chloe zingaro lcsw...chloe zingaro, lcsw 9900 north central expressway suite 500 dallas, texas 75231...
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CHLOE ZINGARO, LCSW
9900 North Central Expressway Suite 500
Dallas, Texas 75231 T. 214-966-0040
CLIENT AGREEMENT AND ACKNOWLEDGEMENT OF MENTAL HEALTH TREATMENT
Please complete and sign at the end stating that you have fully read and understand the information below.
Client Name: ___________________________________ Name of parent/guardian(s) if client under 18 years of age: __________________________________________________________________ Birth Date: __________ Gender:____________ Home Address: _______________________ _______________________ _______________________ Home Number: ______________________ Messages □Yes □No Cell Number: ______________________ Messages □Yes □No Work/Other: _______________________ Messages □Yes □No
Professionals Include: Chloe Zingaro, LCSW Client/Therapist Relationship: You and your therapist have a professional relationship existing exclusively for therapeutic treatment. This relationship functions most effectively when it remains strictly professional and involves only the therapeutic aspect. Your therapist can best serve your needs by focusing solely on therapy and avoiding any type of social or business relationship. Available Services: I offer a wide variety of counseling services, including individual and group services. Effective psychotherapy is founded on mutual understanding and good rapport between client and therapist. It is my intent to convey the policies and procedures used in my practice, and I will be pleased to discuss any questions or concerns you may have. My primary theoretical perspectives include cognitive behavioral therapy, rational emotive behavioral therapy, dialectical behavioral therapy, and prolonged exposure therapy. Risks and Benefits: Counseling and psychotherapy are beneficial, but as with any treatment, there are inherent risks. During counseling, you will have discussions about personal issues which may bring to the surface uncomfortable emotions such as anger, guilt, and sadness. The benefits of counseling can far outweigh any discomfort encountered during the process. Some of the possible benefits are improved interpersonal relationships, reduced feelings of emotional distress, and increased ability to solve problems in one’s life. I cannot guarantee these benefits, of course. It is my desire to work with you to attain your personal goals for counseling and/or psychotherapy.
CHLOE ZINGARO, LCSW
9900 North Central Expressway Suite 500
Dallas, Texas 75231 T. 214-966-0040
Psychotherapy: I provide therapy designed to address many of the issues clients are dealing with. Your first visit will be an assessment session in which you and I will determine your concerns, and if both parties agree that I can meet your therapeutic needs, we will develop a plan of treatment. My goal is to provide the most effective therapeutic experience available to you. If at any time you feel that you and I are not a good fit, I encourage you to discuss this with me to determine if transferring to a more suitable therapist is right for you. If you and I decide that other services would be more appropriate, I will assist you in finding a provider to meet your needs. Appointments: Appointments are typically scheduled on a weekly basis and are approximately 45 minutes long. More frequent sessions or an intensive outpatient schedule are available if determined appropriate by your therapist. If you must cancel or reschedule your appointment, I ask that you call my office at least 24 hours in advance. The full session fee will be charged if a 24-hour notice is not provided. My goal is to use your appointment time for another client. Fee Schedule: $180 for initial evaluation $150 per 45 minute session $75 per Skills Group Training session (DBT) Payment: Payment of fees is expected at the time of each appointment. Please provide payment in the form of CASH, CHECK or CREDIT CARD. If requested, a statement of services rendered can be provided. Emergencies: You may encounter a personal emergency which will require prompt attention. In this event, please contact my office regarding the nature and urgency of the circumstances. Because clients may be scheduled back–to- back, it is not always possible to return a call immediately. However, I will make every effort to respond to your emergency in a timely manner. In the case of a life threatening emergency or a crisis that cannot wait on a call back, call 911 or go to the nearest emergency room. Confidentiality: HIPAA Compliance and use of Protected Health Information (PHI): Your health record contains personal information about you and your health. This is information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI. I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective
CHLOE ZINGARO, LCSW
9900 North Central Expressway Suite 500
Dallas, Texas 75231 T. 214-966-0040
for all PHI that we maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on my website, sending a copy to you in the mail upon request or providing one to you at your next appointment. Duty to Warn/Duty to Protect: If my therapist believes that I (or my child if child is the client) am in any physical or emotional danger to myself or another human being, I hereby specifically give consent to the therapist to contact any person who is in a position to prevent harm to me or another, including, but not limited to the person in danger. I also give consent to my therapist to contact the following persons in addition to any medical or law enforcement personnel deemed appropriate: Name______________________________ Contact Number__________________________ Name______________________________ Contact Number__________________________ Name______________________________ Contact Number__________________________ Incapacity or Death: I understand that, in the event of death or incapacitation of the undersigned therapist, it will be necessary to assign my case to another therapist and for that therapist to have possession of my treatment records. By my signature on this form, I herby consent to another licensed mental health professional, selected by the undersigned therapist, to take possession of my records and prove me copies at my request, and/or to deliver those records to another therapist of my choosing. Consent to Treatment: By signing this client agreement and consent for mental health treatment as the client or guardian of said client, I acknowledge that I have read, understand, and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I voluntarily agree to receive mental health assessment, treatment and services for myself (or my child if said child is the client), and I understand that I may stop such treatment of services at any time. ***Note: If you are consenting to treatment of a minor child, if a court order has been entered with respect to conservatorship of said child, or impacting your rights with respect to consent to the child’s mental health care and treatment, the therapist will not render services to your child until the therapist has received and reviewed a copy of the most recent applicable court order. __________________________________ _____________________ Signature of client Date __________________________________ _____________________ Signature of Guardian Date (if client is under age of 18) __________________________________ _____________________ Chloe Zingaro, LCSW Date
CHLOE ZINGARO, LCSW
9900 North Central Expressway Suite 500
Dallas, Texas 75231 T. 214-966-0040
CONSENT FOR THE TREATMENT OF A MINOR
Minor’s Name:__________________
Date of Birth:___________________
Parent/Guardian Name(s): _________________
We/I, the undersigned__________________, parent(s) and/or guardian(s) of a minor child __________________, give you, Chloe Zingaro, LCSW full and unconditional authority to proceed with a clinical evaluation and treatment as your judgment indicates. Moreover, We/I understand that although I have a right to my child's records, I will waive my right to any records or disclosures, if, in the opinion of Chloe Zingaro, LCSW such disclosure could negatively impact my child or my child's treatment. This consent is given by me/us as parent(s) and/or guardian(s) of said child. We/I have legal power to consent to medical, psychological, and mental health assessment and treatment of minor said child. It is clearly understood that Chloe Zingaro, LCSW is hereby fully released from any claims and demands that might arise, or be incident to the evaluation and/or treatment, provided that the duties are performed with standard care and responsibility to the best of her professional ability.
Signed this ____ day of _________, 20__
__________________________ ________________ Printed name of legal guardian Relationship to minor __________________________ ________________ Printed name of legal guardian Relationship to minor __________________________ ____________ Signature of legal guardian Date __________________________ ____________ Signature of legal guardian Date _________________________ ____________ Chloe Zingaro, LCSW Date
CHLOE ZINGARO, LCSW
9900 North Central Expressway Suite 500
Dallas, Texas 75231 T. 214-966-0040
NOTICE OF PRIVACY PRACTICES: RECEIPT AND ACKNOWLEDGMENT OF NOTICE
Client Name:______________________
DOB: ___________________________
I hereby acknowledge that I have received and have been given an opportunity to read a copy of Margaret Chloe Zingaro, LCSW, PLLC Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Chloe Zingaro, LCSW, at 214-966-0040.
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Signature of Patient/Client Date
_________________________________________________________________
Signature of Parent, Guardian or Personal Representative Date
__________________________________________________________________ * If you are signing as a personal representative of an individual, please describe your legal authority to
act for this individual (power of attorney, healthcare surrogate, etc.).
! Patient/Client Refuses to Acknowledge Receipt:
_________________________________________________________________
Signature of Staff Member Date
CHLOE ZINGARO, LCSW
9900 North Central Expressway Suite 500
Dallas, Texas 75231 T. 214-966-0040
AUTHORIZATION TO CONTACT BY TELEPHONE/VERBALLY IN EVENT OF BREACH OF PHI
I, _______________________________ [Insert Name of Patient/Client], authorize Margaret Chloe Zingaro, LCSW, PLLC to provide notice to me by telephone or verbally in the event of a breach of my protected health information (PHI) by Margaret Chloe Zingaro, LCSW, PLLC . Such conversation shall be documented by Margaret Chloe Zingaro, LCSW, PLLC.
Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Final Rule modifying the HIPAA Privacy, Security, Enforcement and Breach Notification Rules, the verbal or telephonic notice provided to me pursuant to this authorization shall not be simply for the administrative convenience of Margaret Chloe Zingaro, LCSW, PLLC.
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Signature of Patient/Client Date
__________________________________________________________________
Signature of Parent, Guardian or Personal Representative Date
CHLOE ZINGARO, LCSW
9900 North Central Expressway Suite 500
Dallas, Texas 75231 T. 214-966-0040
CANCELLATION POLICY If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for the entire cost of your missed appointment. A full session fee is charged for missed appointments or cancellations with less than a 24-hour notice unless it is due to sudden illness or an emergency. This policy also applies to no shows for group appointments. Your credit card will be billed if you do not show up for, or cancel an appointment within 24 hrs of your scheduled appointment. Thank you for your consideration regarding this important matter. Client Signature (Client's Parent/Guardian if under 18):________________________ Date: ___/___/___
CREDIT CARD PAYMENT AUTHORIZATION
I,_____________________________, hereby authorize Margaret Chloe Zingaro, LCSW, PLLC to keep my credit card information and signature on file and to automatically charge my credit card account for: confirmation of initial evaluation appointments, appointments, missed/canceled appointments including the Initial Evaluation without 24 hour notice (will be charged at full fee), late fees (invoices past 30 days due), chargeback fees, and the full check(s) amount that is/are not cleared by the bank plus a $30 returned check charge per incident, and will not dispute the charges with my credit card company. This authority is to remain in full force and effect until Margaret Chloe Zingaro, LCSW, PLLC has received notification from me in writing in such time and in such manner as to afford Margaret Chloe Zingaro, LCSW, PLLC a reasonable opportunity to act on it.
Client Name: ____________________________ Cardholder Name (as on card):___________________________________ Credit Card Number: ___________________________________________________ CVV Code (3 digits):_____________ Credit Card Type (please circle one): Visa / Master Card/ Discover/ Amex Expiration Date: ______/_______/_______ Cardholder Billing Address (Street Number, Address, City, State, Zip Code) : _____________________________________ _____________________________________ Cardholder Phone Number: ______________________________ Cardholder’s Signature: _________________________________ Date: ___/___/___
CHLOE ZINGARO, LCSW
9900 North Central Expressway Suite 500
Dallas, Texas 75231 T. 214-966-0040