Date: 06-21-24

    Client Information Form


    Cell Phone :

    Work Phone :

    How would you like us to contact you? (Please check)

    Marital Status (Please select)

    Child name :

    Child Date of Birth :

    Child name :

    Child Date of Birth :

    Child name :

    Child Date of Birth :

    Child name :

    Child Date of Birth :

    Child name :

    Child Date of Birth :

    How did you hear about us?

    Referred by

    In Case of Emergency

    Contact Person :

    Relationship :

    Phone Number :

    Email Address :

    Billing Information

    Payment is required at the time of service.
    The standard session is one clinical hour (45-50 mins). You are billed according to the start of your scheduled
    appointment with your provider. If you exceed one clinical hour, you are billed at a prorated amount.

    Responsible party:

    Relationship :

    Phone Number:

    Email Address:

    Insurance and Financial Agreement

    We have therapists at Suncrest Counseling who are paneled with the Deseret Mutual Benefit Administrators
    (DMBA). If you have DMBA coverage and choose to see one of these therapists, we can directly file claims with
    DMBA for their services. You pay your copay. If you see therapists at Suncrest who are not on the DMBA panel
    and they are fully licensed, we can bill DMBA, but you will have a higher co-pay.


    For all other insurance plans, possible benefits may be available if your plan has out of network coverage and you
    meet ALL the necessary requirements. To assist you with your insurance claims, we provide a courtesy INVOICE
    that includes all the relevant information you need to file with your insurance company. We will prepare the
    documentation you need on your invoice, but it is your responsibility to file the claim with your insurance company.

    Furthermore, the insurance company may ask for the clinical notes from your therapy session in order to
    authorize payment.

    In order to protect Suncrest and our clients from insurance retractions, Suncrest reserves the right to withhold all
    insurance payments for at least 90 days after the payment has been received.

    Service

    Published Rates

    Discount Rates

    General Outpatient: (Individual)

    $300

    $100*
    $115*

    $I19*
    $125*

    $129*
    $139*

    $154*
    $179*

    $199*
    $299*

    General Outpatient: (Group)

    $300

    $75
    *The Discount Rate varies depending on which therapist you see.


    Neurofeedback Services

    Rates

    Brain Mapping

    $395

    Brain Training

    $129 ea

    Policy holder:

    Relationship to client :

    Policy holder Date of birth :

    Primary policy or Secondary Policy:

    Client’s Name:

    Date of Birth :

    Policy Number :

    Group Number :

    Please give your insurance card to the front desk, They will make a copy of the card and return it to you once completed. This is required if you would like us to bill your insurance company.

    Cancellations


    Health Information

    Primary Physician :

    Phone Number :

    Prescribing Physician :

    Phone Number :

    List any health conditions:

    Are you taking any medications? (Please select)

    Name :

    Dosage :

    Name :

    Dosage :

    Name :

    Dosage :

    Name :

    Dosage :

    Name :

    Dosage :

    Name :

    Dosage :

    Informed Consent

    Thank you for choosing Suncrest for your treatment needs and trusting us with personal information. Everything
    that is said in a session will be kept confidential among Suncrest therapists. The exceptions to confidentiality are
    as follows:

    • State mandated report of abuse of children and/or vulnerable adults

    • Intent to commit homicide or suicide

    • Information released as required by legal procedure

    • Reimbursement from your insurance company that requires release of information to them (diagnosis, symptoms
      and type of treatment provided). This information may influence future costs and coverage.

    While in treatment, you may experience changes in the following areas: Thinking, emotions, behaviors, and
    relationships. We use several models of therapy including, but not limited to, cognitive behavior therapy (CBT),
    emotional focused therapy (EFT), eye movement desensitization and reprocessing (EMDR), acceptance and
    commitment therapy (ACT), life-span integration, etc. In addition, we do training with equipment which may include
    neurofeedback and biofeedback. Craniosacral massage therapy (by a licensed massage therapist) and yoga (by a
    certified yoga instructor) may also be used as forms of therapy

    If you experience an emergency outside of treatment at Suncrest, you are advised to call 911, go to the nearest
    emergency room, or call the University Neuropsychiatric Institute (UNI) @ (801) 587-3000.
    All therapists who you currently meet with or may meet with at Suncrest will have access to any and all Suncrest
    medical files.

    Payment is expected in full at the time of service before your appointment. If prior notice is not given to cancel an
    appointment, you or the responsible party will be charged in full for that session. We accept cash, checks, money
    orders or credit cards.
    At some point during your treatment you may have the opportunity to meet with an intern. Every intern is
    supervised by a state licensed Suncrest therapist. For all sessions with an intern, we are not able to bill
    insurance.

    Client Rights, Responsibilities and Rules of the Program

    • My privacy for current and closed records is protected and assured, within the limits of confidentiality and my treatment plan.

    • If family members of client(s) choose to be involved they agree to adhere to the rules, regulations and restrictions of Suncrest as outlined in this document.

    • To receive treatment based on need without impartiality and without regard to race, color, sex, nationality or religion.

    • To have my cultural, psychosocial, spiritual/religious, political and personal beliefs and preferences respected.

    • To receive treatment in a caring and humane manner. To be free from mental, physical, sexual, financial, and verbal abuse, neglect and exploitation. To be recognized as an individual with inherent worth and value and to have that worth and value respected in the provision of treatment.

    • To be treated in an environment that preserves dignity and contributes to a positive self-image.

    • To participate in the planning and implementation of my individualized treatment plan. To request consultation and/or review of the treatment plan.

    • To be informed of all costs and fees up front.

    • To complete a request for review of grievance and/or to access advocacy services if I believe that any of my rights have been violated. All grievances go to the president of Suncrest. A grievance may be filed by phone, e-mail, or letter. Contact information is available upon request.

    • Prior to involuntary termination clients will be verbally informed of any existing behavior(s) that would warrant such an action. It will be made clear to the client at the time of the warning that he/she has received a verbal warning. Verbal warnings will be documented in the client’s electronic file by the therapist/staff member who administered the warning. If a problematic behavior continues following the verbal warning the client will then receive a written warning that their actions will result in involuntary termination. In some cases, we may give you a warning, and in other cases you will automatically be terminated.

    • To be provided with reasons, should involuntary termination occur, you must write a letter to the President of Suncrest.

    • To be provided with criteria for re-admission to the program you must submit, in writing, a request to the President of Suncrest. The President will review your request and notify you by mail within 90 days of the receipt of your request.

    • To be provided with treatment in a smoke free environment and afforded the right to smoke in accordance with the Utah Clean Air Act.

    • To provide, to the best of my knowledge, accurate and complete information about present problems and past difficulties with other therapy institutions and other concerns related to my care.

    • As a condition for Suncrest Counseling to provide you services, you agree not to record (e.g., audio and/or video) any part of your sessions with any Suncrest Counseling professional.

    • If you would like a copy of the HIPAA regulations, please ask the front desk receptionist.

    • I am responsible to come to my session sober. I will not arrive at Suncrest under the influence of any substance or alcohol that may hinder my ability to learn and grow in the process of counseling.

    • I am responsible to notify Suncrest within 24 hours prior to my appointment if I will be cancelling. If outside this window I understand that I am responsible to pay a $50 fee.

    • I am responsible and privilege for my actions and resulting consequences if I refuse to participate in the planning and implementation of my treatment plan.

    • I have the responsibility to be considerate of the rights of other clients and Suncrest staff.

    • I am responsible for my belongings. I understand that I have the responsibility to notify Suncrest staff of any lost or stolen personal belongings. I can expect Suncrest to make any reasonable effort to locate these items.

    • I have the responsibility and privilege to ask questions about any part of the treatment/program that I do not understand.

    Notice of Privacy Practices

    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.

    Why we are providing you with this notice:


    We are required by a federal law known as the Health Insurance Portability and Accountability Act (HIPAA) to give you this notice. This notice will tell you about the ways we are to use and disclose health information about you, and will describe your rights and our obligations regarding the use and disclosure of that information.

    Your health information:


    This notice applies to the information and records we have about your health, health status, and the health care services you receive from Suncrest. This information relates primarily to counseling services you have received from Suncrest.

    How we may use and disclose health information about you:

    For treatment: We may use or disclose health information about you to facilitate counseling and other treatment within this company.

    For payment: We may use and disclose health information about you so that we can be paid by you, an insurance company, or another party, for the services we provide to you. For example, we may need to give your health insurance company information about our services to you so the company will pay Suncrest for these services.

    For professional operations: We may use and disclose health information about you in order to run this office and make sure that you and other clients receive quality care. For example, we may use your health information to evaluate our performance, or to contact you to remind you of your appointments, or to cancel an appointment.

    Please notify us in writing if you do not want us to contact you to remind you of an appointment or where you prefer us to contact you to cancel an appointment.

    Special situations: I may use or disclose your health information without your permission for several reasons. These reasons include:

    • Disclosing your health information when we believe that disclosure is necessary to prevent a serious threat to your health and safety or the health and safety of another person.

    • Disclosing your health information as required by federal, state, or local law.

    • Disclosing your health information as required by law to prevent injury or suspected abuse or neglect.

    • Disclosing your health information in response to a court order, subpoena, warrant, summons or similar process.

    Other uses and disclosures of health information: Except where otherwise required or authorized by law, we will not use or disclose your health information for any purpose without your written authorization. If you authorize us to use or disclose health information about you, you may revoke your authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization, but we cannot take back any uses or disclosures we have already made with your permission.

    Your rights regarding your health information: You have the following rights with regard to your health information:

    • You may inspect and copy your health information, with certain exceptions.

    • If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend the information.

    • You may obtain an account of our disclosures of your health information. This is a list of all of our disclosures of your health information for purposes other than treatment, payment and health care operations.

    • You have the right to request that we restrict or limit our use or disclosure of your health information to only treatment, payment or health care operations. We are not required to comply with your request.

    • You may request that we communicate with you about your health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

    • You have the right to receive a paper copy of this notice.

    If you want to exercise any of these rights, please contact us, in writing at our office where you are receiving counseling.

    Changes to this notice:We have the right to change this notice. If we do so, the new notice will apply to the health information we may already have about you and the health information that we receive in the future. We are required to abide by the most current notice that is in effect. We will post a summary of the most current notice in our office. You are entitled to receive a copy of the most current notice.

    Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the U. S. Department of Health and Human Services. To file a complaint with Suncrest, please contact us at (801) 255-1155.

    This notice is effective as of July 2010.

    If you would like a copy any of the following paperwork that you have signed; please ask the front desk and they will provide a copy for your use.

    Teletherapy and Electronic Media Policy


    1. Internet or phone - This policy refers to the communication and delivery of services via telecommunications technology. It is not limited to the use of the internet and may for example,involve the use of the telephone for communication or delivery of services (therapy sessions).
    2. Teletherapy Acceptable for Therapy - Although the American Psychological Association (APA) and other mental health associations (American Association for Marriage and Family Therapy, etc.), have recognized teletherapy to be an acceptable practice for therapists.
    there remains many unique challenges associated with its use.
    3. Privacy Risks - When using teletherapy there are certain unavoidable risks to your privacy While taking every effort to make electronic communications as secure as communications and records are in a traditional office environment there are inherent limitations given the nature of the media involved Issues such as computer viruses phishing identity theft and difficulty maintaining privacy on the Internet are examples of significant related concerns.
    The Teletherapy services that Suncrest provides are in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and other legal requirements. However if the teletherapy services malfunction during a session, the remainder of the session will be done by phone.
    4. Safety Plan for Emergencies - It's important at the beginning of each teletherapy session that I know your physical location and you identify for me the closest emergency room. For any time period in which teletherapy services are provided at a distance, it is important that you have a plan established to respond to any emergencies that may arise, since an employee of Suncrest cannot be present to personally conduct an evaluation. At a minimum, this involves an agreement to consult the closest emergency room to evaluate your condition, should that become necessary to protect you or someone else.
    5. Credit Card on File - A credit card must be on file prior to your teletherapy session, unless other arrangements have been made with our accounting department.