On Boarding Forms
Client Registration
For the client registration, you will need the following information:
Last Name ______________________ First Name ___________________________
Gender _____________________ Date of Birth _____________________
Address _____________________________City ___________________ Zip Code _______________
Home Phone ___________________ Cell Phone ___________________ Work _________________
SS# (Required for Insurance) _____-______-__________
Custodial Parent/Guardian/Emergency Contact _____________________
Insurance Information
Primary Insurance Name of Insurer ___________________________
Group __________________ Policy# ___________________________
Subscriber Name ___________________________ D.O.B. ___________________________
Relationship to Patient _____________________ Employer ___________________________
Primary Insurance Name of Insurer ___________________________
Group ___________________________ Policy# ___________________________
Assignment and Release
I, the undersigned certify that I, (or my dependent), have insurance coverage and assign directly to all insurance benefits, if any, otherwise payable to me for services rendered. I understand and agree that I am financially responsible for all charges, legal and clinical, whether or not paid by Insurance. I hereby authorize the provider and all employees to release any and all information necessary printed or verbal to secure the payment of benefits. I authorize the use of this signature on all claims, manual or electronic.
Client Rights and Informed Consent
COUNSELING SOLUTIONS, LLC 725 HEARTLAND TRAIL MADISON, WI 53517
Client’s Rights and Informed Consent
Consistent with HFS 94, Wisconsin Administrative Code, Counseling Solutions, LLC, wants you to be aware of your right as a client and asks for your informed consent to receive treatment. Included with this form is a pamphlet explaining your rights and the grievance procedure available to you. Please read and keep it with your records.
The following are general points of information about the therapy process and treatment.
The purpose of therapy is to help alleviate the problems and symptoms that you present.
Therapy is conducted in sessions between you and your counselor talking about the problems presented.
If there are any expected side effects from therapy, they will be discussed with you.
Your counselor will suggest alternative treatment modes and assist in referrals when appropriate and necessary.
The possible consequences of not receiving therapy or ending therapy will be discussed.
The content of all sessions will be held confidential and can be disclosed outside this program only with your signed approval unless a specific statutory exception applies or a duty to warn exists.
Your signature below indicates that you are giving consent to participate in therapy sessions and you understand your rights.
You have the right to withdraw informed consent at any time in writing. Otherwise, this consent will be valid for one year, (12 months).
If you have any specific questions, please ask your therapist. We look forward to working with you.
I have read the above information and have been notified of my rights and grievance procedure available to me. I hereby give my informed consent to receive treatment. I have also been advised of the cost of treatment.