Parent Coaching Intake Form Light On Anxiety Parent Coaching Intake Form Step 1 of 12 8% Helpful Tips Before You Start1. Our form is most compatible with Google Chrome. If you would like to pause when working through the form, please use the save and continue link at the bottom of the page. 2. If you would like support or assistance in filling out Light On Anxiety’s intake form or if you would like to schedule a time for a care manager to fill out this form with you, contact [email protected] and we would be happy to assist you with this process. 3. PLEASE NOTE: The time and effort you put into filling out this intake form serves as the initial building block to your treatment plan. All information will be reviewed by your intake therapist prior to your 1st session so we can assist you in moving past obstacles you and your family are experiencing as rapidly as possible.Why are you seeking parent coaching support at this time? What are your treatment goals?* Attendance Policy*Consistent attendance is an essential part of CBT. Missing more than 1 out of 4 scheduled sessions may result in termination of services until your schedule allows for regular attendance in ongoing therapy services. I understand Light On Anxiety’s Attendance Policy and acknowledge that failure to maintain regular session attendance may result in the termination of therapy services.Electronic Communication / In Between Session Support Policy*– Email with Light On Anxiety is solely for administrative purposes. – Emails will be responded to within 1 business day. – If you would like to address a clinical matter outside of your regularly scheduled appointment time, please contact [email protected] to access “On Demand” therapy services. I understand Light On Anxiety’s policy around electronic communication and in between session support.Light On Anxiety's Child Custody Litigation PolicyI hereby confirm I have brought my child to Light On Anxiety to address his/her mental health issues. I understand that the role of Light On Anxiety is to treat mental health issues and that LOA will not become involved in any custody or visitation disputes. I recognize that for my child’s mental health, it is important not to involve the therapist in court proceedings. I therefore agree that as a condition of treatment for my child, I will not seek to have my LOA therapist testify in court, give a deposition, or an affidavit. I understand that the therapist will only become involved when the therapist determines it is necessary to protect the child. I agree to advise my attorney that the treating therapist will not become involved in any custody/visitation litigation. I agree that should I seek the therapist’s involvement in such litigation I will be responsible for the therapist’s attorneys fees in consulting an attorney to avoid involvement, and if ordered by the court to participate in the litigation, I agree to pay one week in advance of any court hearing for a minimum of at least 3 hours of the therapist’s time at the rate of $300 per hour. I understand that if I seek to involve the therapist, he/she may immediately discontinue care with my child. I acknowledge and agree to Light On Anxiety’s Child Custody Litigation PolicyPatient Legal Name* First Last Patient Preferred Name Date of Birth* Month Day Year Email* Phone*What is your preferred method of communication?* Email Phone Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is your child a client of Light On Anxiety?* Yes No How did you hear about Light On Anxiety?* Physician / Healthcare Provider Health Insurance Google Light On Anxiety Event Article or Media Appearance Book Authored by Light On Anxiety clinician Facebook Twitter Instagram Friend/Family School Contact Other If other, please indicate:* Name of Referring Provider* Referring Provider Organization (if applicable) Referring Provider PhoneReferring Provider Email Enter your email below to sign up for the Light On Anxiety newsletter and receive anxiety fighting tips and tools. * indicates required Email Address * First Name Last Name Payment Authorization Form This form provides important information regarding billing procedures and payment policies at Light On Anxiety. If you have any questions, please contact us at (312) 508-3645 or [email protected] prior to signing this form. Insurance-Based Services Light On Anxiety is an in-network provider with Blue Cross Blue Shield of Illinois (BCBSIL) Preferred Provider Organization (PPO), Blue Choice PPO and Aetna. Your insurance will provide a quote of benefits, not a guarantee of payment. While the filing of insurance claims is a courtesy we extend to our in-network clients, all charges are your responsibility from the date services are rendered. If your insurance company has not paid a claim within twenty (20) days of submission, you accept full responsibility for payment in full for any outstanding balance. It is recommended that you contact your insurance company prior to beginning treatment at Light On Anxiety in order to review your specific benefits including preauthorization requirements and your copay and deductible amounts. For all other insurance plans, clients are responsible for paying Light On Anxiety directly. We are happy to submit claims electronically, on a monthly basis, to facilitate obtaining out of network payment. We recommend contacting your insurance company to learn about your out of network benefits. Private Pay Rates All clients not utilizing in-network insurance have the right to receive a “Good Faith Estimate”. Private pay rates for clients not utilizing in-network insurance benefits are below. Master Level Clinician: Intake and treatment planning sessions (first two sessions): $180 each ($360 total) 25 minute sessions: $90 40 minute sessions: $135 53 minute sessions: $180 Doctorate Level Therapists: Intake and treatment planning sessions (first two sessions): $260 each ($520 total) 25 minute sessions: $130 40 minute sessions: $195 53 minute sessions: $260 Cancellation Policy All appointments cancelled with less than 24 hours notice are subject to a cancellation fee. Charges for missed appointments are not covered by insurance and are your responsibility. Coordination of Care Light On Anxiety values collaborative care with other providers as it helps to create the most integrated and appropriate treatment plan. If you are currently taking psychotropic medications, Light On Anxiety requires a 20 minute collaborative care meeting with the medication prescriber at the start of treatment. If you are using insurance benefits for Light On Anxiety services, we will attempt to obtain reimbursement for this collaborative care service from your insurance company. If the insurance company does not provide reimbursement, you will be charged at a prorated private pay rate. We attempt to keep all collaborative care exchanges as quick and effective as possible, typically about 20 minutes. Collaborative care will be billed at a prorated rate based on the time spent. Twenty (20) minutes of collaborative care will be billed at a rate of $70.Are you the individual responsible for billing?* Yes No Name of individual responsible for billing*Note: By providing this information to Light on Anxiety you authorize communication with individual financially responsible for your services for billing and administrative information exchanges. Email address for individual responsible for billing* Phone number for individual responsible for billing*Will you be using health insurance benefits to access Light On Anxiety services?* Yes No Insurance Plan* BCBS PPO Blue Choice PPO Aetna Other (please specify below) Insurance Plan Are you the primary insured?* Yes No Name of primary insured* Relationship* Self Spouse Parent Other Address for primary insured* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth for primary insured* Month Day Year Insurance Claim Submission Requirement* I acknowledge that If I do not upload a picture of the front and back of my insurance card, I will email a copy of my insurance card to [email protected] upon submission of this form, or I will be charged at Light On Anxiety’s private pay rates. Please upload a picture of the FRONT of your insurance card.Note: If you are unable to attach a file, please email a photo of both the front and back of your insurance card to [email protected] Max. file size: 64 MB.Please upload a picture of the BACK of your insurance card.Max. file size: 64 MB.Member ID (Please be sure to include letter pre-fix to number, "X" or "XXX")* Group Number* Credit Card on File Light On Anxiety requires that all clients maintain a credit card on file to cover any balance due after your insurance benefits are applied. For clients who are uncomfortable leaving a credit card on file through our secure billing system, clients may pay Light On Anxiety’s private pay rate via cash or check at the time of session for all services received. In the event that reimbursement is received from the insurance company, the client will be refunded any overpayment. Here’s how it works: 1. We securely save your credit or debit card before your visit. 2. If in network, we work with your insurance plan to determine your payment amount for the visit. 3. We process the payment for you automatically.Credit Card Type* Visa Mastercard Discover American Express Name on Credit Card* Credit Card Number* Expiration Date* Security Code (3 digits on back of card)* Is the billing address the same as listed for the parent above?* Yes No Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Authorization of Fee Payment In signing this form, I understand and agree to the following regarding billing and payment for charges related to my treatment at Light On Anxiety: 1. There is a 24 hour cancellation policy. When I schedule an appointment and cannot attend a session, I must provide at least 24 hours notice. If I do not provide at least 24 hours notice, I will be charged a $40 cancellation fee. I understand that this cancellation fee will not be covered by insurance. 2. Payment of services (copays and deductibles) is expected at the time of service. If in-network health insurance is used for my sessions, Light On Anxiety will seek reimbursement from the health insurance company. Any unpaid amounts, copayments and deductibles are my responsibility to pay. 3. I authorize recurring charges for fees, copayments and deductibles to be charged to the credit card provided on this form. I authorize the payment of fees to Light On Anxiety for services rendered. I authorize that my card may be used to resolve any and all balances in full for session charges, consultative charges and cancellation fees. I agree to provide payment at the time services are rendered. I agree to maintaining up to date credit card information on file to resolve all balances for services provided, unless otherwise agreed in writing with Light On Anxiety. I understand and acknowledge that late payments may be subject to an additional late payment fee and that ongoing noncompliance with payment terms may incur collection charges if the outstanding balance is not resolved in a timely manner.Authorization of Fee Payment* I agree to the authorization of fee payment as described above.Print Name of Signee (Individual Responsible for Payment)* Signature – Authorization of Fee Payment*Date of Signing* MM slash DD slash YYYY Consent I agree to the privacy policy.Consent to Treatment*What can I expect from initial visit? The first 2 sessions are devoted to a comprehensive assessment of your concerns and the development of a treatment plan. After the initial assessment is completed, the treatment plan will be reviewed and recommendations will be provided regarding which Light On Anxiety therapist will be the best fit based on clinical needs and scheduling requirements. What will treatment entail? Treatment will include one or a combination of the following: individual therapy (which can include family members), referrals to a psychiatrist for medication evaluation, specialized exposure therapy or referrals to a physician for medical evaluation. What is expected of me? We expect you to come prepared to work hard and play an active role in treatment. We will serve as your anxiety coach and teach you the skills and provide you with the support to move forward in living a vital life. But it is up to YOU to do the hard and transformative work of applying these new skills in your every day life. How frequently will we meet? A treatment plan will be customized to your needs and therefore, after the initial assessment, your therapist will be able to provide you with a recommendation for treatment intensity. When will treatment be completed? Light On Anxiety strives to make treatment as effective and efficient as possible. Therefore, progress towards your defined therapeutic goals will be measured frequently. As you move past the challenges that led you to initiate therapy, your therapist will discuss with you the process of terminating treatment as you become your own anxiety coach. If you are in a mental health emergency and require immediate assistance, please go to the nearest hospital emergency room and leave a voicemail message for your therapist to notify them of the emergency (312.508.3645). If you believe that you need therapy that provides 24 hour crisis management, please discuss this with your therapist and they will help you find a referral to a program that can best meet your needs. Do you accept Medicare/Medicaid? Light On Anxiety Treatment Centers are not a covered provider for Medicare or Medicaid. Therefore you or your legal representative accept full responsibility for payment of all charges. Usual Medicare limits to charges and services do not apply. By choosing to work with Light On Anxiety, you acknowledge that you completely forego the use of these benefits for your treatment at this center and agree that neither you nor any representative will file any claims to Medicare or Medicaid, nor will you ask the provider to do so. You acknowledge that you freely enter this contract with the knowledge of your right to obtain Medicare covered services from providers who have not opted out of Medicare, and understand that you are not compelled to enter into private contracts with providers who have not opted out of Medicare. Are there any limits to confidentiality? The information you share in therapy is confidential and will not be disclosed without your written permission except when you may pose a danger to yourself or others or as required under Illinois and Federal law. If we ever suspect you are at risk to harm yourself or others, we are required to report this to the Firearm Owners Identification (FOID) program. If you disclose information related to suspected child or elder abuse, Light On Anxiety is obligated to report it. If Light On Anxiety receives a court order signed by a judge to release your information, we are obligated to honor it. Light On Anxiety Litigation Policy I agree that I am here for treatment and that I have been advised that if I need an expert witness in my case, I should hire someone specifically for that purpose. I understand that my Light On Anxiety therapist will not serve as a witness in any type of litigation. I agree to advise my attorney that Light On Anxiety will not become involved in any litigation. I agree that should I seek the Light On Anxiety’s involvement in such litigation I will be responsible for Light On Anxiety’s attorney fees in consulting an attorney to avoid involvement. If ordered by the court to participate in the litigation, either in giving a deposition or testifying or if I voluntarily agree the following rules shall I apply: 1. Fees for time involved in preparing a report(s) for LOA attorney or the court must be paid in advance before such report will be written. 2. The fee for LOA testimony or deposition must be for a 3 hour block of time at $900 for the three hours. Any time exceeding the 3 hours including travel time, shall be billed at the rate of $400 per hour. Fees must be paid at least one week in advance of the testimony being given. If not paid in advance, LOA will not appear to give testimony. 3. If the testimony date is cancelled or rescheduled with less than one business day’s notice, the fee will not be returned or will still be owed. Any further rescheduling will require the payment of another 3 hour minimum fee. Light On Anxiety In Person Treatment Policy Completion of this health consent form is required prior to initiating in person treatment at LOA or entering a LOA office space, in order to maximize health and safety for all. In order for LOA to provide you with in-person services, the following protocols must be followed by clients and providers: ease let us know. By consenting to in-person treatment you acknowledge that there is still a potential risk of exposure and that you agree to follow the safety protocols outlined above in order to engage in in-person services. In addition, you agree that if your health status changes, you will delay entering an LOA office space/receiving in person treatment until you are no longer experiencing COVID-19 (or any other infectious disease) symptoms and have been symptom free for the appropriate time frame, per CDC guidelines. Light On Anxiety Telehealth Treatment Policy Benefits and Risks of Telehealth Telehealth refers to providing services remotely using telecommunications technologies such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person therapy and telehealth, as well as some risks. For example: Risks to Confidentiality Because telehealth sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. We will take reasonable steps to ensure your privacy, but it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. Data Protection The nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. We will make every attempt to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth). Technology Issues There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies. Appropriateness of Telehealth Usually, we will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work. From time to time, we may schedule in-person sessions to “check-in” with one another. We will let you know if we decide that telehealth is no longer the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services. Emergencies and Technology Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan before engaging in telehealth services. We will ask you to identify an emergency contact person who is near your location and who we will contact in the event of a crisis or emergency to assist in addressing the situation. We will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency. If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call us back. Instead, call 911, or go to your nearest emergency room. Call us back after you have called or obtained emergency services. If the session is interrupted and you are not having an emergency, disconnect from the session and we will wait two (2) minutes and then re-contact you via the telehealth platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, call us on the phone number provided to you. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. Fees The same fee rates will apply for telehealth as apply for in-person therapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance provider does not cover electronic telehealth sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to engaging in telehealth sessions in order to determine whether these sessions will be covered. Records We will maintain a record of our session in the same way we maintain records of in-person sessions in accordance with our policies. I consent to treatment. I certify receipt and understanding of Light On Anxiety’s informed consent and agree to all its terms and conditions.Date* MM slash DD slash YYYY Signature – Consent to Treatment* Clinical InformationFrom 0-10 (0 being the least), please indicate your level of emotional distress relating to parenting in the past week.* What do YOU see as the top 3 parenting problems you are experiencing?*On a scale of 0-10, how much distress do these problems cause you?*Challenge 1Challenge 2Challenge 3On a scale of 0-10, how motivated are you to work on the problems above?*Challenge 1Challenge 2Challenge 3Describe a recent moment where you experienced your top problem. How much distress were you experiencing in that moment (0-10)? What behaviors did your child engage in? What behaviors did you engage in?* Clinical HistoryHave you ever had outpatient therapy before? If so, when and what for? What did you find helpful and what did you find unhelpful? * Medication InformationAre you currently taking any psychotropic medication?* Yes No Current Psychotropic Medication and Dosage* Have you taken any psychotropic medication(s) in the past?* Yes No Past Psychotropic Medication(s) and Dosage(s)* Date(s) during which past psychotropic medication(s) were taken.* Describe your current physical health:* Good Fair Poor Please describe your sleep quality (check all that apply).* I tend to procrastinate going to bed (i.e. frequently stay up watching TV, etc.). I have a difficult time falling asleep once in bed. I frequently wake up in the middle of the night. I have difficulty falling back to sleep after waking up in the middle of the night. I normally only get a few hours of sleep. I frequently oversleep. I am drowsy during the daytime. I nap during the daytime to supplement poor sleep. I have difficulty concentrating / completing work due to drowsiness. I have overall good sleep quality. What health and wellness behaviors do you strive to engage in (check all that apply)?* Balanced nutrition Regular exercise Meditation / mindfulness Socializing with friends / family Spirituality Volunteering / community engagement Lifelong learning Other (please describe) Other health and wellness behavior(s):* Do you now, or have you ever, had any difficulties with substance use? If yes, please describe such difficulties.*Do you have any current or prior legal issues? If yes, please describe.*Regarding the questions above, is there any information you consider clinically relevant and would like to share about your co-parent's medical history (if applicable)?* Additional Releases of InformationIf you would like Light On Anxiety to coordinate care with any individuals or providers on your behalf, please complete an additional release of information. Note: To ensure progress on intake form is not lost, right click on the link to open the release of information in a new tab/window. Family HistoryPlease describe any family history of significant psychiatric problems.*Has anyone in your immediate family died by suicide?* Yes No Please describe your childhood family experience:* Outstanding home environment Normal home environment Chaotic home environment Witnessed physical/verbal/sexual abuse toward others Experienced physical/verbal/sexual abuse from others Other If other, please indicate.* Relationship HistoryWhat is your relationship status?* Single Married Partnered Separated Divorced Widowed Committed Relationship Engaged Remarried Other Please indicate name(s) and age(s) of children.* How satisfied are you with your current family life?* Feel free to share more information. Educational HistoryHighest Level of Academic Pursuit High School Vocational Training College Graduate School Average Grades:* Disciplinary problems?* Aspects of school that excel/excelled in:* Aspects of school that struggle/struggled in:* History or suspected history of learning or attentional concerns:* History of bullying or teasing at school?* Overall feelings and attitude towards school:* Employment HistoryAre you currently employed?* Yes No What is your profession?* Do you enjoy your current line of work?* Have you ever been fired from a job?* Yes No Please explain.* Is there anything else you would like to share with the clinical intake team to assist us in designing your customized treatment plan?*