Client Intake Form

1. The “Person(s) Responsible for Payment” is personally responsible for the payment of my professional fees. This includes payment for appointments which are made but not kept or rescheduled by you, or, if a health insurance carrier or EAP does not reimburse claims due to ineligibility for coverage. [NOTE: This office does not mail out bills for missed appointments. Please complete the attached Personal Guarantee of Payment.]
2. This office only submits claims to one (“primary”) insurance plan. Payment of benefits is assigned to my office. If an insurance claim is denied by the insurance carrier, the Person(s) Responsible for Payment is ultimately responsible for payment of fees. Amounts due for over 60 days are subject to collection by third party agencies if necessary.
3. Insurance claims require a diagnosis to be submitted to the carrier. It must be a diagnosis for which your policy has determined treatment to be medically necessary. (Your carrier should define this term in your benefit plan’s description.) Re-authorization for more treatment sessions requires that I disclose information about you to your insurance company. You may view this information in advance.
4. Accepting an new appointment, indicating date and time, is an agreement. Rescheduling by you must be done over the phone with me within no less than 48 hours of the original appointment. This policy is further described in the attached Disclosure Statement.

Subject to my review of the attached Disclosure Statement, I freely consent to receive, or discontinue with proper notice, diagnostic and treatment services from Robert Odell, MSW, LICSW. I have been given information regarding my rights and responsibilities as a client. I may address any concerns or grievances with Robert Odell, or the Washington Department of Health.

My signature below confirms my understanding and agreement to the terms above, and to receive services from Robert Odell, MSW, LICSW.

Credit/debit card or bank checking account information (including pre-tax medical flex accounts) is used as a personal guarantee of payment. Account number is transferred to a digitally encrypted format. The only circumstances under which the account will be accessed are:

1. Payment for services: For services rendered on a private (not insured) basis, the amount due will be deducted from
2. Insurance-related payment: For payment of a deductible, co-insurance or co-payment. If insurance is denied due to lack of member eligibility, payment of fees specified in Section II A. of the Disclosure Statement below.
3. No show/late cancellation/reschedule: In the event that a client makes an appointment but does not keep it, or fail to provide notice within 48 hours, cancellation policies apply (see Disclosure Statement.) No separate statement or bill will be issued by US Mail. The amount due is deducted within one week of the appointment date.
4. Account change: If your account information changes, or charges declined, you agree to provide new, valid account information upon request.

   You are entitled to receive a written receipt for any payments you have made.

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

It is your right as a client to select the mental health professional who best suits your needs. Before you sign this statement, your consent to treatment requires that you know about my services, and the terms under which I provide them.

I practice according to the Code of Ethics of the Clinical Social Work Association. A copy of this Code is available on request. Please refer to the attached summary of the ethical practices I observe.

I. DISCLOSURE TO CLIENT

A. Credentials

I am a Licensed Independent Clinical Social Worker, and not affiliated with any other practitioner(s). At your request, I can describe the requirements for State of Washington licensure for Clinical Social Work.

B. Confidentiality

The confidentiality of our work is of utmost importance. State of Washington law holds that our communication is privileged information, identical to that between doctors and patients, or lawyers and clients. See Section II. A(b) below.

If your mental health insurance benefit requires a review of treatment to authorize additional sessions, then certain information about you may have to be shared with an insurance or managed care company. I will always review these disclosures with you in advance. Please review the information about my patient Privacy Practices mandated by the 1996 Federal law known as Health Insurance Portability and Accountability Act (HIPAA).

C. Education, training & experience

I received my Masters degree from the University of Southern California School of Social Work. In this program, I completed two one-year clinical internships: a Los Angeles County community mental health clinic serving indigent, severely/persistently mentally ill and homeless populations; and, a corporate employee assistance program (EAP), providing assessment, counseling and referral for personal, work-related and chemical dependency problems.

My post-graduate clinical experience includes individual & family therapy in a South Central Los Angeles psychiatric hospital. I then practiced in a Los Angeles court mandated residential treatment center for adolescent boys, including sex offenders, providing individual, group and family treatment.

I have provided individual and family therapy, case management and emergency room psychiatric assessments throughout Seattle, for Fairfax Hospital. In 1998, I began an office practice in an adjacent clinic, working with psychiatrists, psychologists, nurses, clinical social workers, marriage & family therapists and mental health counselors. I have practiced independently and privately since 1999.

My continuing education has included training in marital therapy, human sexuality, ethics, clinical supervision, workplace trauma debriefing, therapy for children and adolescents, EMDR, conflict resolution, child abuse prevention and reporting, and non-violent crisis intervention. I have always exceeded State of Washington Department of Health requirements for continuing education hours.

D. Types of psychotherapeutic counseling provided

Couples & relationships, marital and partnership, with an approach that integrates sexuality as a primary expression of each partner’s sense of self; Adults, specializing in the treatment of depression, anxiety disorders (Panic, PTSD), grieving, problems related to work and career, and relationships;

E. Counseling methods

No treatment method is more important to me than your belief that we are collaborating in finding new possibilities for your health and well-being. My methods are guided by understandings of how people develop over time. I am interested in individual growth, and how it is effected by important relationships. I try to get as close as I can to the meanings that you find within these relationships, in your personal and family histories, life events, and the successes and problems of living.

F. Course of Therapy

If you wish, we can agree in advance to the number of sessions in your treatment plan. You have the right to cancel treatment at any time, subject to the 48 hour notice requirement described below in the Statement of Office Policies, Section B. below.

G. Professional associations

I served a two year term as President of the Board of Directors of the Washington State Society for Clinical Social Work from 2008-2010. I maintain membership in the International Critical Incident Stress Foundation.

H. Complaints

If you have a complaint or inquiry about my professional services, you may contact the State of Washington Department of Health. I maintain forms and instructions for such complaint or inquiry.

II. STATEMENT OF OFFICE POLICIES

A. Fees & Payment Policies

Please refer to your signed copy of my Financial Policies statement. Here is a schedule of my fees, as submitted for private payment or for insurance reimbursement:

(b) Reports: Authorized releases of treatment information to third parties is accomplished by a report separately written by me (Psychotherapy Notes are separately stored from the Medical Record, as defined by Federal law, and as such the Notes are not typically discoverable.) My charge for writing these reports is $100/hr. The number of hours will be agreed to in advance. Insurance does not reimburse this service. My fee for phone based professional consultation with other mental health or medical professionals is $100/hr

(c) Appointment policy: In couples therapy, the couple is the client. It presumes the participation of both partners in any appointment. If only one partner appears (for at least 30 minutes) without adequate notice for an appointment, the appointment is recorded as a late cancellation (see II B. below for fee policies.)

(d) Couples records: Records consist of the Medical Record, which contains basic/generic information about any appointment. Couples jointly hold rights to the Medical Record, so waivers must be signed by both parties in order to release it. More specific and particular content of therapy is recorded in the Psychotherapy Notes, which I maintain separately from the Medical Record. Under the law (HIPAA), Psychotherapy Notes are my property, and are broadly protected, including in legal proceedings like divorce actions, or medical disability applications.

B. Appointment cancellation, rescheduling and changes

Your appointment is an agreement to meet on that date and time. If you do not appear, your credit or debit account will be charged via the pre-authorization in the Personal Responsibility for Payment form.

I accept voice mail and e-mail, for changing or canceling appointments. For Monday appointments, notify me no later than Thursday 12P; for Tuesday, no later than Friday 12P.] If you are late, and do not notify me by phone, I will remain in the office for a maximum of 30 minutes past the appointment time.

For a late cancellation (less than 48 hours notice): If you reschedule within 4 business days, I charge a fee equal to 75% of what I normally receive from you and/or your insurance carrier. After four business days, the full cancellation fee will be charged. If I fail to appear, without notice, for your appointment, either your insurance co-payment, or your private fee for the next appointment will be waived. (See below,¶2 of Special Office Policies, for Emergency Service notice)

C. Insurance coverage

Most insurance policies cover treatment by Licensed Independent Clinical Social Workers. I bill your insurance company, and they will issue statements to my office and to you of benefits paid or denied. Health insurance carriers need a diagnosis for which they consider psychotherapy treatment to be "medically necessary." I must evaluate on an ongoing basis whether your symptoms meet these 'medical' criteria. If they do not, I cannot submit claims. I can help you evaluate whether this requirement fits with your therapeutic goals.

D. Urgent or emergency contact I make reasonable efforts to be reachable by phone, text or e-mail if you urgently need to speak to me. I cannot return your call while in session with another client. I will return your call at your request. If your situation is life-threatening or psychiatrically disabling, please dial 911. If you are in a crisis before we are able to speak, call the King County United Way Crisis Line at (206) 461-3222. They can refer you to a community resource, including emergency assistance.

AGREEMENT

Prior to signing below you have the opportunity to ask Robert Odell for further explanation, or have received same, for any of above disclosure information and office policies. PLEASE NOTE APPOINTMENT CANCELLATION POLICY - 48 BUSINESS HOUR REQUIRED NOTICE

My primary goal is to develop the closest possible treatment relationship with you in the most ethical environment I can create. Disclosure of these professional and personal ethics to you seeks to prevent relationship practices that I believe can hurt or destroy treatment. If you have questions or concerns about any of these policies, please discuss them with me as soon as possible.

1. Your rights as a client do not end when the treatment relationship ends, including the right to confidentiality. I only disclose information about you with your informed consent or written permission. Neither your death nor mine terminates these rights. Exceptions are specified under Federal laws, and the State of Washington (RCW). Written records are destroyed 5 years after the last date of service.
2. I will not develop a social relationship with you outside the office, regardless of the length of time that my services have terminated. I will not accept social or family event invitations from you, and do not offer same. This is not an expression of a lack of interest in you, nor any evaluation of these events.
3. At no time will I engage in any physical contact with you in our relationship, other than the shaking of hands as a greeting or parting.
4. I will not accept any gifts, including food or invitations to meals. This is not a refusal to acknowledge nor a withholding of goodwill, in seasonal or holiday greetings or well wishes to you. It is instead the recognition that professional service, offered and received, is sufficient and complete.
5. I neither accept nor provide any other services other than the practice of psychotherapy and counseling. I will not enter into any business or financial relationships with clients, other than the receipt of professional fees for service rendered.
6. To help ensure the confidentiality of your status as a client, if I see you in a public setting, I will not initiate any recognition or familiarity with you. If you choose to initiate visible or audible greeting or recognition with me, I will reciprocate, but will initiate no further exchange unless requested.
7. I will only initiate appropriate referrals to other health professionals with a client's consent. I make reasonable efforts to identify at least two professionals for each type of referral. I never accept or solicit any compensation of any kind in return for making or accepting a referral. I do not refer clients to specific attorneys, nor to accountants, financial planners or credit counselors.
8. Fragrance Policy: Please refrain from the use of any cologne, after-shave or perfume prior to future appointments. This is a courtesy to all other clients. Some clients may have allergic sensitivity to ingredients in these products.
9. Emergency Service for Critical Incidents: I am contracted with several emergency service networks that help victims of incidents that can cause emotional and psychological trauma. These include robberies, industrial accidents, large layoffs and sudden deaths. I may be called to the scene of an emergency on the same day it occurs, or a day or two after an incident.
   
   I must provide these services on a particular date, but make every effort to maintain my scheduled office appointments. However, if schedule changes are unavoidable, I will immediately call all affected clients to reschedule appointments.
   
   If called to the scene on the same day an incident occurs, I may not be able to reach you in time to prevent your coming to your scheduled appointment. The likelihood of this happening is quite small. If this does occur, your rescheduled appointment will have any copayment or coinsurance waived.
   
   Please also be aware that I may receive emergency text messages from these service networks at any time. This is the only interruption to our appointment that I allow. When I receive a message during an office appointment, I will notify you and then respond as briefly as possible. The interruption lasts less than two minutes, and I will make up this time to you during the appointment.