Client Intake Forms

Client-intakeform

Step 1 of 8

WELCOME to the New Client Intake Forms Section:

The following collection of forms is meant to gather your information so that we may enter you into our electronic health records (EHR) system called TherapyNotes. All of your protected health information (PHI) is encrypted and kept secure throughout this process.

Let us know if you need any assistance. Thanks!

Client Information Form
Client Information Form

First Name*

Last Name*

Middle Initial

Sex*

Male/Female/Other
Pronouns*

She/Her, He/Him, They/Them, Other
Sexual Orientation*

Lesbian, Gay, Bi, Straight/Heterosexual, Something else, Unknown, Choose not to disclose
Gender Identity*

Male, Female, Transgender Male, Transgender Female, Genderqueer, Other, Choose not to disclose
Race*

White/Black/Hispanic or Latino/Asian/Native Hawaiian or Pacific/Choose not to disclose
Language*

Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*
Can We Text This Number?*

Yes/No/Text Only/Call Only
Social Security Number*

Date of Birth*
MM slash DD slash YYYY

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Phone Number*

FOR MEDICAID RECIPIENTS ONLY
Name of Insurance Company

Member ID Number

Medicaid ID Number

PLEASE PROVIDE THE FOLLOWING INFORMATION ONLY IF YOU HAVE COMMERCIAL INSURANCE:
Name Policy Holder

DOB of Policy Holder
MM slash DD slash YYYY

Relationship to Client

Place of Employment

Name of Insurance Company

Member ID

Annual Deductible Amount

Group Number

Copay Amount

Targeted Case Management
Do you have any of the following

Depression

Schizophrenia

PTSD

Bipolar

Addiction

Anxiety
Other

Needs & Goal

Housing

Food

Disability

Transportation

Employment

Clothing

Legal Assistance

Education

Medical Referral
Other

What to expect
You will be contacted by your case manager within 48-hours, and they will meet you twice a month in order to help you complete your needs and goals.
I am interested in Case Management*
I am interested in Case Management
I am NOT interested in Case Management
Client Printed Name

Phone
Signature

Date
MM slash DD slash YYYY

Clients Rights
Clients Rights

Right to request how we contact you.
It is our normal practice to communicate with you at your home address and daytime phone number you gave us when you scheduled your appointment, about health matters, such as appointment reminders etc. Sometimes we may leave messages on your voicemail. You have the right to request that our office communicate with you in a different way.
Right to release your medical records.
You may consent in writing to release your records to others. You have the right to revoke this authorization, inwriting, at any time. However, a revocation is not valid to the extent that we acted in reliance on such authorization
Right to inspect and copy your medical and billing records.
You have the right to inspect and obtain a copy of your information contained in our medical records. To request access to your billing or health information, contact the office manager. Under limited circumstance we may deny your request to inspect and copy. If you as k for a copy of any information, we may charge a reasonable fee for the costs of copying, mailing and supplies.
Right to add information or amend your medical records.
If you feel that information contained in your medical record is incorrect or incomplet e, you may ask us to add information to amend the record. We will make a decision on your request with 60 days, or some cases within 90 days. Under certain circumstance, we may deny your request to add or amend information. If we deny your request, you have a right to file a statement that you disagree. Your statement and our response will be added to your record. To request an amendment, you must contact the office manager. We will require you to submit your request in writing and to provide an explanation concerning the reason for your request
Right to an accounting of disclosures.
You may request an accounting of any disclosures, if any, we have made related to your medical information, except for information we used for treatment, payment, or health care operational purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to the Privacy Officer. We will notify you of the cost involved in preparing this list.
Right to request restrictions on uses and disclosures of your health information.
You have the right to ask for restrictions on certain uses and disclosures of your health information. This requestmust be in writing and submitted to our office manager. However, we are not required to agree to such a request.
Right to complain.
If you believe your privacy rights have been violated, please contact us personally, and discuss your concerns. If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individ ual will not be retaliated against for filing such a complaint
*
I HAVE READ, UNDERSTOOD, AND AGREE TO ALL OF THE ABOVE INFO.

Consent to Release Information
Release of Information To/From*

Who you would like to have access to your medical information.
Patient Name*

I consent for Kentucky Mental Health Care (KMHC) to release my (or my dependent’s) personal healthcare information (PHI) to requesting third party organizations, including, but not limited to: the social security administration (SSA) and other government entities, medical offices, mental health offices, and attorneys. I understand that PHI is considered every page of my (or my dependent’s) electronic health record file, including, but not limited to: intake forms, progress notes, treatment plans, itemized bills, assessments, file uploads, and discharge paperwork. I understand that there is a potential for disclosure of this information by the third-party recipient and if that occurs, federal law may not protect the information and KMHC is not liable.
Client Signature*

Parent/Guardian must sign if client is a minor

Date*
DD slash MM slash YYYY

Right of Revocation

I understand that I have the right to revoke this authorization at any time by sending written notice (address below) to Kentucky Mental Health Care, LLC. I understand that a revocation is not valid to the extent that Kentucky Mental Health Care, LLC has acted in reliance on such authorization. This authorization does not expire until I submit a written request. A hard or digital copy of this release shall have the same force and effect as the original.
Client Signature

Parent/Guardian must sign if client is a minor

Date*
DD slash MM slash YYYY

Notice to Receiving Provider or Organization

You may not re-disclose any of this information unless the individual who consented to this disclosure specifically consents in writing to such re-disclosure
Corporate Mailing Address

Kentucky Mental Health Care | 5115 S. 3rd Street | Louisville, KY 40214
Non Consent
I do not wish to consent to the release of information at this time. I understand that I may want to revisit this in the future. I can reach out to the front office if I wish to change this.

HIPAA Notice of Privacy Practices
HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice describes our policies related to the use and disclosure of your healthcare information. Your health information may be used for the purposes of providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allows us to use and disclose your health information for these purposes.
TREATMENT We may need to use or disclose health information about you to provide, manage or coordinate your care or related services. Which could include consultants and potential referral sources.
PAYMENT PAYMENT Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. We may bill the person in your family who pays for your insurance.
HEALTHCARE OPERATIONS We may need to use information about you to review our treatment procedures and business activity. Information may be used for certification, compliance and licensing activities.
There are some instances where we may be required to use and disclose information without your consent. For example, but not limited to: Information you and/or your child or children report about physical or sexual abuse: then by Kentucky State Law, we are obligated to report this to the Department of Children and Family Services; If you provide information that informs us that you are in danger of harming yourself or others, we must report this also; Information may be used to remind you of /or to reschedule appointments or treatment alternatives; Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order; Clinical records, psychotherapy notes and other disclosures require a separate signed release of information.
You have a right to or will receive notification of a breach of any unsecured personal health information. You have a right to restrict any disclosure of personal health information where you have paid for services out-ofpocket and in full.
METHOD OF CONTACT BY OFFICE
We may send you appointment reminders by text message or phone call and leave a voice message. NOTICE OF PRIVACY PRACTICES AND CLIENT RIGHTS: I have read and received a copy of the Notice of Privacy Practices and Client Rights document.
Client/Guardian Signature**

Date*
MM slash DD slash YYYY

Informed Consent
INFORMED CONSENT
By signing this form, you agree to receive mental health services provided by Kentucky Mental Health Care, LLC, and its independent contractors. We know that starting counseling is a big decision and you may have many questions. We will do our best to answer any questions or concerns. This form explains information about KMHC policy, State and Federal Laws, and your rights about counseling. All KMHC employees and contractors have met the highest level of education, certification, and licensing requirements set forth by Kentucky state law. Counseling practices, philosophy and plan limitations and risks will be discussed with you today

TREATMENT PROCESS AND DOCUMENTATION
It is the mental health professional’s responsibility to keep accurate records including Evaluations, Treatment Plans, and Progress Notes. By signing this document, you are consenting to the Treatment Plan that your provider creates and agree to any goals, objectives, and therapy techniques that may be used in your therapy process

INSURANCE BILLING
If you plan to use insurance to pay for services, claims will be sent to the insurance company based on information used at the time of service. Sometimes, insurance information may change or may not be up to date. If for any reason, inaccurate information related to deductibles, co-pays, or number of available sessions, etc. is retrieved at the time of service, KMHC will bill the client for any additional costs associated with mental health services rendered. Additional services may not be provided until the client’s balance is current. If balances remain unpaid for 60 days, client information will be sent to a collection agency.

EMERGENCY ROOM/HIGHER LEVEL OF CARE FOLLOW-UP TREATMENT POLICY
Potential patients at KMHC will be assessed during their outreach phone call (or email) in order to see if they’ve been in an emergency room and/or higher level of care. KMHC is not under any obligation to serve these potential patients within 7-days, but as best practice, we will do our best to get these individuals scheduled with one of our providers within that time frame.
Existing patients at KMHC are responsible for reporting any ER and/or higher level of care visit within 3-business-days of discharge. KMHC staff and providers are cognizant of the possibility someone has been in the ER and/or a higher level of care, but are not responsible for guaranteeing this 7-day time frame can or will be met.

CONFIDENTIALITY AND EMERGENCY SITUATIONS:
Confidential information discussed in session is not discussed with anyone without your written permission except for:
1. Diagnosis and dates of service shared with your insurance company to process your claims
2. Information you tell KMHC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services
3. Where you sign a release of information to have specific information shared
4. If you tell KMHC you are in danger of harming yourself or others
5. Information shared with
6. When required by law.
If you need to contact me between counseling sessions, please call my office. E-mail, text messages and social networking sites are not confidential and I may not be able to respond. If an emergency situation would happen, you can call my office to have a counselor call you. If no call is received within 15 minutes or you can’t wait call 911.

CONFIDENTIALITY AND EMERGENCY SITUATIONS:
Confidential information discussed in session is not discussed with anyone without your written permission except for: 1. Diagnosis and dates of service shared with your insurance company to process your claims 2. Information you tell KMHC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services 3. Where you sign a release of information to have specific information shared 4. If you tell KMHC you are in danger of harming yourself or others 5. Information shared with 6. When required by law. If you need to contact me between counseling sessions, please call my office. E-mail, text messages and social networking sites are not confidential and I may not be able to respond. If an emergency situation would happen, you can call my office to have a counselor call you. If no call is received within 15 minutes or you can’t wait call 911.
KMHC does not want to terminate your care.
With that being said, there are a lot of people in need of services and only so many open appointment spots. We have to prioritize those who are more compliant and who cancel less. Our general guideline is to allow for three cancellations without notice before we terminate your care. Our contracted clinicians may still choose to terminate care prior to three cancellations, and we as a company may choose to continue care after three cancellations. Please try your best to make all scheduled appointments. If you can’t make it, please cancel with 24+ hours notice when possible. Cancellations given with this level of notice will not usually count against you. KMHC will always attempt to make contact via your preferred method of communication before sending a termination notice. If you need help making it into the office or with getting ahold of the right tools to utilize TeleHealth, let us know and we’ll do our best to assist you. Our front office notifies me of potential terminations and I have also instructed them to give my direct number to any client faced with termination of care. Feel free to contact me if you have any questions or concerns. Thank you for trusting KMHC to serve your mental health treatment needs.
Joseph Nalley, CEO
Client/Guardian Signature**

Date*
MM slash DD slash YYYY

Telehealth Consent
I agree to participate in a telemedicine evaluation and/or ongoing treatment performed by an independently contracted provider who assumes sole responsibility and liability for treatment. By signing this agreement, I authorize the electronic transmission of my medical information and/or videoconference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. *Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small. I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person. I understand that medical records of telemedicine services will be kept at Kentucky Mental Health Care. I understand that some or all of my medical information may be used for teaching or educational purposes. I agree to have my telemedicine medical records reviewed for the purposes of evaluation (data collection, analysis and presentation in verbal or written format at scientific meetings). I understand that any presentation will not identify me by name or other identifiable markers.
Client Name:*

Client Signature:*

Today’s Date*
MM slash DD slash YYYY

Client Intake Forms

Client-intakeform

Step 1 of 8

WELCOME to the New Client Intake Forms Section:

Client Information Form

Client Information Form

FOR MEDICAID RECIPIENTS ONLY

PLEASE PROVIDE THE FOLLOWING INFORMATION ONLY IF YOU HAVE COMMERCIAL INSURANCE:

Targeted Case Management

What to expect

Clients Rights

Clients Rights

Right to request how we contact you.

Right to release your medical records.

Right to inspect and copy your medical and billing records.

Right to add information or amend your medical records.

Right to an accounting of disclosures.

Right to request restrictions on uses and disclosures of your health information.

Right to complain.

Consent to Release Information

Right of Revocation

Notice to Receiving Provider or Organization

Corporate Mailing Address

Non Consent

HIPAA Notice of Privacy Practices

HIPAA NOTICE OF PRIVACY PRACTICES

METHOD OF CONTACT BY OFFICE

Informed Consent

INFORMED CONSENT

TREATMENT PROCESS AND DOCUMENTATION

INSURANCE BILLING

EMERGENCY ROOM/HIGHER LEVEL OF CARE FOLLOW-UP TREATMENT POLICY

CONFIDENTIALITY AND EMERGENCY SITUATIONS:

CONFIDENTIALITY AND EMERGENCY SITUATIONS:

KMHC does not want to terminate your care.

Telehealth Consent

Our Services

Business Development

Contact Info