Registration

First Name(Required)

Middle Name or Initial

Last Name(Required)

Date Of Birth(Required)

Age(Required)

Legal Gender(Required)

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Address(Required)

Street Address Address Line 2 City State ZIP Code

Cell Phone

Home Phone (optional)

Email(Required)

Relationship Status(Required)

Spouse or Partner's Name (if applicable)

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Insurance Company(Required)

Subscriber ID (Member ID)(Required)

Group Number (if applicable)

Referred by:

What brings you to counseling, and what are your goals for therapy(Required)

Have you had previous counseling?(Required)

Yes

If yes, please describe your past counseling experience (when did you go?, how long did you attend, what were you working on?, what was that experience like?).

Describe your educational background. (highest degree, what you studied, etc)

What does your spouse/partner do for work and is it a full-time or part-time job?

Provide details on your current marriage/relationship. How long have you been together/married? How would you describe your relationship? etc.

Provide details on any past marriages/relationships (how long did it last, when did it end, what was the relationship like, etc).

Any military history?

Yes

If yes, what branch, what was your experience, when did you serve?

List how many children you have and their ages. Also describe which relationship they are from (your current relationship or a past relationship) and the quality of your relationship with each of them.

List any hobbies or interests you have.

What do you do for work? How long have you been there? Do you like it?

Any past trauma or abuse? If so, please provide any details that you are comfortable sharing.

Describe any medical problems or health concerns.

List any medications and dosages (if applicable). Also describe what they are for, how long you have been on them, and how effective you feel they have been.

Who prescribes your medications?

Describe any substance use history (past and present). Include the frequency and quantity of use.

Describe any religious or spiritual beliefs you have and how important it is to you.

Describe your social life? Do you have many close friends? How often do you do things with them?

Describe your family of origin. Are your parents still alive? Are they married? What was their relationship like to each other? List your siblings and their ages. Describe your relationship with your parents and siblings.

Clients Rights and Expectations Rights and Risks:

You may ask questions about any aspect of the counseling process.
If you have been referred by a court or state agency, you have the right to divulge only what you want to be included in a report.
Therapy is most effective when you are open and can speak honestly about your emotions and experiences.
Therapy may include talking about emotionally provoking subjects and scenarios.

Confidentiality

Information shared by you in session will be kept confidential.
Information will not be released without your written consent, except for professional consultation if needed and unless required by law.
Progress notes will be stored securely online through a platform called Upheal. Upheal handles protected health information for counselors, adhering to HIPAA regulations as a Business Associate. Momentum Counseling, Inc has signed a Business Associate Agreement (BAA) to protect data that is shared with Upheal. Under the BAA, Upheal adheres to regulations such as the HIPAA Security Rule and Privacy Rule. This ensures that electronic health information (ePHI) is safeguarded through appropriate administrative, physical, and technical measures, ensuring its confidentiality, integrity, and security.
I am required by law to disclose information pertaining to suspected child abuse, the inability to care for one’s basic needs for food, clothing or shelter, and threatened harm to oneself or others.
The court may subpoena counseling records.
It is understood that information regarding treatment and diagnosis may be provided to an insurance company.

Appointment Expectations

All appointments are telehealth only (video sessions online) and are scheduled through our website.
If you will be in your vehicle for the session, make sure that you are not driving and that you are parked in a safe place and not along the road.
Please arrive on time, as you use up your own time when you arrive late for an appointment. The usual length of an appointment is 50 minutes.
Late cancellation (less than 24 hours before)and/orno-show appointments are billed to the client for the full amount. In the case of illness, please notify us no later than 9:00 a.m. the day of the appointment. Please leave a message if you get voice mail.
If your appointment is cancelled or missed, please reschedule on our online calendar.
Insurance companies will not pay for no-show charges or late cancellation charges.

Fees

The client portion (co-pay) of fees is expected at the time of service. We ask that you make this payment online just PRIOR to your appointment.
Your health insurance may help you recover some of your counseling costs. Most group policies, but few individual policies cover outpatient psychotherapy. Please verify with your company the amounts of coverage for outpatient psychotherapy by licensed professionals. If your policy requires prior authorization to receive services, it is your responsibility and needs to be handled prior to your first visit. ·Insured clients are expected to take care of their fees as services are rendered. Our office will bill your insurance company for services provided. This office cannot accept responsibility for collecting your insurance claims or for negotiating a settlement on a disputed claim. You are responsible for payment (and insurance claims) on your account. Failure to pay your part may jeopardize your benefits, availability of treatment and appointments.Co-pays are not negotiable.
Clients paying on a cash basis, and not billing an insurance company are expected to pay in full at time of service unless a payment plan has been previously arranged.
Except in the case of minors or when other arrangements are made, the person receiving the counseling service is financially liable.
Accounts become delinquent after thirty (30) days.Accounts 90 days in arrears will be terminated.
Any change in my financial situation I will discuss with my therapist. In the event you find it necessary to change mental health providers and require records to be sent from Momentum Counseling, your account will need to be paid in full.

Session Fee(50min) - $150 Non or Late Cancellation - full amount based on your policy or agreement Bounced Check Fee - $35

Emergency Contact Information

If you are experiencing an emergency, please call 911 or visit your local emergency room.

Validation

I have read, understand and agree to the above policies. I understand that I may request a copy of these policies to take with me if desired. I hereby authorize Momentum Counseling, Inc. and my therapist to release any information acquired in the course of my therapy to my insurance company (if client is a minor, parent or guardian sign). I understand my insurance coverage is a relationship between me and my insurance company, and I agree to accept financial responsibility for payment of charges incurred. I understand that a re-billing fee/financial charge complying with Massachusetts State Law will be applied to any overdue balance, and in the event of non-payment, I will bear the cost of collection and/or court costs and reasonable legal fees should this be required. I have read and/or received a copy of Momentum Counseling’s Privacy Policy

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