2015 NEW CLIENT CONFIDENTIAL INFORMATION

KC COUNSELORS, LLC
ANNE WAGNER, R.N., M.S., L.P.C.

PLEASE PRINT

Todays Date:___________________

Name (first, middle, last):_________________________________________________________

Gender: Male____ Female____ Date of Birth:________________ Age_________

Social Security #________________________

Marital Status: Single___ Married___ Divorced___ Separated___ Widowed___ Partner___

Address:_______________________________________________________________________
Number Street City State Zip Code

Home Phone:_________________________ Ok to call this number? Yes____ No____

Cell Phone:___________________________ Ok to call this number? Yes____ No____

Work Phone:__________________________ Ok to call this number? Yes____ No____

Email Address:__________________________________________________________________

Do you want a reminder call the day before your appointment? Yes_______ No_______

Do you prefer we leave text or reminder call (if reminder call is wanted) and where?__________

Occupation:_____________________________ Employer:_____________________________

Referred by:____________________________ Ok to acknowledge referral? Yes____ No___

______________________________________________________________________________

Name of Significant Other or Parent/Guardian (if minor)__________________________

Address (if different from above):____________________________________________

Phone Number in case of emergency:_________________________________________



Have you ever seen, or are you currently seeing, a counselor, psychologist or psychiatrist?______

If yes, please indicate the name of therapist/agency and dates seen:_________________________
POLICY STATEMENT


Thank you for choosing Anne H. Wagner, R.N., M.S., L.P.C. as your therapist. She is
committed to your treatment being successful. Please understand that payment of your bill is
considered part of your treatment. The following is a statement of her policies, which she
requires that you read and sign prior to any treatment. Please let us know if you have any
questions or concerns.

If you are a PRIVATE PAY client, the charge for a first-time consultation is
$90.00. The charge for additional follow-up therapy is $80.00 per session.
These sessions are in 50 minute increments. If other arrangements for private
pay have been made with Anne Wagner, R.N., M.S., L.P.C., the billing manager
will be notified. Please feel free to discuss session fees with the billing manager
is you have any questions.

If you have INSURANCE COVERAGE, the charge for the first time consultation
is $170.00. The charge for additional follow-up therapy thereafter is $140.00.
These charges will be filed to your insurance company appropriately. For further
information, please refer to (3) below.

If you have insurance coverage, we will file claims to your insurance company as
a courtesy. It is the clients responsibility to get any referrals needed to be seen
by Anne Wagner, R.N., M.S., L.P.C. Anne accepts direct payment from the
insurance company for services rendered.

The client is financially responsible for those charges not covered by the
insurance company. This includes deductibles for the year. Payment
arrangements for deductible payments may be made through the billing office. In
the case of a high deductible, your cost would be $90.00 for the initial visit
and $80.00 for follow-up sessions thereafter until your deductible is met.

The client is responsible for paying their co-pay/co-insurance/percentage/cost at
the time of each session. We accept cash, checks, Visa, Mastercard, Discover,
and American Express. Please be advised that Anne Wagner, R.N., M.S., L.P.C.
respects her clients and their time. We understand that emergencies and life
happens, but please call if you are unable to make your appointments. IF YOU
DO NOT CALL WITHIN 24 HOURS OR DO NOT SHOW UP FOR YOUR
APPPOINTMENT YOU WILL BE CHARGED $40.00.

The client is responsible for any calls made to Anne Wagner, L.P.C after office
hours that lasts beyond 15 minutes. You will be charged whatever your regular
session fee is.


Upon termination, a final bill will be submitted to the clients insurance company.
After the response of the insurance company, the client or responsible party will
receive a final bill. Any balance remaining after 60 days after the receipt of the
final bill by the client or responsible party will have the opportunity to make
payment arrangements made with Anne Wagner, R.N., M.S., L.P.C. or the billing
office.



I have read the policy statement and I understand and agree to the policies of this office.



___________________________________________________________________________
Client (or responsible party)





































PSYCHOTHERAPY PRACTICE INFORMATION AND INFORMED CONSENT
FOR THE PSYCHOTHERAPY OFFICE OF
ANNE H. WAGNER,R.N., M.S., L.P.C.
K.C. COUNSELORS, LLC


WELCOME


Welcome to my practice at KC Counselors, LLC. Please read this document carefully and
note any questions you might have so you and I can discuss them. This document has had
some changes made to it so read it carefully. Once you sign this, it will constitute a
binding agreement between us.

Psychotherapy is not easily described in general terms. It varies, depending on the particular
issues that the client wants to address. There are a number of different approaches that can
be used. It is not like visiting your medical doctor in that psychotherapy requires an active
effort on your part. In order to be the most successful, you will have to work both during
sessions and at home.

While it may not be easy to seek help from a mental health professional, it is hoped that you
will be better able to understand your situation and feelings and move toward resolving your
difficulties. Using my knowledge of human development and behavior, I will make
observations about situations as well as suggestions for new ways to approach them. It will
be important for you to explore your own feelings and thoughts and to try new approaches in
order for change to occur. You may bring family members to a therapy session if you feel it
would be helpful or if I recommend this.

SCHEDULING AND SESSIONS

Appointments are scheduled on Wednesday, Thursday, and Fridays. You may schedule an
appointment by calling 816-926-1036. Please call to cancel or reschedule your
appointment within 24 hours if you cannot make it for any reason or you will be
charged a fee of $40.00 for the missed appointment. Please note that, by law, your
insurance company is NOT liable for payment of a missed appointment. In these cases, you
will be held financially responsible for the missed session. I understand that things come up
from time to time and you have to miss an appointment. I would greatly appreciate it if you
called 24 hours ahead of time to cancel your appointment as I have a waiting list of clients
wanting an appointment. In such cases there will not be a charge for a missed session. As
stated above, no calls no shows will be charged $40 for missed session. After 2 no calls, no
shows your therapy will be terminated and you will be referred elsewhere.





CONFIDENTIALITY


No one can see or receive your records without your written permission, with the exception
of (1) insurance filings (including diagnosis, dates, and types of treatment), (2) managed care
requests for additional sessions (including diagnosis, description of problems and treatment,
and prognosis), and (3) subpoenas for court or deposition. You will be informed about these
exceptions in advance.

The content of your session is confidential; your privacy is protected, with the exceptions
noted above, or when you request a release of information, or:

1. If you threaten bodily harm to another individual (the therapist is required to
notify that individual and take protective action). This includes suspected abuse
of the elderly or disabled, and suspected sexual abuse. This also includes when a
third-party communicates to the therapist that a client is threatening harm to
another.
2. If you threaten bodily harm to yourself or are suicidal (the therapist may need to
inform family members, legal authorities, or health personnel).
3. If the therapist has probable cause to believe that a child is being or has been
abused (the therapist is required by law to report to authorities). This includes
neglect and emotional abuse.
4. If the therapist is following ethical steps to collect an overdue account balance.
5. If the therapist is discussing your case in an ethical fashion with a professional
associate (keeping your identity protected) for professional purposes (this will not
be done with an associate with whom you are personally acquainted).
6. If the therapist learns of unprofessional conduct on the part of another licensed
professional (the therapist may be required to inform the appropriate board).

If you have questions regarding confidentiality, you should bring them to my attention so that
we can discuss the matter further.

If you have any questions regarding this Psychotherapy Practice Information and Informed
Consent form please let me or the staff know.

By signing this Psychotherapy Information and Informed Consent form I, the undersigned
client, acknowledge that I have both read and understood all the terms and information
contained herein. Ample opportunity has been offered to me to ask questions and seek
clarification of anything unclear to me. Therefore, I give my consent to treatment and/or
evaluation under the guidelines described.



______________________________ _______________________
Signature of Client Date


ANNE WAGNER, RN, MS, LPC
7611 STATE LINE RD SUITE 135
KANSAS CITY, MO 64114
PHONE: 816-926-1036
FAX: 816-926-1038


ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES



I, ______________________________________________, have been given an opportunity
to review this offices Notice of Privacy Practices. I understand that a copy of this Notice of
Privacy Practices is available for me to take home upon my request.




Please Print Name



Signature



Date




For office use only:

We attempted to obtain a written acknowledgement of receipt of our Notice of Privacy
Practices, but acknowledgement could not be obtained because:


1. Individual refused to sign.
2. Communication barriers prohibited obtaining the acknowledgement.
3. An emergency situation prevented us from obtaining acknowledgement.
4. Other (please specify)

________________________________________________________________________
________________________________________________________________________

CANCELLATIONS AND NO CALL, NO SHOWS POLICY

As I have had to decrease my office hours, I have fewer appointments available for clients. It
is very important that you call if you are going to have to cancel your appointment,
preferably 24 hours ahead of time if you can. I have a waiting list of clients that want an
appointment and if we have ample notice that you are not coming we can then offer an
appointment to those on the waiting list. I realize that things can come up at the last minute
and you are unable to give 24 hours notice. Please, still call and you will not be charged for a
missed appointment.

If you dont show up for your scheduled appointment and you have not cancelled it before
hand, you will be charged $40 for that session. If you have insurance, the insurance
company will not pay for missed sessions so you will be responsible for paying it on your
own. After two no calls, no shows your therapy will be terminated and you will be referred
out to another professional at that time.








OUTSIDE PAPERWORK POLICY

As of this year I will not fill out paperwork that is received outside of this office. This
includes disability forms. I am not in a position to provide the information that is required
for disability forms. I will send medical records if they are requested but, again, I am not
filling out paperwork.




I have read the above policy statements and understand and agree to the policy statements of
this office.




________________________________________ ________________
Signature of Client Date


INTAKE QUESTIONNAIRE


Primary Care Physician________________________________________________________

Other Physicians_____________________________________________________________


WHAT BROUGHT YOU HERE TODAY?
In the space provided below, please indicate a brief description for todays visit:__________







MEDICATION USE:
List below all current medications that have been prescribed for you:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________


PLEASE CIRCLE ANY OF THE FOLLOWING THAT PERTAINS TO YOU:

Anxiety Suicide Thoughts Sleep Changes Alcohol Use

Nervousness Aggressive Thoughts Inability to Sleep Drug Use

Stress Paranoia Excessive Sleep Headaches

Fears Hallucinations Daytime Napping Stomach Aches

Depression Hearing Voices Tiredness Dizziness

Unhappiness Seeing Visions Appetite Changes Sexual Problem

Loneliness Irritability Weight Gain Confusion

Guilt Mood Swings Weight Loss Poor Memory