordered therapy if you do not also meet medical necessity requirements. You and your therapist will consider whether you meet those criteria in your first session.

I have read and understand the above insurance disclosure and have chosen the following (check just one box)
I am providing my information for FPS to bill my insurance company or KanCare.
I am DECLINING to provide insurance or KanCare information. I will pay cash in full at time of service or will provide a credit card on file.
I understand that my services fall into a category that will not be paid for by insurance and I will instead pay for them in full at time of service.

 

Policy Holder Relationship: 
Date of Birth of Policy Holder Gender of Policy Holder: 
Cell Phone Number
Home Phone Number
Work Phone Number
Address LIne 1
Address Line 2
City/State/Zip
Policy Holder Email Address
Employer Associated With Insurance
Insurance Company Name
Insurance ID Number
Group Number
We will need a copy of your insurance card. You take a picture of it and email to carriepoemba@fpssecure.com or you can upload it here: 
 

Client Medical Information

Have you ever been to our office before?
Have there been divorces, deaths, or serious illnesses in your family recently? Yes No
Are you currently pregnant (women):
Do you plan on becoming pregnant (women):
Physician Name, Address, Phone Number, and Fax:
Approximate date of last medical exam:
Approximate date of your last menstrual period (women):
Please list any contraceptive you use regularly including implants, shots, IUDs, and vaginal inserts (women):
Please describe any medical or surgical conditions you are currently being treated for (e.g.., thyroid, autoimmune, hormonal imbalances, etc.). If none, write "none."
Please describe any episodes of seizure or fainting you have experienced, how recently they have occurred, and how this condition is being treated. If none, write "none."
Please describe any head injuries you have received. If none, please write "none":
Please describe any allergies you have to medications or other substances. Please be sure to note if you are allergic to cats (we have one in Wes Crenshaw and Kelsey Daugherty's office suite). If you have no allergies, please write "none."
Have you ever been diagnosed with bipolar (manic-depressive) disorder, schizophrenia, schizoaffective disorder, or another psychotic disorder?
Are you having difficulty performing your duties as a parent, employee, spouse, student etc.
Do you receive social security disability benefits or have they been applied for?
Have you thought of hurting yourself within the last 5 years?
Have you ever attempted suicide?
Have you thought of hurting someone else within the last 3 years?
Have you ever harmed or attempted to harm someone else?
How Often Do You Drink Alcohol?
How Often Do You Smoke Cigarettes?

Please indicate/describe in detail anything else about your health history that you think would be useful or important for your practitioner to know. If none, write "none."
 
 

Current Medications

Please list below all medications you're currently taking for any condition. If you prefer, you can get a printed list from your pharmacy and bring it to your first appointment for us to scan and keep on file or you can have them fax it to 785-371-4519.
 
Name Indication Dose/Frequency Start Date Prescriber
 

Psychiatric Medication History

 
Please list below any psychiatric medications (e.g.., medications for depression, anxiety, bipolar disorder, ADHD, etc.) you've been on in the past. If you prefer, you can get a printed list from your pharmacy and bring it to your first appointment for us to scan and keep on file or you can have it faxed to 785-371-4519.


Is there any medication you have taken that you have had an allergy or adverse reaction to? Please note below and explain the reaction:


 

Counseling and Psychiatric History

Therapist Dates Diagnosis Setting
Inpatient* Outpatient
Inpatient* Outpatient
Inpatient* Outpatient
Inpatient* Outpatient
Inpatient* Outpatient

* If you marked any of the above items as "inpatient" list below the client's age during the psychiatric hospitalization(s) and the facility in which the client was hospitalized. 

Substance Use History

Substance Age at Onset Current Use Method Last Used

 
Have you ever felt the need to cut down on your drinking or drug use?
Have you ever been annoyed by criticism of your drinking or drug use?
Have you ever felt guilty about your drinking or drug use?
Have you ever had a morning “eye-opener” (used drugs or alcohol first thing in the morning to get started or relieve withdrawal)?

Family History

If the client is an adult, please tell us about the family you raised or are raising. If the client is a minor, skip this and go on to the next section.
 
Your Childrens' Names Age Living With Medical, Mental Health, or Substance Abuse Problems


Please tell us about the family that raised the client.  For minors, complete information about current family.

Name Age Current Location Medical, Mental Health, or Substance Abuse Problems

Checklist of Concerns (All Ages) 

Abuse-emotional Drug use (prescription, OTC, street drugs, etc.) Perfectionism
Abuse-neglect Eating problems (over-, under-eating, low appetite) Pessimism
Abuse-physical Emptiness Picking at body (nails, fingers, skin)
Accident prone or clumsy Failure (school, work, social) Pregnancy
Acts bossy toward others Fears, phobias Procrastination
Aggressive toward others Financial troubles (debt, impulsive spending) School problems
Alcohol use Friendships Self-centeredness 
Anger, hostility, arguing, irritability Gambling Self-esteem (low)
Anorexia Gets into more trouble than others Self-neglect, poor self-care habits
Anxiety, nervousness, worry Grieving, mourning, deaths, losses, divorce Sexual Desire (low)
Attention, concentration, distractibility Guilt Sexual conflict in relationships
Bed wetting Headaches, migraines Sexual dysfunction (pain, erectile dysfunction, etc.)
    Health, illness, medical concerns, physical problems Sexual or gender orientation concerns
Break up of romantic relationship Impulsiveness, loss of control, outbursts    
Breaks or destroys things Inferiority feelings Shyness, social anxiety
Bulimia Infertility Sleep problems (too much, too little, insomnia nightmares, sleep walking)
Bullying Offender Interpersonal conflicts     
Bullying Victim Irresponsibility Smoking (tobacco)
Career concerns, goals, and choices Judgment problems  Soiling or wetting during day
Child Custody Legal matters, charges, suits Stealing 
Childhood issues (adults) Loneliness Sucking or chewing (thumb, clothing, blanket)
    Lying Suicidal thoughts or behavior
Codependence Marital conflict Temper problems, self-control, low frustration tolerance
Compulsions Memory problems    
Confusion Menstrual problems, PMS, endometriosis
Weight loss or gain
Constipation or diarrhea Mood swings Withdrawal, isolating
Cruelty to Animals Motivation, laziness Work problems, overworking, can't keep a job
Crying easily        
Decision making, indecision, mixed feelings, putting off decisions Obsessions    
Depression, low mood, sadness, crying Oversensitivity to rejection    
Diabetes Panic attacks    
Divorce, marital separation Parenting, child management, childcare    

 


Additional Information For Minors Only (adult clients can skip)

 
 Child was adopted at  Who Does Child Live With:
Who has legal custody of the child?: Has the child ever been sexually abused? 
 Yes     No    Possibly
Who cares for the child during the day?:   Has the child ever been physically Abused?
 Yes     No    Possibly
Who disciplines the child at home?:             Has the child ever been removed from the home by the court or social services?  Yes    No    
What school does the child attend? Have there been divorces, separations, deaths, or serious illness in the family since the child’s birth? 
 Yes     No
What is the grade is the child in? What is the child's teacher's name:
 
Mother’s age at child’s birth:                   Father’s age at child’s birth:      
 
 
Length of pregnancy Child's Birthweight  

Which of the following happened to the mother during the pregnancy?
     
 Serious illness  Spotting blood  Severe vomiting/nausea  Alcohol Use  Prescription Med Use
 Marijuana Use  Other drugs Cocaine, crack or similar drug    
Other problems during pregnancy:

Which of the following occurred during the birth of the child:
     
 Born other than head first  Difficult labor  Blue or yellow color at birth Problems breathing  Rh blood problem
Other problem at birth:

Which of the following occurred while the child was a baby?
   
 Difficulty with breast or bottle-feeding   Difficulty giving up bottle or pacifier  Failure to thrive
 Wanted to eat too much or too little   Difficulty eating solid food  Had colic
Other problem when child was a baby:

Which of the following occurred before age 5?
   
 Stomachaches or vomiting  Problems in potty training  Clumsiness  Slow sitting up or walking alone
 Slow learning to talk or difficult to understand  Accident prone    
         
 

Signature

I have completed and read the Family Psychological Services Consent to Treatment and Payment Forms and my questions have been answered. I consent to receive services from Family Psychological Services, LLC if services are offered under these terms. I realize that this document outlines the core issues of informed consent and that others may come up during my therapy. If that happens, I am free to talk to my therapist about these issues.

Electronically sign this document in the square below using your finger (touch screen) or a mouse or trackpad before you submit it. If you've never done this before, it's a bit of an awkward process and your signature won't look great, but it is a valid legal signature. You only get one chance, so do your best.
 


Submitting This Form 


After you have completed the document click the button below to submit it to our office staff. Please come to your appoitnmen.