Please print, fill in and bring to your first appointment.

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Welcome to Tarsa Counseling Associates!


FINANCIAL POLICIES:
Co-payments/ Co-insurances/Deductibles-These are due at the time of each appointment.  If your yearly health insurance deductible is not yet met you are expected to pay the full amount of the session until it is met.  Cash, checks, credit cards and medical spending cards are accepted.  You are responsible to pay for sessions not covered by your insurance company.

24 HOUR CANCELLATION POLICY-Clients are expected to contact their therapist to cancel or reschedule appointments 24 hours in advance with the exception of emergencies.  This allows therapists time to contact clients who are on their waiting lists.  You will be charged for scheduled appointments that are not cancelled or rescheduled 24 hours before your appointment time.

PAPERWORK-There is a charge for letters and paperwork requested by and for you.  This includes medical leave paperwork, FMLA and disability forms.  Insurance companies will not cover this cost so it is the client's responsibility to pay for this additional service.

PHONE CONSULTATIONS-Phone calls over 5 minutes will be billed to you at the same rate as an office visit and adjusted to time used.

PRIVATE PRACTICE-Although there are other therapists in the building we are not affiliated with them. 

PARENTAL CONSENT FOR TREATMENT OF CHILDREN 10-18:
Parents of children 10 and up are asked to sign a parental consent form which lists my policies related to working with children.

COURT TESTIMONY:
It is my policy not to serve as a witness in court proceedings for such things as divorce or child custody.  If you are coming to therapy to secure an expert witness then I will ask you to see another therapist.


CONFIDENTIALITY AND YOUR RIGHT TO PRIVACY:
As a client of Julia Tarsa MA LLC I understand that I have the right to have information about my diagnosis and treatment kept private.  I understand that information identifying an individual as a client receiving or having received counseling services will only be released under the conditions stated under "Release of Information".  In addition, a client may sign a Release of Information form to disclose information for a determined purpose to another health care provider such as a primary care physician.  I  understand that I may be contacted for appointment changes, changes in the practice, billing related matters or for the purpose of sharing educational materials or information on services that may be of interest to me.


RELEASE OF INFORMATION
The "Registration Form for Billing" includes a release of information statement and line for your signature authorizing Julia Tarsa MA LLC to furnish information from your mental health records to her biller for the express purpose of verifying the information necessary to determine the extent of insurance coverage and process payments.

Federal law and regulations do not protect any information about a crime committed by a client either at the office of Julia Tarsa MA LLC or against any person who works there or any person who  F works for her or about any threat to commit such a crime.  Federal law and regulations do not protect any information about suspected child, elder or vulnerable adult abuse and neglect from being reported under state law to appropriate state and local authorities.  Information is not protected if a client appears to be in immediate danger of harming him/herself or others.  If directed by a  court order information may be released.

I do hereby consent to assessment and treatment for mental health services to be provided by Julia Tarsa MA LLC.  I promise to pay for all services rendered to me or my family members, including with limitations, any deductions, coinsurances or amounts not paid and/or not covered by my insurance.  By signing below, I have documented that my rights as a recipient of services by Julia Tarsa MA LLC and the federal confidentiality requirements, have been explained to me and written materials about my rights and confidentiality have been provided in this document.

I have read and understand the statements in this document and consent to each of them.


______________________________________                          _____________________________
Signature of Client                                                                          Date
(or guardian if client is under 18)

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                                                                                        Julia Tarsa MA LLC
                                                                  REGISTRATION FORM FOR BILLING

            *Please note insurance companies require that we provide social security numbers when we do billing.


INTAKE DATE__________________________________  REFERRED BY:_________________________________

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PATIENT NAME:____________________________ DATE OF BIRTH_________________________AGE________

ADDRESS:_______________________________________________________________________________________ 

CITY:_____________________________________________STATE:_______________ZIP:_____________________

SS#:__________________________________EMPLOYER:________________________________________________

PHONE:________________________CELL:________________________WORK:_____________________________
Can we leave a message?______           Can we leave a message?_____          Can we leave a message?_______

SEX:  FEMALE    MALE            MARITAL STATUS:  SINGLE     MARRIED     DIVORCED

RESPONSIBLE PARTY:______________________________________Date of Birth:__________________________

ADDRESS:_______________________________________________SS#:_____________________________________

CITY:_________________________________________STATE:______________________ZIP:__________________


INSURANCE #1:_________________________________________________________________________________

POLICY #:_______________________________________________________________________________________

POLICY HOLDER:____________________________________________________SS#:________________________

INSURED DOB:_______________________EMPLOYER:_______________________________________________


INSURANCE #2:______________________________________________________________________________

POLICY #2:___________________________________________________GROUP:________________________

POLICY HOLDER:_______________________________________________SS:___________________________

INSURED DOB:_______________________________EMPLOYER:_______________________________________

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EMERGENCY CONTACT

NAME:_____________________________________________ RELATIONSHIP:____________________________

HOME PHONE:_______________________________________WORK PHONE:_____________________________

PRIMARY CARE DR:___________________________________PH#_____________________________________

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INSURANCE INFORMATION (PLEASE PRESENT INSURANCE CARD AND PHOTO ID FOR PHOTOCOPY AT FIRST SESSION)

In order to submit a claim for payment to us for services covered under your policy, I must have authorization to release medical information to your insurance company and to my billing company for paper and electronic billing.  I authorize the release of any medical information necessary to process my medical service claims.  I permit a copy of this authorization to be used in place of the original.  I hereby authorize Julia Tarsa, MA LLC and her billing company to file for benefits on my behalf for mental health services received.  Insurance payments shall be made directly to Julia Tarsa MA LLC.  I certify that I am financially responsible for all services not paid for by insurance.  This authorization is valid indefinitely until revoked by myself or by Julia Tarsa MA LLC by written request.  I consent to Julia Tarsa MA LLC to provide professional services to me.  

Signature___________________________________________________Date_____________________________


______________________________________________________________________________________________



                                                                                                          JULIA TARSA MA LLC
                                                                                    CLIENT INFORMATION SHEET

                 Please fill out the paperwork as completely as possible as all questions asked are for therapeutic purposes.

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CONTACT INFORMATION:

Name:___________________________________________________Female_____Male_____

Cell Phone:__________________________  E-Mail Address:_________________________________

May I contact you via cell phone?______   May I contact you via e-mail?_______

May I text you via cell phone?______

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OCCUPATION:

Occupation:______________________________________________Part-time_______Full Time________

Employer(s):_______________________________________________________________________________

Retired?_______  Downsized/Laid off______  Full Time Mom?______Self-Employed?______ 

Full-Time Student?_____ Part-Time Student?____  School:______________________________________

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CURRENT ISSUES(S):

What brings you here at this time?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

What efforts have you made to resolve this (these) problems already?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

What changes do you want to see as a result of counseling?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Is the current issue causing problems at work/school?  If yes, please explain.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________


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ARE YOU EXPERIENCING ANY OF THE FOLLOWING?
____Depressed mood ____Decreased energy _____Anxiety/fear/panic____Hopelessness 
____Thoughts of harming self ____Thoughts of harming others____Tearfulness
____Loss of interest in activities ____Loss of energy ____Changes in sexual behavior
____Muscle tension ____Weight gain/loss ____Physical pain
____Irritability ____Guilt ____Angry outbursts ____Nightmares ____Indecision
____Difficulty concentrating ____Change in alcohol/drug use ____Headaches
____Change in sleep pattern ____Grief ____Feelings of worthlessness
____History of emotional, physical/sexual trauma

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HOUSEHOLD MEMBERS:

Name                                                                      Age                            Relationship

__________________________________      _________      __________________________

__________________________________      _________      __________________________

__________________________________      _________      __________________________

__________________________________      _________      __________________________


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MEDICAL HISTORY:

Have you had previous counseling or treatment experience and if so what was the name of your provider(s)?  (including substance abuse, inpatient treatment):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If you had previous counseling how was the experience for you?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list your current medical conditions (if any):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies:________________________________________________________________________________________

Please list your current  medications (over the counter, prescription, herbal):
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________

Are you under the care of a psychiatrist?______If so, whom?__________________________________

If you have been diagnosed with an emotional or mental disorder(s) what is it?________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever deliberately harmed yourself?_______  Are you currently having such thoughts?_________

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FAMILY HISTORY:
Has anyone in your family been: ____depressed ____a heavy drinker ____suicidal
____mentally or emotionally ill ____a substance abuser ____homicidal _____violent
____physically abusive____very anxious ____sexually abusive ____chronically ill
____a perfectionist ____very moody ____angry/irritable a lot
Has anyone in your family had a nervous breakdown?_____
Is there anything that you would like to share about your family history?
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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CHEMICAL USE PATTERN:

Have you ever used alcohol or drugs more then you meant to?______  Are you, your family, your friends or your work worried about your use?_____

What is your history with substances?  Please list below:

Substance                                        How often?             How much at a time?         Age first used?         Date of last use?

_____________________      __________________    ______________            ___________    ____________

_____________________      __________________    ______________            ___________    ____________

_____________________      __________________    ______________             ___________    ____________

_____________________      __________________    ______________             ___________    ____________


Do you smoke/chew tobacco products?______  How much per day?__________

Have you overdosed on or had an adverse reaction to alcohol/drugs?______

Have you overdosed or had adverse reactions to any prescription or over-the-counter drugs?  If so, explain:___________________________________________________________________________________

Do you ever drink or abuse substances before work or during work hours?______

Do you sometimes need medication/herbal or over-the counter formulas to sleep or feel calm?_____  If so,
what do you use?_______________________________________________________________________________

Have you missed work or school, had accidents or become ill because of drugs or alcohol?____

Have drinking and/or drugs caused any of the following problems for you:
____Family ____Friends ____Spouse ____Children ____Work ____Legal ____Health ____Financial ____School

Have drinking and or/drugs led to changes in your behavior or personality and if so how?
____Depression ____Verbal abuse ____Social Isolation ____Physical Abuse
____Embarrassment due to behavior ____Combative ____Changing Moods ____More Relaxed ____Irritability ____Unkept Promises ____Insomnia ____Sexual Performance ____More/less social

Have you ever been arrested?  If yes, what for and what date:__________________________________

Do you drive while under the influence of drugs or alcohol?_____

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LEGAL HISTORY:

Are you presently involved in any active cases (civil, traffic, criminal)?  Explain:
__________________________________________________________________________________________________________________________________________________________________________________

SUPPORT SYSTEMS:

List family and friends who you consider to be your support:
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List support groups, activities, interests, hobbies, organizations, including religious:
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


REFERRALS:

Who can I thank for referring you?_______________________________


Please bring this paperwork with you to the first session.


______________________________________
Print Name of Client


______________________________________                ________________________
Signature of Client                                                                  Date
(or guardian if under 18)




________________________________________________________________________________________________

(Optional Form)

                                                                                           Julia Tarsa MA LLC
                                                                                 Licensed Professional Counselor
                                                                       Phone: (517)881-7276 & Fax: (866) 611-6497
                                                                            E-Mail:  julia@tarsacounseling.com


Dear Physician,

It is my recommendation to my clients that they make their Primary Care Physician aware that they are currently in counseling.  This allows for coordination of services.  You are invited to contact me if you would like to discuss this patient's case. 

Julia Tarsa, MA LPC
Psychotherapist


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Name of Doctor:____________________________________  Phone:______________________________

Name of Practice:___________________________________   Fax:_______________________________

I authorize my doctor to exchange information with Julia Tarsa, MA LLC for the purpose of coordination of services.  I understand that this authorization shall remain in effect for one year from the date of my signature below or for the course of this treatment whichever is longer.  I understand that I may revoke this authorization at any time by written notice to Julia Tarsa, MA LLC.



___________________________________________       __________________________________
Print Client's Name                                                                     Date


___________________________________________
Client's Signature

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                                    2109 Hamilton Rd., Office 200, Okemos, MI  48864

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                                                                                       Julia Tarsa MA LLC
                                                                            Licensed Professional Counselor


                                      PARENTAL CONSENT FOR THE TREATMENT OF ADOLESCENTS


To the parent(s) of teenage clients,

Counseling adolescents ages 13-17 years of age can be challenging and rewarding for a therapist.  My hope is that I can assist your child in: moving forward in their development, getting through the rough spots (ie. changing schools) and finding helpful resources.  For teenagers to open up they need to trust me.  To provide this safe environment I ask the parent(s) of my teenage clients to sign this release form acknowledging that they understand that the sessions are confidential.   The term "parent" on this form also includes guardians.  

I will not share what your teen has shared with me with these exceptions:

>     If they are going to hurt themselves or someone else (this includes cutting).

>    If they have committed a crime at my office or against me or my staff.

>    If they are planning to run away.

>    If a judge requires me to testify.

>    If your health insurance company needs information to process payment.

If after the initial session it seems like your child and I are a good match I require a committment by you to bring your teenager to 3 more sessions.  This allows the bonding process to be established so that we can begin working on deeper issues.  This might mean that you as the parent may have to put up with some complaining.  

At the beginning of the first session I ask that you meet with me and your child.  During that time I will ask you to discuss what behaviors your child is exhibiting that concerns you.  I will also invite your teen to talk during this time.  Parents are always welcome to ask to meet with me and your child to discuss progress or concerns or to ask questions as part of any of the sessions.  

If you are not comfortable with my policies for counseling adolescents I would be glad to refer you to another qualified therapist with experience in counseling adolescents.    

I agree to Julia Tarsa MA LLC's policies for counseling adolescents listed in this document.  I have asked my teenager to read this document and to sign it.

___________________________________________________      ______________________________
Parent/Legal Guardian                                                                  Date

___________________________________________________      ______________________________
Parent/Legal Guardian                                                                   Date

___________________________________________________      ______________________________
Teenage Client                                                                             Date