• New London, Newport, Claremont & the Upper Valley

Child Client Information

Client's Name (First, MI, Last) Preferred Name or Nickname
DOB Age Gender
Parent/Caregiver 1
Parent/Caregiver 2
Relationship
Relationship
Mailing Address
Mailing Address
Physical Address (if different)
Physical Address (if different)
*Please DO NOT list any numbers where you would prefer not to receive calls or messages.
Home Phone Home Phone
Cell Phone Cell Phone
Work Phone Work Phone
Email Email
As a courtesy, we offer the option of appointment reminders by email, text or landline phone message. These messages are delivered 48-hours in advance. These serve as reminders only & should not be relied upon exclusively. Please also be sure to note your appointment in your own personal calendars.
  • Would you like to receive optional courtesy reminders?
  • Yes
  • No
  • Requested Method:
  • Email
  • Text Msg
  • Landline Phone Msg

Financial Information

I understand that I am responsible for charges incurred that are not covered by my insurance and that I am responsible for understanding my coverage and for knowing when the limits of my coverage are being exceeded. I authorize the release of information necessary to file a claim with my insurance company, including electronically, and assign benefits to Counseling Associates of New London, PLLC, Counseling Associates of Newport, Counseling Associates of Claremont & and Counseling Associates of The Upper Valley.

A copy of this signature is as valid as the original. We have a standard 24-hour cancellation policy. Please notify your therapist as soon as you know you will be unable to keep an appointment and at least 24 hours, preferably 48 hours, in advance of the scheduled time. The policy of this office is to charge $60 for those missed sessions not canceled with 24 hours’ notice. Insurance companies will not pay for sessions that you miss, and it would be fraudulent for us to submit a claim for missed sessions.
Signature Date
Primary Insurance Company
Secondary Insurance Company
ID#
Group#
ID#
Group#

Please provide the insurance card(s) for copying at the time of appointment.

Responsible party to whom statements will be sent if different from Client.
Mailing Address
Phone

Relationship
Coordination of Care

Coordination of care among healthcare providers improves quality of care and achievement of treatment goals. Authorizing this coordination of care with your primary care provider or another professional is optional though, increasingly, insurance companies are requiring this and considering this standard of care. If you authorize coordination of care with your primary care provider (PCP), Counseling Associates will send a confirmation to your provider that we have met for this initial session. Coordination of Care may also include brief periodic updates regarding treatment and other coordination communications either in writing or by phone. We are happy to answer any questions you may have about coordination of care and this authorization.

I authorize coordination of care between my primary care provider (PCP) and Counseling Associates. Please sign release on next page.

I decline coordination of care at this time. Do not complete form on the following page.


I have questions about coordination of care and would like to wait and speak with my therapist.

I have other providers or individuals for whom I would like to authorize communication.

Consent to Treatment

I acknowledge that I have received, have read (or have had read to me), and understand the Information for Clients brochure (available on the website or in office) that includes:

  • Counseling Associates Practice Information
  • CA Cancellation Policy
  • Notification of Privacy Policies Regarding Protected Health Information (PHI)
  • NH Mental Health Bill of Rights

I understand the information about the therapy I am considering. I have had all my questions answered to my satisfaction.

I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist and that, as with any treatment, there are some risks as well as many benefits with therapy. I am aware that I may stop my treatment with this therapist at any time. I understand that I will still be responsible for paying for the services I have already received. I understand that there may be consequences to such a decision outside of my therapist's control (e.g. if my treatment has been court-ordered, I will have to respond to the court).

My signature below indicates that I understand the information about the therapy I am considering, and I have had all questions answered to my satisfaction. I agree to abide by the terms outlined throughout my professional relationship with Counseling Associates of New London, PLLC, which includes Counseling Associates of New London, Newport, Claremont & the Upper Valley. I consent to receive services from Counseling Associates & I agree to take an active role in my own treatment.

Information

 
  • Yes
  • No
If yes, please note the name of therapists and approximate dates.

Health Information

 
Primary Car Provider Date of Last Physical
Other Providers
  • Current Health
  • Good
  • Fair
  • Poor
  • Yes
  • No
Allergies No known drug allergies

Current Medications

 
MedicationDosage MedicationDosage

Substance Use

 
Are you or your child concerned about their
  • alcohol
  • tobacco, or
  • other substance use?
Physical Health Issues
Mental Health or Substance Abuse Treatment History, including hospitalizations
  • Yes
  • No
  • Yes
  • No
School successes and concerns

Signature of client (or person acting for client)

Date

Printed Name

Relationship to Client
   
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