Tangled Web Therapeutic Services LLC

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Justina Pope
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Tangled Web Therapeutic Services LLC Hello, Since you have made your first appointment, I want to provide you with the information you will need to find my office as well as a few forms for you to

Parkridge Plaza will be on the right From 100, take the exit for 108 W. Turn right after the sign for Oakland Center. Turn left into the parking lot. Parkridge Plaza will be on the left.

1 Tangled Web Therapeutic Services LLC Hello, Since you have made your first appointment, I want to provide you with the information you will need to find my office as well as a few forms for you to complete. Directions: From Route 29, take the exit for 108 E. Turn left after the sign for Oakland Center. Turn right into the parking lot. Parkridge Plaza will be on the right From 100, take the exit for 108 W. Turn right after the sign for Oakland Center. Turn left into the parking lot. Parkridge Plaza will be on the left Route 108 Suite 234 Columbia, MD View from route 108 View from parking lot I am located in suite 234. Go up the stairs and turn right. The suite will be on your left after the fire extinguisher. Please go in, help yourself to a beverage and have a seat in the waiting room. I will come out to get you at your appointment time. Please complete all of the following forms and bring them to your first session. -Intake 1 per person -Fee Schedule 1 per person -Financial Agreement -Appointment Reminder/Encrypted 1 per person, This is the sign in you will use to complete the biographical information survey on therapyappointment.com Please call if you need to change your appointment, have questions about the forms, or need help locating my office. I look forward to meeting you! Lexa Grobicki LCMFT

2 INTAKE Today s : Name: of Birth: / / Age: Gender: Male Female Is it ok to send mail, , and leave messages? Yes No Specify: Address: Home Phone: Cell Phone: Address: Work Phone: How did you find me/who referred you? What type of therapy are you seeking?: Family Couple Individual What is your Relationship Status?: Single Dating Cohabiting Engaged Married Domestic Partnership Separated Divorced Widowed Other: How long have you been in your current relationship? How satisfied are you? (1 not, 10 very)? Emergency Contact I suggest you inform them they are your contact, this person will be called if you are in danger of hurting yourself or others or need additional support in order to stay safe or in the case of a medical emergency. Name: Phone Number: Brief Intake 1. Please list and provide dates of any psychiatric diagnoses or psychiatric medications or hospitalizations for psychiatric reasons 2. Please list any difficulties you experience with your appetite or eating patterns 3. Please list any concerns with your finances 4. Please describe your religious affiliation, faith or belief system 5. What is your cultural background 6. Please list any legal actions either civil or criminal you are involved in

3 FEE SCHEDULE Tier 1 Tier 2 Tier 3 Tier 4 Income for treatment unit 50 Minute Session 90 Minute Session 0-$ $80.00 $ $40,000-$69, $ $ $70,000-$99, $ $ $100,000+ $ $ Rates are based on the gross annual income of the treatment unit either an individual, couple, or family. Rates may be negotiated. Individual gross annual income: Total Treatment Unit gross annual income : The agreed on Tier: /individual sessions and /couple or family sessions Signature

4 FINANCIAL AGREEMENT I understand that I am responsible for paying the full therapy session fee at the time the service is rendered. I understand that I can pay for services with cash, check or credit card. How would you like to pay for services today and future visits? Please check below: Cash Check (please make check out prior to your session to Alexandra Grobicki) (See General Policies for returned check policy) Credit Card The following is required even if you do not plan to regularly pay with a credit card: Name(s) of Client(s) who have permission to bill to this card (yourself and any other family members who may use this credit card to pay for sessions): Cardholder s Name (exactly as it appears on card): Type of card: Visa MasterCard Discover American Express Credit card number: Expiration date: CVV Code: Cardholder s Billing Address: Would you like a receipt ed to you? Yes No Do you consent to the secure storage of your credit card information? Yes No By checking yes, I consent to the secure storage of my credit card information with Merchant Warehouse for recurring billing for services as outlined above. Credit card information is considered to be Protected Health Information under HIPAA. By my signature, I am waiving my right to keep this information completely private, and requesting that it be handled as I have noted above. I understand that only a reference number will be stored in TherapyAppointment.com s encrypted servers and associated with my account. My signature below indicates that I authorize Alexandra Grobicki LCMFT and Tangled Web Therapeutic Services LLC and Therapyappointments.com/Merchant Warehouse to charge my credit card after the above named client(s) meets for a therapy session with a licensed therapist from Tangled Web Therapeutic Services LLC unless the session is paid for at the end of session with either cash or check. I also authorize this card to be used for payment if the above named client(s) is unable to attend a scheduled session and does not provide at least 24 hours cancellation notice. Additionally, I authorize this card to be used for payment of any other services that I obtain (see general policies). I understand that the full session fee will be charged even if the above named client(s) arrives to a session late or leaves the session early. I understand that I am responsible for having a sufficient credit line available, and that I am responsible for all charges incurred by Alexandra Grobicki LCMFT and Tangled Web Therapeutic Services LLC due to rejected credit card transactions. This authorization will expire upon termination of therapy and/or when the above named client s account with Alexandra Grobicki LCMFT and Tangled Web Therapeutic Services LLC is settled. Signature of Cardholder

5 APPOINTMENT REMINDERS/ENCRYPTED You can receive an appointment reminder to your address, your cell phone (via a text message), or your home phone (via a computer generated voice message) the day before your scheduled appointments. In addition, you will be able to access TherapyAppointment.com in order to complete a Biographical Information Survey, check your appointment time, and send and receive secure encrypted . Your name: Requested login name: (letters or numbers only) Requested password: (letters or numbers only) Your address: Your cell phone number: Your cell phone carrier (circle one): Alltel AT&T Boost Mobile Nextel Sprint SunCom T-mobile Verizon VoiceStream Virgin Mobile (Other) Where would you like to receive appointment reminders? (check one) Via a text message on my cell phone (normal text message rates will apply) Via an message to the address listed above Via an automated telephone message to my home phone None of the above. I ll remember my appointments on my own. Appointment information is considered to be Protected Health Information under HIPAA. By my signature, I am waiving my right to keep this information completely private, and requesting that it be handled as I have noted above. You are responsible for remembering your appointments and missed session fees still apply even if you do not receive an automated reminder that you have requested. If you ever have questions about your appointment time, please contact your therapist. Signature

LIFEWAY PREMARITAL INFORMATION FORM LIFEWAY REFERRAL INFORMATION

LIFEWAY PREMARITAL INFORMATION FORM Name: First MI Last Date of Birth: / / Gender: M F Marital Status: Single Engaged Divorced Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone: