Revised 4/27/2020

BestWay Counseling
REGISTRATION FORM
Please provide the following information and answer the questions below. Please note all information
provided here is protected as confidential information for BestWay Counseling purposes only.
Date: ____________________________
Last Name: ________First Name: ______

Marital Status: S / M /D/Sep/W

Other Names: ________

Date of Birth: _j_j__

Sex: MF

Address: __________________
City: _____ State: ___________ ZIP Code: ________
Phone:
Home: _______

Mobile:________

Other:________-----------------

Dr: ______________

Insurance:

Family:_____________

Friend: __________________

Other: _______________
Reason for Referral: ____________________

What significant life changes or stressful events have you experienced recently?

Page 1 of 10

Revised 4/27/2020

Family members, relationships & support system:
Relationship:Name:

Are you spiritual or religious?

1_'YesPlease tell us more about your faith:

Page 2 of 10i,NoRevised 4/27/2020

Please answer to the best of your knowledge
In this section please circle yes/ no if there is a fmily history of any of the following issues. Thenplease indicate the family member that had the issue and if they were on your mother/ father's sideof the family.

Alcohol/ substance abuse

Yes/ No

Anxiety

Yes/ No

Depression

Yes/ No

Domestic Violence

Yes/ No

Eating Disorders

Yes/ No

Obesity

Yes/ No

Obsessive Compulsive Behavior

Yes/ No

Schizophrenia

Yes/ No

Suicide Attempts

Yes/ No

Hobbies or Interests:

Page 3 of 10

Revised 4/27/2020

Are you currently employed?

Yes

NoAre you happy with your current employment situation?

Yes

NoDo you enjoy your work?

Yes

No

Is it a stressful Job?

Yes

NoYes

No

Please explain your current work situation:

Other work history:

Are you on disability?

Rate on a scale from 1 to 5 (one being poor and 5 being excellent) circle ONE
How would you rate your current physical health?

12

3

4

5

Please list any specific health problems or conditions you are currently experiencing:

Page 4of 10

Revised 4/27/2020

Primary Care Physician:------------------------------Are you currently experiencing any chronic pain?

i-----.'. No

If yes, please explain:

Please list any medications you are currently taking:

Have you ever been prescribed psychiatric medication? (Please provide dates as well):Medication: ______________YesINoDate Prescribed: ____________

Do you have any allergies?

PH#_______

Please let us know what pharmacy you use:

location: ___________________________________

Please list any specific sleeping problems you are having; including nightmares:

Page 5 of 10

Revised 4/27/2020

How would you rate your current sleeping habits?
1
2
3
4
5
How many days a week do you exercise?

At what Intensity do you exercise?
L Low

� Moderate

cHigh

Have you had any changes in appetite?
Please explain:

Height: ________________

Weight: _____________ __Do you have a history of, or currently use, drugs or alcohol?

Yes

If so, please explain:

Have you received treatment for drugs or alcohol?

l:Yes

Where / When:

Page 6 of 10''-.

No�NoRevised 4/27/2020

Do you smoke or use nicotine products?

L_ J Yes

�NoWhat do you use and how much:

Are you currently experiencing overwhelming sadness, grief, or depression?--, Yes:--7 NoIf yes, how long have you had these feelings and what are your symptoms?

Are you currently experiencing anxiety, panic attacks, or have any phobias and what are yoursymptoms? : _!Yes

LJ No

If yes, when did these begin?

Page 7 of 10

Revised 4/27/2020

What is your educational history?

Yes

Have you ever been arrested?
Dates of arrest:

Sentence:-----------

� J- No

Charges: _____________---------------------------------

Has CPS ever been involved?

: Yes

If yes, please explain:

Page 8 of 10No

Revised 4/27/2020

Have you previously received any type of mental health services? (Psychotherapy, psychiatric services,inpatient treatment, etc.)--Noo If yes, please give us the name and location of former therapist/ practitioner, and dates oftreatment
Name & Location; Dates:

What are your strengths?

What are your weaknesses?

What would you like to accomplish with your therapy?

Page 9 of 10

Revised 4/27/2020
In case of an emergency who should we contact?
Name:_____________

Phone: _____________

Please make sure the following pages are signed and dated before
returning this packet to the front desk.

If there is any additional information you wish to share please use the space below:

Page 10 of 10

WELCOME TO BestWay COUNSELING

Welcome to BestWay Counseling. Please fill out thefollowing pages to the best of your ability. Make sure they are signed anddated.

The first set of pages contain our policies and consent forms for your treatment.

The rest of the packet will aid the counselor and doctor in your treatment.
When you are finished bring the packet up to the front window.

Additionally, please list an emergency contact below.

Name: _____________

Phone:------------

Relationship:__________

If there is any additional information you wish to share please use the space
below:

Revised
4/27/2020

BestWav Cot1.•mseling, h1c.
Acknowledgment FormI, ------------� acknowledge that I have received a copy of Noticeof Privacy Practices of Best Way Counseling Inc . effective April 27, 2020, as
required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA.).

Patient Signature

Date

POA/Guardian Signature

Date

BestWay Counseling
NO-SHO\iV AND CANCELLATION POLICY CONTRACT
For Therapists/Psychiatrists
TO EXISTING AND NEV\/ CLIENTS:
In order to create more availability for those clients who show dedication to their treatment and for those clients\,\fairing to receive services, it is necessary for our agencies to work towards a zero tolerance policy for no-show/no­call clients and for those who frequently cancel their appointments. Therefore:
Effective March 27, 2020 the fee for rnjssing an appointment (\vithout a 24-hour notice) will be:3$25 00 for therapy appointments

Please keep in mind that this fee will not be covered or paid bv your insurance. You will be billed and will be
expected to pay the fee in full before your next appointment can be scheduled. In addition, your services will beterminated following 2 occurrences of missing an appointment without providing a 24-hour notice.
C;\NCELLATIONS:YOU lVIUST CALL 24 HRS fN ADVANCE• You must cali during normal business hours to cancel and reschedule an appointment.
e Please do not leave a voicemail message to cancel your appointment this will not be considered a twentv­
four hour notice.
0Please identify the reason for your cancellation.
e Please work with the secretary to reschedule for the same week if possible.
FAILURE TO CALL 24 HOURS IN ADVANCE:
If you do not give 24 hours' notice for your cancellation:eYou will be charged a $25.00 fee for therapy.
t,Due to the amount of people who are currently on our wait list it could be a month before we are able to getyou in to see the cotmselor.
,s,
In the event your case is closed due to cancellations, your file may include a statement addressing non­compliance for the treatment process.
Please work diligently to see that you follow treatment protocol.
Your signature below indicates you have received, read, and agree to the terms of this policy.
Signature of Client/Parent/Guardian
Revised 4/27/2020 wlDate

APPOINTMENT COMPLIANCE POLICYFor Therapist

TO EXISTING AND NEW CLIENTS:
Our :Mission:
We are primarily a counseling based agency. All new patients are set up with a counselor who wili establish atreatment plan for you.
Counseling Appointment Compliance:
We understand there will be times that appointments can't be kept. However, it is vital to the success of yourtreatment that you stay compliant with the treatment plan your counselor has set foiih for you. This includes
providing a 24-hour notice in the event that you can't keep your appointment

Non-Compliance
We reserve the right to cancel any upcoming appointments you have if you are not compliant with your treatment
plan with your counselor/ doctor. Thjs may ultimately result in the termination of our services.
Please work diligently to see that you follow your treatment plan.
Your signature below indicates you have received, read, and agree to the terms of this policy

Signature of Client /Parent/GuardianDate

BestWay Cow1seling 1101 N. Royal AYenue, Evansville, Indiana
812-437-0038

HI003

Consent to Use Protected Health Information for Treatment, Payment,and Health Care Operations (TPO)

Revised 4/27/2020

I consent to allow Debra Corn N.P. lnc./Best Way Counseling Inc. to use or disclose my protected health information
for treatment. payment, and health care operations.
*Treatment means the provision, coordination, or management of health care and related services by one or more
health care providers.
* Payment means the activities undertaken by a health care provider or health plan to obtain or provide
reimbursement for the provision of health care.
*Health care operations means conducting quality assessment and improvement activities; reviewing thecompetence or qualifications of health care professionals; underwriting; premium rating, and other activities related tohealth insurance contracts; medical reviews; legal reviews; auditing functions; and business management andgeneral administrative activities of Debra Corn N.P. lnc./Best Way Counseling Inc.
I consent to allow Debra Corn N.P. lnc./Best Way Counseling Inc. to disclose my protected health information fortreatment activities of another provider.
I consent to allow Debra Corn N.P. lnc./Best Way Counseling Inc. to disclose my protected health information toanother covered entity or to another health care provider for the payment activities of the entity that receives theinformation.
I consent to allow Debra Corn N.P. lnc./Best Way Counseling Inc. to disclose my protected health care information toanother covered entity for health care operations activities, provided that Debra Corn N.P. lnc./Best Way CounselingInc., and the other covered entity has or had a relationship with the below named patient. The disclosure must be fortreatment, payment. or health care operations, or for the purpose of health care fraud and abuse detection orcompliance.
I grant Debra Corn N.P. lnc./Best Way Counseling Inc., or agents worl<ing on their behalf, permission to contact myinsurance company (-ies) for my benefits and to provide the necessary information for payment of my claim. I also
authorize and request my insurance company to pay directly to Debra Com N.P. lnc./Best Way Counseling Inc. theamount due in my pending claim for psychotherapeutic treatment and services, by reason of such treatment andservices rendered.
Insurance Company Name and Address
Insurance Company Name and Address
Consent to Use protected Health Care Information for TPO!\Jame of patient __________________(Please print)
Signature of Person
Authorizing Consent.____ ______ __Witness Signature:
Date of Signature:
Verbal consent may be accepted only in the event written consent cannot be obtained, but shall be accepted only if
verbal consent is witnessed and signed by two persons. Verbal consent for the above was obtained on (Date), and given after full disclosure of this form to _________(Parent/Guardian).
I have been informed of my right to receive a copy of Notice of Privacy Practices ofDebra Corn N.P. lnc./Best Way Counseling Inc. and to review this notice prior to signing this consent form.

Consent for Evaluation and Treatment

HI004
Revised 4/27/2020

The undersigned hereby requests and agrees to an evaluation of____________ by Best Way
Counseling, Inc. and/or Debra Corn N.P. Inc. staff. This is a voluntary assessment /evaluation and further careand/or treatment may be recommended.
I agree not to hold Best Way Counseling, Inc. responsible for any adverse effects as a result of such evaluation
and/or referral for services. Best Way Counseling, Inc. will maintain patient confidentiality in accordance with stateand federal regulations. I authorize Best Way Counseling, Inc. to release any/all diagnostic information from thisevaluation and subsequent treatment to other professional staff at this facility in order to facilitate care. Having been
apprised of the recommendations made from this evaluation, I voluntarily consent to services by Best WayCounseling, Inc.
- To maintain the confidentiality and to respect the right's of privacy of other clients.
- To participate in treatment services and understand that I will be kept informed ofplans for treatment and may withdraw this consent at any time.

This information may not be disclosed or used for any other purposes than as stated in The Consent to Use
Protected Health Care Information for Treatment, Payment, and Health Care Operations and the Privacy Practices ofBest Way Counseling, IncI understand Best Way Counseling, Inc.is required by the Health Insurance Portability andAccountability Act of 1996 (HIPM) to provide me with a copy of Privacy Practices of Best Way Counseling, Inc. also
which I am entitled, but not required, to review prior to consenting to treatment and consenting to the use ofprotected health care information for treatment, payment and health care operations.

Patient Signature

Date

Parent/Guardian's Signature (if applicable)

Date

Witness Signature

Date

Verbal consent may be accepted only in the event written consent cannot be obtained, but shall be accepted only if
verbal consent is witnessed and signed by two persons. Verbal consent for the above was obtained on ____and given after full disclosure of this form to _______________________ Date
Parent/Guardian
Consent was witnessed by:WitnessWitness

Contents of all therapy sessions are considered to be confidentiaL Goth verbal information andNritten records about a client cannot be shared witi1 another parcy without the written consent of
the client m the client's legal guardian. Noted exceptions are as follows:

1DLt"i:y ·;:,:; Warn and! Prro-.:eci:
When a dient discloses intentions or a plan to harm another person. the mental healih
professional is required to warn the intended victim and report this information to iegai authorities.
In cases in wr1icl1 the ciieni: discioses or impiies a pian for suicide, the health care professional isrequired to notify legal autl1orii:ies and malce reasonable attempts to notify the family of tl1e client.
,'.;buse o-,- ClliDclueu1 arml VuH1ioern[0De Av11JJflts
If a client states or suggests that he or sl1e is abusing a child (or vulnerable adult) or has recently
abused a child (or vulnerable aduit), or a chiid (or vulnerable adult) is in danger of abuse, tilemental health professional is required to report this information to the appropriate social ser✓ice
and/or legal autf1orities.
?rerwtall E,;posrnre to Corri:rnlllleci St1f;ils�a11,c0s
Mental Health care professionals are required to report admitted prenatal e;(posure to controlled
substances that are potentially harmfui.
fiflino•.s/Gua,ciuarisG,ip
Parents or legal guardians of non-emancipated minor c!ienis have the right to access the clients'
records.
insurance r·rnvadlers (when applicable)
Insurance companies and other third-party payers are given information that they request
regarding services to clients.
Information that may be requested includes, but is not limited to: types of service, dates/times ofservice, diagnosis, treatmenL plan, description of impairment, progress of ti1erapy, case notes,
c:nd summaries.
I agree to the above limits of confidentiality and understand their meanings and ramii'ications.

Client Signature (Client's Parent/Guardian if under t8)

1 oday's Date