Printed Name of Client
Date of Birth
Effective Starting Date
By signing this document you are acknowledging the following: 1. I have been offered and/or received a copy of Therapeutic Services Agency, Inc. (TSA)'s Client Information and Office Policy Statement as well as the Notice of Privacy Practices. I understand my rights, including those related to confidentiality and its limitations. 2. I understand the service that will be provided and I consent to treatment for myself or for a minor child for whom I am the child's parent or legal representative. Mental health services may include diagnostic interview, psychotherapy, skills training, psychological testing (if indicated), specialized assessments (if indicated) and involvement in the treatment planning process for all services that are received through this clinic. 3. The recording of sessions in any form (video, audio, etc), without explicit written consent of all parties involved, is prohibited. 4. I authorize TSA to release/exchange information with my insurance company. I hereby authorize payment directly to TSA of the policy benefits otherwise payable to me, but not to exceed the provider's regular charges for the period of treatment. I understand that I am financially responsible to TSA for all charges not covered by my current benefits and all co-pays are due at time of service. Check here if you are covered by a county contract. Check here if you are covered by a county contract.
Name of County
Check here if someone other than insurance/county is paying for services. Check here if someone other than insurance/county is paying for services.
If checked, indicate here who the responsible party is
5. Please choose an option: I have a primary care medical provider and want to coordinate care with them. I understand I must complete a Release of Information form with my medical provider's contact information and fax number if I want to coordinate care. I have a primary care provider and DO NOT want to coordinate care with them. I DO NOT have a primary care provider.
Date
Printed Name of Legal Representative
Please note, you are responsible for knowing your benefits and coverage. You are responsible for notifying TSA of any insurance change or loss of coverage. Should you obtain services without coverage, it is your responsibility to pay TSA for services received. If you are covered by a county contract and that contract ends, you are responsible for paying TSA for services rendered. If payment for client responsibility is not rendered, services may be suspended until payment is received. 