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Please complete the New Patient Registration Form only if you are NOT experiencing suicidal thoughts. Dial 911 in an emergency. Or call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255), 24 hours a day, 7 days a week, or use the Lifeline Chat at the Lifeline website. The Lifeline is free, confidential, and available to everyone.

Presenting Problem *

Please note Visions and its counselors do not provide court-mandated services or accept patients whose care will likely involve courts. If this is the case, please do not complete this form and locate another practice to better meet your needs.

Patient Full Name *

First

Middle

Last

Gender *

Male
Female

Date of Birth (mm/dd/yyyy format) *

Physical Street Address *

City *

State *

Zip Code *

Patient Phone *

Patient Email *

Is the patient a minor? Please read the consent to treatment carefully. You are agreeing to avoid court, subpoening Visions counselors, or your records to ensure the therapeutic purpose of the services. Visions' counselor will not serve as expert witnesses or be involved in court proceedings of any kind. *

Is there a court order that establishes custody/guardianship and guideline for treatment? Please note Visions and its counselors do not provide court mandated services or accept patient's whose treatment will likely involve courts. If this is the case please do not complete this form. *

Legal Guardian Name

First

Middle

Last

Guardian Phone *

Guardian Email *

Other Legal Guardian Name *

First

Middle

Last

Please continue only if the other legal guardian has consented to treatment and agreed to avoid court for any reason.

Other Guardian Phone *

Other Guardian Email *

Is the focus of treatment couples counseling? *

Visions' therapist utilize Prepare Enrich relationship assessment with every couple. The assessment is administered online and the couple will receive a Couples Report and workbook to use in sessions. The cost of the Prepare Enrich assessment is $35 per couple and is not covered by insurance or EAP, it is paid directly to Prepare Enrich when you take the assessment. Please read the consent to treatment carefully. You are agreeing to avoid court, subpoening Visions counselors, or your records to ensure the therapeutic purpose of the services. Visions' counselor will not serve as expert witnesses or be involved in court proceedings of any kind.

Spouse Name *

First

Middle

Last

Spouse Gender *

Male
Female

Spouse DOB (mm/dd/year) *

Spouse Phone *

Spouse Email *

Spirituality Customization *

How can we help you? Select all that apply*telehealth only *

Primary Payment Source

Insurance ID # *

Group ID # *

Medicaid ID# if applicable

DoD ID# or Sponsor SS# (DoD ID# preferred if military)

Copayment $ *

Deductible $ *

Subscriber Name *

First

Middle

Last

Subscriber DOB (mm/dd/yyyy format) *

Subscriber's Employer *

Patient's relationship to the subscriber *

Self
Child/Dependent
Spouse

Do you have a secondary insurance company? *Medicare is not accepted *

Yes
No

Secondary Insurance

Please complete the secondary insurance if there are multiple insurers for behavioral health.

Secondary Insurance ID # *

Secondary Insurance Group ID # *

Secondary Insurance Subscriber Full Name *

First

Middle

Last

Secondary Insurance Subscriber DOB mm/dd/yyyy *

Patient's relationship to the Secondary Insurance Subscriber *

Self
Child/Dependent
Spouse

Are you using EAP for the sessions? If so obtain authorization information before continuing with this form *

Employee Assistance Program (EAP) Insurance Company Name *

Employee Assistance Program Telephone Number *

Authorization Number (Call to obtain an EAP Authorization) *

Number of Sessions Authorized *

Authorization Expiration Date *

Counseling Consent to Treatment: This Counseling Consent to Treatment (“Consent”) is entered into between [Patient or Guardian], hereinafter referred to as “Patient,” and [Visions and Counselor], hereinafter referred to as “Counselor,” for the purpose of providing counseling services to Patient. Patient understands and agrees that by entering into this Consent, he/she is voluntarily seeking counseling services from Counselor and agrees to the following terms: Confidentiality: Patient understands and agrees that any information disclosed during the counseling sessions will be kept confidential to the fullest extent allowed by law, with the following exceptions: a. If Counselor believes that Patient presents an imminent risk of harm to self or others, Counselor may be required by law to take steps to protect Patient or others. This may include notifying appropriate authorities or seeking hospitalization for Patient. b. If Counselor is required by law to disclose information, such as in response to a court order or subpoena, Counselor may be compelled to disclose confidential information. c. If Patient reports any abuse or neglect of a child, elderly person, or disabled person, Counselor is required by law to report this to appropriate authorities. d. If Patient discloses any information about current or past illegal activities, including drug or alcohol use, Counselor may be required by law to report this to appropriate authorities. Telehealth: Patient understands and agrees that Counselor may provide counseling services through telehealth, which includes phone, video, and other electronic means. Patient understands that telehealth has potential risks and limitations, including the risk of technical failures or breaches of confidentiality, and agrees to assume these risks. HIPAA: Patient understands and agrees that Counselor is required by law to comply with the Health Insurance Portability and Accountability Act (HIPAA), which sets standards for the privacy and security of protected health information. Patient understands that Counselor will not disclose Patient’s protected health information without Patient’s written consent, except as required by law. Fees: Patient understands and agrees to pay for counseling services at the agreed-upon rate, and to provide payment at the time of service or as otherwise agreed upon. Termination: Patient understands and agrees that either party may terminate the counseling relationship at any time, with or without cause, and that the termination will be discussed in the final counseling session. By signing below, Patient acknowledges that he/she has read and understands the terms of this Consent and agrees to be bound by its terms. *

Print name and Signature

Agreement to Avoid Court Involvement: This Counseling Agreement (“Agreement”) is entered into between the Patient or Guardian, hereinafter referred to as “Patient,” and (Visions and or its Counselors), hereinafter referred to as “Counselor,” for the purpose of providing counseling services to Patient. Patient understands and agrees that by entering into this Agreement, he/she is voluntarily seeking counseling services from Counselor and that any information disclosed during the counseling sessions will be kept confidential to the fullest extent allowed by law. Patient also understands and agrees that this Agreement is made with the understanding that no court involvement of any kind will be sought or requested by either party. Therefore, Patient and Counselor agree to the following terms: Patient will not subpoena Counselor or request Counselor’s records for any court proceeding, including but not limited to criminal, domestic relations, divorce, child support, or any other reason. Counselor will not voluntarily provide any information to any court or third party regarding Patient’s counseling sessions without a court order or Patient’s written consent. Patient understands that if he/she violates this Agreement by subpoenaing or requesting Counselor’s records for any court proceeding, Counselor may be compelled to produce the records or testify in court. Patient and Counselor agree that if a court order is issued compelling Counselor to testify or produce records, Counselor will notify Patient in writing as soon as practicable and Patient will have the opportunity to obtain legal counsel and contest the subpoena or court order to the fullest extent allowed by law. This Agreement shall remain in effect for the duration of the counseling services provided by Counselor to Patient. If for some reason a judge orders the counselor to produce records or testify, the patient agrees to compensate the therapist for the time it takes to produce the records, travel, and court appearance, and for any income loss resulting from not seeing other patients due to court involvement. The patient agrees to pay an upfront out-of-pocket fee of $250.00 per hour for these services, with a minimum fee of $1,000.00. This fee shall be due and payable upon receipt of an invoice from the therapist. If the patient fails to pay this fee, the therapist may take legal action to collect the unpaid amount. By signing below, Patient and Counselor acknowledge that they have read and understand the terms of this Agreement and agree to be bound by its terms. *

Print your name and signature

Legal Guardian Signature *

Legal Guardian Signature *both legals guardian's signature are required when the patient is a minor *

Spouse Signature required if the focus is couples counseling *