Forms

Forms.jpgThroughout your time at LifePointe Counseling, LLC you will need to fill out a variety of forms.  Some of these forms are mandatory, such as the registration and client questionnaire paperwork. 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 them in to their health care provider, but we also have hard copies available upon your request in our office.

BlueDividerGreenDiamond

Hold Harmless Agreement

As LifePointe prepares to open it’s doors to see 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.  Most insurance companies are still allowing for Telehealth sessions, if you are uncomfortable coming in to the office, but it might depend on your particular plan.  If you are unsure, please call our office to see if your insurance company is still offering Telehealth sessions for everyone, and if they are not you will need to call your insurance and retain affirmation that Telehealth is covered under your particular insurance plan.

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.

BlueDividerGreenDiamond

New Client Paperwork

Before you obtain treatment from a provider at LifePointe Counseling, LLC, you will need to complete some basic mandatory paperwork. You may print and complete the New Client Packet and the Client Questionnaire prior to your first appointment and bring these documents with you to your appointment.  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 out these forms in our office.

 

BlueDividerGreenDiamond

Financial Forms (Optional)

Whether you plan to use your insurance or pay privately for our mental health 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 would like to pay for our services by credit/debit/HSA card and would like to leave your payment information on file, you may print and complete our Credit Card Authorization form.  If you are submitting a request for sliding scale fees, please review the Sliding Scale Table document and complete the Financial Disclosure Form.  Please note that not all of our health care providers provide sliding scale rates.  If you have any further questions, please contact our front office at 314-849-2120.

BlueDividerGreenDiamond

Consent Forms

Consent forms are optional for you to fill out.  Providing us with a completed Authorization For Disclosure form allows us to legally coordinate care with other health care providers, such as your general physician or previous mental health providers.

BlueDividerGreenDiamond

Marketing Documents