SMC Client Agreement

1115 Dunlap Road Anderson, SC 29621 / P.O. Box 1424 Anderson 29625 Phone 864-225-0792 Fax 864-226-3968

PATIENT INFORMATION

Full Name

Date of Birth

Month

Day

Year

SS#

Marital Status

Single

Married

Widowed

Divorced

Gender Identity

Cell Phone

Alternate Number

May We Leave A Detailed Message

Yes

Multi-line address

Country/Region

Address

City

Zip / Postal code

Email Address

May We Email You?

Yes

EMERGENCY CONTACT

Emergency Contact Name

Phone

Relationship to Patient

MEDICAL/ MENTAL HEALTH/ MEDICATION INFORMATION

May We Contact Your Primary Care Physician(s)?

Yes

Primary Care Physician(s)

Phone:

Health & Family Medical / Mental Health History:

Food Allergies

Other Allergies

Smoking

Yes

Alcohol Use

Yes

Drug Use

Yes

Caffeine (Coffee/other): Type:

Current Medications:

FINANCIALLY RESPONSIBLE PARTY

(If different from patient)

Name

Phone

Relationship to Patient

Date of Birth

Multi-line address

Country/Region

Address

City

Zip / Postal code

INSURANCE / PAYMENT INFORMATION

INSURANCE AND PAYMENT POLICY

We are a provider for most major insurance companies. Please provide your correct and current insurance information. While we bill your insurance as a courtesy, payment for your portion of insurance, cash pay, or other services is due on or before the day of service, unless other payment arrangements have been made with our office.

Credit/HSA/FSA card information can be submitted safely and securely through our website or directly by contacting the office. It is the responsibility of the client/guardian to pay for any non-covered services, which may include, but are not limited to, phone consultations, record requests, professional letters, crisis support, and late/missed appointment fees. Please note that text messages may incur additional fees.

Payment plans may be arranged to prevent your account from becoming overdue, with a 2.5% interest. Appointments may be rescheduled as necessary. A $75 fee will be applied for cancellations within 24 hours, and full session fees will be charged if an appointment is missed without notice.

Declined payments incur a $30 fee. Unpaid balances that have been outstanding for 90 days or more may be referred to an outside collection agency, for which you are responsible for all associated fees.

Policy Holder’s Name

Policy Holder’s Date of Birth

Primary Insurance Company

Relationship to Client

Policy Number

Group Number

Secondary Insurance Company

Relationship to Client

Policy Number

Group Number

Self-Pay

PLEASE CHECK EACH BOX BELOW AS ACKNOWLEDGEMENT

I understand an assessment doesn’t guarantee follow-up. Required documents must be submitted before my appointment.

I acknowledge that all communication must occur through the office (a fee of $25 may be applied to texts or social media attempts).

I understand that telehealth and crisis sessions are billed and submitted to insurance as applicable.

I understand that a fee will be charged for Letterhead paperwork/forms, Medication refills, and Prior Authorizations

I understand my records may contain sensitive protected information and require my authorization for release, except to my insurance.

I understand that the office transmits information electronically and absolve the practice of liability if information is inadvertently received by a third party.

I understand that the office reserves the right to dismiss any patient who is noncompliant with treatment, payment, or office policies.

Notice of Privacy Practices (HIPAA)

Your Health Information is confidential and protected by law. By signing below, you acknowledge receipt of our Notice of Privacy Practices, available upon request.

Signature of Client/Representative

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Date

Month

Day

Year

Authorization for Release of Information

I give (if applicable) permission to the Stress Management Center to share my psychological/psychiatric diagnoses or release information/records to the following agency/ person(s)

Name

Phone

Purpose/ Relationship

Name

Phone

Purpose/Relationship

For Couples/Family Counseling

All participants must sign and date the document below to acknowledge their understanding of session confidentiality. For minors (under 18) in joint custody, both parents must sign

Full Name

Date

Sign

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Full Name

Date

Sign

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CONSENT FOR TREATMENT AND RELEASE

I have read and understood these forms. All of my questions have been answered. I give my consent to treatment and to speak with a clinician. I authorize my provider to discuss my care with other interoffice clinical providers as needed. The Stress Management Center may update

this policy at any time. By receiving services you agree to these terms

Signature

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Date

Signature Parent or Legal Guardian (if applicable)

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Stress Management Center

1115 Dunlap Road

Anderson, SC 29621

P.O. Box 1424

Anderson, SC 29625

Phone: 864-225-0792 | Fax: 864-226-3968