Forms

Forms.jpgAt LifePointe Counseling, you will need to fill out a variety of forms.  Some of these forms are mandatory, such as the registration. Other forms are optional and/or related to specific issues you may encounter.

For your convenience, we have organized these forms by topic with a designation as to whether they are mandatory or optional.  Most clients prefer to print these documents at home and bring the completed forms with them on their first visit.  However, we also have hard copies available upon your request in our office.

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Hold Harmless Agreement

Since LifePointe is now seeing clients in person again, there are new protocols and guidelines that have been put in place.  If you want to be seen in person, you MUST sign this agreement, and you MUST follow the guidelines within the agreement.  Also, most insurance companies are still allowing for Telehealth sessions, if you are uncomfortable coming in to the office.  If you are unsure if your insurance company covers telehealth, please call your insurance company and request confirmation that Telehealth is covered under your particular insurance plan.  Be sure and bring that confirmation with you whether it is a document or an email.

You can print and sign this agreement yourself and bring it to the office, or you can read through it here and sign a copy at the office when you arrive for your appointment.

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New Client Paperwork

New client paperwork is mandatory.  Legally we have to provide you with our HIPAA, Notice of Policy Privacy, and Client Rights documents.  If you would like to save computer ink and paper, you may simply print the “New Client Packet – Printable/Without HIPAA” document listed below, then simply read our “Notice of Policy Privacy and Client Rights”.  Or, if you prefer, you may come to your appointment 15-20 minutes early and fill them out in our office.

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Financial Forms 

Whether you plan to use your insurance or pay privately for our services, the forms below serve to clarify our financial policies and procedures.  We encourage you to read our Financial Policies document prior to your first visit.  If you will be paying for our services by credit/debit/HSA card, it will be required to have one of these cards on file with our office. This simplifies paying your co-pay or if there is a charge for a missed appointment or late cancellation.  Missed appointments and late cancellations should be part of your first session discussion.  If your provider does not bring it up, be sure and ask.  If you are submitting a request for sliding scale fees, please review the Sliding Scale Table document and complete the Financial Disclosure.  If you have any further questions, please contact our office at 314-849-2120.

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Consent Forms

Consent forms are mandatory to fill out if you desire your provider to legally coordinate care with other health care providers, such as your general physician or previous mental health providers.

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Marketing Documents