Miller Counseling Services, PC

Secondary Insurance Coverage: Please note that we only file secondary coverage to plans in which we participate and only if we participate with primary coverage for out of network plans. If you have any

questions about this, please let us know upon arrival. Thank you.

Gender Marital Status Employment F M Single Married Other Employed FT Student PT Student Other

Client Name________________________________________________ Date of Birth____/_____/____ (First) (Middle Initial) (Last) Address______________________________________________________________________________ Home Phone(______)______________________ Cell Phone(______)____________________________ Email Address_________________________________________________________________________ Emergency Contact ____________________________________|___(______)_____________________ Name Relation Phone Employer____________________________________ Work Telephone(_____)____________________ Referred to us by_______________________________________________________________________

Appointment Reminders (choose ONE):

Automated Telephone Call ( Home OR Cell). Email Reminder Text Reminder (standard messaging rates apply) None

Insurance Information (Required unless you are a Private Pay/no insurance client) Primary Insurance Carrier______________________________________ Effective Date ___/____/____ Subscriber ID#____________________________________________ Group#____________________ Your Relationship to Insured: Self Spouse Child Other Insurance Tel#_________________________

Insured’s Information (All fields required before we can file out of network claim)

Insured’s Name_________________________________ Insured’s Date of Birth_____/_______/_____ Insured’s SSN#________-_______-________ Insured’s Marital Status (if used as insurance ID) Single Married Other Insured’s Address______________________________________________________________________ Insured’s Phone Number_(__________)______________________ Insured’s Gender M F Insured’s Employer_____________________________________________________________________

Cell Phone Carrier (Required for Text Reminders, Circle One) Verizon AT&T Boost Nextel Sprint SunCom T-Mobile Virgin Cricket US Cellular MetroPCS Qwest ACS Other:____________________________

Therapist___________________ Initial Appt Date______________ Session Time ________________ PPWK Arrival________________ Client ID#____________________

Miller Counseling Services, PC

Personal History Form

308-A W. Millbrook Rd. Raleigh NC, 27609 919-848-2100 O | 919-848-2009 F Revised 10/8/12

Please fill out applicable fields

Name:________________________ Date of Birth:_____/______/______ Client ID#:_____________________

Relationship Information Single Engaged Married Divorced Separated Cohabitating Widowed Anniversary Date:____/_____/_____ Years Married______ How long separated/divorced/widowed?____ Number of client previous marriages___________ Number of spouse previous marriages___________ Spouse/Partner Name:____________________________ Spouse phone________________________ Names, Gender, Ages of Children_________________________________________________________

Medical Information

Please fill out any information for any health care professionals (psychiatrists, psychologists, nutritionists, mental health care professionals etc.) below.

Provider Profession Provider Phone# Dates Treated Reason

Current Psychiatric & Non-Psychiatric Prescription Medications Medicine Dose Length Prescribed Reason

Any Medical Issues? ____________________________________________________________________________________ ____________________________________________________________________________________ ___________________________________________________________________________________

Miller Counseling Services, PC

Personal History Form

308-A W. Millbrook Rd. Raleigh NC, 27609 919-848-2100 O | 919-848-2009 F Revised 10/8/12

Please fill out applicable fields

Name:________________________ Date of Birth:_____/______/______ Client ID#:_____________________

Parent Information (Circle Custodial Parent if applicable)

Employment Information

School Information

Additional Information

Mother:_________________________________ Email:________________________________________ Mother Address:_________________________________________________________________________ Mother Home Phone:______________________________ Mother Cell Phone:______________________ Father:__________________________________ Email:_________________________________________ Father Address:_________________________________________________________________________ Father Home Phone:_______________________________ Father Cell Phone:_______________________ Legal Guardian:___________________________ Email:_________________________________________ Legal Guardian Address: __________________________________________________________________ Legal Guardian Home Phone:________________________ Legal Guardian Cell Phone:________________

Occupation:________________________________________________ FT PT Unemployed Employer:___________________________________________________________________ Length of time with Employer/most recent job:_____________ Length of time unemployed___________

Experience at Workplace (check all that apply) Pattern of Tardiness Absenteeism General Performance General Satisfaction Negative Feelings Difficulty with Supervisor Difficulty with Co/workers

College Level College or University Attending_________________________ Major_________________ Minor_________ Extra-Curricular Activities or Interests_________________________________________________________

Elementary, Middle or High School Level Name of School:__________________________________________ Public Private Homeschool School Address:___________________________________________________________________________ School Phone:___________________________ Grade:___________ Principal:________________________ Learning Disabilities/Special Needs:___________________________________________________________ Tutoring:___________________________ Strengths/Talents/Sports________________________________ Extra-Curricular Activities or Interests:_________________________________________________________

Reason for consulting with our practice? ________________________________________________________________________________

Reason for seeking counseling at this time/brief history of main issue: ________________________________________________________________________________________________________________________________________________________________

What do you hope to get out of counseling? ________________________________________________________________________________

How can we be of most help to you?__________________________________________________ Any additional information you wish your therapist to know about your situation?

________________________________________________________________________________________________________________________________________________________________

J

Susan S. Miller, PhD, LPC, NCCMiller Counseling Services, P.C.

308-A West Millbrook RoadRaleigh, North Carolina 27609

919-848-2100

Cancellation & Parent Feedback Policy

Cancellation: I understand that you occasionally will be unable to attend your scheduled appointment. When this happens, I ask that you notify our office as soon as possible, so that I may make your appointment time available to another client. Unless it is an emergency, or you or your child become urgently sick, you need to provide 24 hours cancellation notice, or you will be charged the full fee for your session. Whenever possible, I do try to reschedule a missed appointment within the week.

Parent Feedback: In situations of separation or divorce within a family, it is this office’s practice to meet for parent feedback sessions with both parents if necessary so that all parties are hearing the same information about their child. This gives parents the opportunity to understand and discuss their child’s progress in therapy in an open environment where questions are encouraged.

********

I have read and I understand the policies stated above and agree to accept responsibility as described.

_____________________________Please Print Name____________________________ _________________Client Signature Date

Form E- Informed Consent David Wiley 1

David Wiley, MS, LPC LPC #2457

Miller Counseling Services, P.C. 919-848-2100(O) 919-848-2009(F)

308-A West Millbrook Road www.MillerCounselingServices.com

Raleigh, North Carolina 27609 dwile8@gmail.com

Administrative Director: Sarah Miller, MA mcs.receptionist@gmail.com

Professional Disclosure Statement/Client-Therapist Services Agreement

Welcome to Miller Counseling Services, PC. Counseling is a professional relationship that requires thoughtful consideration. The following information is designed to provide important information that will ensure that you know what to expect from counseling and the therapeutic relationship, my professional services and business policies. I am a Licensed Professional Counselor in North Carolina. I have practiced in a variety of behavioral health settings in the Triangle area of North Carolina since 1981, including innovative approaches to substance abuse and chronic pain management, crisis intervention, as well as working with relationship issues with couples and families. I earned a Master of Science degree in Counselor Education through the School of Education at North Carolina State University. My undergraduate degree, a Bachelor of Arts, was earned through the University of North Carolina at Greensboro. Additionally, post-graduate studies included a unique program through Azusa Pacific University, in collaboration with the organization Focus on the Family.

Therapeutic Counseling Services Psychotherapy is not easily described in general statements. It varies depending on the mix of our

personalities and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Some of the modalities that I use in therapy are: Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Talk therapy, Interpersonal Psychotherapy, Integrated Spirituality and Faith-Based therapies, Positive Psychology, Creativity therapy, Expressive Arts therapy, and other holistic approaches to psychological treatment. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable and possibly intense emotions. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. If you desire Faith-based Spiritual counseling, I will provide a safe place to explore your spirituality as it pertains to your journey. You may not be sure if you want to discuss your spirituality, and I would want you to feel comfortable to explore or not explore as you see fit. I believe that wellness is holistic, covering the whole person; cognitive, spiritual, emotional, relational and physical. Some of the modalities used in this type of therapy may be prayer/meditation, guided imagery, mindfulness/relaxation/contemplative exercises, inspirational reading, and exploration of distorted core beliefs that are affecting a person’s ability to live healthy emotional/spiritual life. Balance is emphasized for holistic healing. Treatment plans are individualized according to your needs. I would be happy to discuss any questions that you may have regarding how I counsel from a Faith -based perspective. You might also take a look at my website (www.MillerCounselingServices.com) to get more information. Our initial session is a Diagnostic Child or Adult Interview and will last about 90 minutes. Regular sessions are about 50 minutes. The first few sessions will involve a diagnostic evaluation of your needs or your child’s needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. I will be happy to help you set up a consultation with another mental health professional for a referral or a second opinion, if you would like. If your situation is beyond my expertise or scope of services, I will assist you in finding appropriate services with another specialist/setting.

We typically send out regular emails to our clients to communicate pertinent information about mental health, upcoming events, workshops, and opportunities to participate in groups. By signing this, you will automatically be placed on our email list for our updates, blog posts, and receive information that is relevant to you and/or your loved ones. Please be sure to let us know or “unsubscribe” if you do not want to continue receiving emails.

Team Approach At Miller Counseling Services, PC we work in a team approach to provide you with more comprehensive

and effective mental health counseling services. We provide individual, group, couples and family counseling. Substance abuse assessment, continuing care following treatment, chronic pain management, and eating disorder treatment are among specializations. Our team of professionals holds the educational degrees, certifications and licenses necessary to provide the counseling, coaching and therapy services for our patients. When necessary, we will consult with other mental health and medical professionals regarding patient care. Since Miller Counseling Services, PC provides treatment as a team, your PHI will be shared among professional

Form E- Informed Consent David Wiley 2

team members at Miller Counseling Services, PC who are part of your individualized treatment plan for the purpose of serving you more effectively in your healing journey. Your signature on the consent form will indicate that you understand this and understand that Miller Counseling Services, PC goes by strict confidentiality guidelines as described further in this agreement.

Sessions I typically see patients initially for an assessment phase that lasts from 2 to 4 sessions. During this time, we

can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I usually schedule one 50-minute session (one appointment hour = 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more/less frequent. I will schedule bi-monthly and monthly appointments as needed, as well. I may recommend other therapy such as substance abuse counseling or assessment, family or couple counseling, life or creativity coaching, group therapy as well as outside referrals to a nutritionist, psychiatrist, medical doctor, or other alternative health professionals or other treatment facilities and agencies. This could be part of your treatment protocol that provides the best outcome for your particular emotional and physical needs.

Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, unless we both agree that you were unable to attend due to circumstances beyond your control (such as unpredictable crisis or illness). It is important to note that insurance companies do not provide reimbursement for cancelled sessions. If it is possible, I will try to find another time to reschedule your cancelled appointment within the week.

Professional Fees Initial Diagnostic Session is $160. 50 minute session is $115. 30 minute session is $65.

MCS has different fees for different services such as individual and group therapy and coaching, psychosocial and educational testing, workshops, and phone consultations. These fees will be broken down into the hourly or less than hourly fees as low as 15 minute increments. Other services include report writing, some telephone conversations lasting longer than 10 minutes, preparation of records or treatment summaries, assessments, and the time spent performing any other service upon which we agree. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time in increments of 4 hours. That would include preparation and transportation costs, even if I am called to testify by another party. As a result of the difficulty of legal involvement, I charge $300 per hour for preparation, transportation and attendance at any legal proceeding. This cost is not reimbursable through insurance plans. Miller Counseling Services, PC does not encourage legal involvement on our part.

Contacting Me Due to my work schedule, I am often not immediately available by telephone. My telephone may be

answered by confidential voice mail that I monitor frequently. It may be answered by a trained professional receptionist or another member of the professional team. I will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times and

numbers when you will be available. If you are unable to reach me and feel that you can’t wait for me to

return your call due to a mental health emergency (suicidal, harmful to others or not able to function

alone), you will need to contact your family physician or your psychiatrist, the nearest emergency room

and ask for the psychiatrist on call, the Holly Hill Hospital Respond Line at 919.250.7000, or call 911

emergency services. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

Limits on Confidentiality The law protects the privacy of all communications between a patient and licensed professional counselor.

In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:

I may occasionally find it helpful to consult other health and mental health professionals about a client. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (Personal Health Information – PHI).

You should be aware that I contract administrative staff. In most cases, I need to share protected information with my Administrative Director and Receptionist for both clinical and administrative purposes, such as

Form E- Informed Consent David Wiley 3

scheduling, billing and quality assurance. All administrative staff have been given training about protecting your privacy and has agreed not to release any information outside of the practice without my permission.

I also may have contracts with an accountant, my malpractice carrier and a lawyer. As required by HIPAA, I would have a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this practice data except as specifically allowed in the contract or otherwise required by law. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.

If I believe that a client presents an imminent danger to his/her health or safety, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.

There are some situations where I am permitted or required to disclose information without either your consent or Authorization:

If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided you, such information is protected by the counselor-client privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.

If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.

If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.

If a client files a worker’s compensation claim, and my services are being compensated through workers compensation benefits, I must, upon appropriate request, provide a copy of the client’s record to the patient’s employer or the North Carolina Industrial Commission.

There are some situations in which I am legally obligated to take action, which I believe are necessary to attempt to protect others from harm and where I may have to reveal some information about a client’s treatment. These situations are unusual in my practice.

If I have cause to suspect that a child under 18 is abused or neglected, or if I have reasonable cause to believe that a disabled adult is in need of protective services, the law requires that I file a report with the County Director of Social Services. Once such a report is filed, I may be required to provide additional information.

If I believe that a client presents an imminent danger to the health and safety of another, I may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim, if identifiable, and/or calling the police.

If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I

will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.

Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of

professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or the record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.

In addition, I also keep a set of Personal Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Personal Psychotherapy

Form E- Informed Consent David Wiley 4

Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record and information revealed to me confidentially by others. These Personal Psychotherapy Notes are kept separate from your Clinical Record, and are protected in a locked environment. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal to provide them.

Minors & Parents I respect the right of children to independently consent to and receive mental health treatment. While

privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment and this requires that some private information disclosed by a child or teen be shared with parents. It is my policy not to provide treatment to a child or teen under 16 unless he/she agrees that I can share whatever information I consider necessary with his/her parents. For teens 16 and over, I request an agreement with my client allowing me to share general information about the progress of the teen’s treatment and his/her attendance at scheduled sessions. I expect parents or guardians to respect that communication between myself as therapist and their child/teen/ward is confidential. The exception would be if I believe that the child is in danger or is a danger to someone else. In such a case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child or teen, if possible, and do my best to handle any objections he/she may have. In situations involving separated or divorced families, the person who initiates services for a

child is the person responsible for payment, regardless of any other arrangement made with the ex-spouse.

Billing and Payments You will be expected to pay for each session at the time it is held, unless we agree otherwise. We accept

check, money order, credit card (Visa, MasterCard, Discover), and cash as payment for your counseling services. Adolescent clients who drive themselves to my office should be provided with payment from parents for each session. In case of proven financial hardship, I may be willing to scholarship. A late fee of $20 per month will be assessed against any balance outstanding over 45 days. Any returned checks will be charged a fee of $40.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.

Insurance Reimbursement As a courtesy to our clients, our office will file insurance claims for policies that cover outpatient out of

network counseling. To determine coverage, call the phone number on your insurance card and request to verify benefits. Clients pay in full amount at time of services provided and the reimbursement from the insurance company (if any) is returned directly to you.

Insurance Companies and EAPs often require that I diagnose your mental health condition to determine reimbursement. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and I have no control over what the company does with it once it is in their hands. It will become a part of your Permanent Health Record. By signing this Agreement, you agree that I can provide requested information to your carrier.

Complaints Should you have a complaint regarding my services, you would need to contact my licensing board, North Carolina Board of Licensed Professional Counselors, PO Box 1369, Garner, North Carolina 27529-1369, phone: 919-779-5642.

Client Signature_____________________________________________________________________ Date_____________________________

Therapist/Intern Signature________________________________________________________ Date_____________________________

Supervisor Signature_______________________________________________________________ Date_____________________________

K

Miller Counseling Services, P.C.308-A West Millbrook Road

Raleigh, North Carolina 27609919-848-2100 919-848-2009 fax

CONSENT FOR RELEASE OF PERSONAL HEALTH INFORMATION

Name and address of facility/person being asked to release information:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I, ____________________________________, hereby authorize the above-named (client name)facility/person to release specified information concerning me or ________________

(client name)to Miller Counseling Services, PC which includes Personal Health Information(PHI) pertinent to my treatment plan.

I, ____________________________________, also authorize Miller Counseling (client name)Services, PC to release specified information concerning me or__________________ (client name)to the above-named facility/person which includes PHI pertinent to my treatment plan.

I understand that I may revoke this consent at any time except to the extent that action based on this consent has been taken. This consent will expire automatically after 1 year from the date on which it is signed, unless it is a blanket release to an insurance company for hospitalization benefits or for research purposes.

This authorization and request is fully understood and is made voluntarily on my part.

Signed__________________________________________________ (specify if signature is that of client or legal guardian)

Therapist_________________________________________________

Date_____________________________________________________