Judy’s New Client Forms

 
This form provides information about our services, fees, billing, and confidentiality.  Please read and initial all sections and sign on last page.  Feel free to discuss any questions you have regarding the content of this document during our first session.  Judys_forms_files/Judy%20Chamberlin%20Client%20Agreement%20form.doc


The following forms are provided for your convenience.  Please complete them prior to our first appointment.  This will allow us to spend more time during our first session on discussing your goals and expectations for our work together, rather than on completing paperwork. 

Judys_forms_files/Judy%20Chamberlin%20Client%20Agreement%20form_1.doc
Client AgreementJudys_forms_files/Judy%20Chamberlin%20Client%20Agreement%20form_2.doc
Intake InformationJudys_forms_files/Judy%20Chamberlin%20intake%20Form.doc
Judys_forms_files/CMS1500_ClaimForm.pdf
Insurance Claim FormJudys_forms_files/CMS1500_ClaimForm_1.pdf
Judys_forms_files/ElectronicPaymentAuthorization%5B1%5D.pdf
Payment Authorization FormJudys_forms_files/ElectronicPaymentAuthorization.pdf
Please complete the top section of Page One of this document.Judys_forms_files/Judy%20Chamberlin%20intake%20Form_1.doc
If you would like to use your insurance benefit to cover a portion of the cost of counseling, please complete the top section of this document , located just above the provider section of the form.  I will complete the provider section after our session so that you may submit this form for reimbursement from your insurance company.  Judys_forms_files/CMS1500_ClaimForm_2.pdf
This form provides various automatic payment options for your convenience so that you may get the most out of our time together without having to spend time from our sessions to take care of payment of services.  Judys_forms_files/ElectronicPaymentAuthorization_1.pdf
HIPAA RegulationsJudys_forms_files/HIPAA%20regs.pdf
This form is for your information.  It provides an explanation regarding the use and storage of  your private information by Journey Coaching and Counseling Services. Judys_forms_files/HIPAA%20regs_1.pdf
Minor ConsentJudys_forms_files/Judy%20Chamberlin%20Consent%20to%20treat%20a%20minor%20form.doc
Please complete for consent to treat a minor.Judys_forms_files/Judy%20Chamberlin%20Consent%20to%20treat%20a%20minor%20form_1.doc