Family Ties Counseling, Inc.
Helping individuals and families grow, one heart
at a time.....
Required Forms.
These forms are required before your first. If you are a private pay or general insurance client, you should print and complete the packet labeled "General Packet". We should have made an agreement when we initially spoke on the phone. Medicaid and Tricare clients have additional requirements placed by the insurance and should print the appropriately labeled packet. Bring them with you to your first appointment. While it seems there is a great deal of information required, the information is either required by law, or will greatly assist me in helping you. Thank you for taking the time!
Packet for private pay and all other insurances. There are a limited number of insurance openings available, and if you are receiving an insurance spot, this should have been agreed upon in our phone consultation.
Tricare Only: All documents required for Tricare clients are included. CLIENT AUTHORIZATION IS REQUIRED BEFORE THE FIRST APPOINTMENT AND IS THE CLIENT'S RESPONSIBILITY! Additional paperwork such as releases are under "Elective Forms" below.
Medicaid Only: All documents required for Medicaid clients are included. Additional paperwork such as releases are under "Elective Forms" below.
Caseworker: If a child or adolescent is currently in the custody of the Department of Human Services, the caseworker should print this packet and mail the original documents to Family Ties.
You do not need to print this document. However, you will have to sign (in the client rights form) that this form has been offered to you. You may print the document to read it if you like.
Elective Forms....
Elective Forms
The following forms are elective and not required for all clients.
Print only the forms that apply to your situation.
Sign to authorize me to speak with another person. Without authorization, I cannot confirm or deny knowledge of you.
Release of Information for Family or Couples counseling. Must be signed when client is 15 or over.
Required for treatment of a child that is currently in shared custody. Both parents with custody will need to sign.
Print and sign if you are wanting to borrow a book or video or are purchasing materials.
Used to set up a payment plan. Also used if a third party such as a parent or friend is willing to pay for sessions.
Used to update your credit card information if: 1. Your chart is being re-opened after some time. 2. If we have not seen you in over six months. 3. Your credit card on file has expired.
Print and sign if you have moved, obtained new phone numbers, or new insurance information. Also can be used in the case of a change of details or other information that we will require.
Print and sign page 2 of the two pages, sign and bring with you to your session. This form is to be used if you are interested in opting out of your insurance.
This form is here to help you verify your insurance benefits with your insurance company. Print and fill out when you call to verify what your benefits are.
Please read the instruction for telehealth. Sign the consent form and return via the instructions on the document. Zoom instructions for telehealth sessions are also included.