nicole noyes 6855 w clearwater ave ste b kennewick, wa ......kennewick, wa 99336 760 774 9142...

Nicole Noyes 6855 W Clearwater Ave Ste B

Kennewick, WA 99336 760 774 9142

[email protected] www.nicole-noyes.com

Dear Future Client,

Thank you for contacting me to discuss your therapy needs. Therapy can be overwhelming, challenging and life changing. I am excited to take this journey with you. Included is the intake packet and a questionnaire. Please fill out all the paperwork and bring them to your first session. The first session is considered an intake and assessment session. We will discuss current symptoms and therapy goals to meet your needs. All appointments thereafter we will be working towards your therapy goals. Throughout your treatment, I will provide education on your mental health diagnosis as needed.

Payment are due at the beginning of session.

I currently do my own scheduling. If you need to reschedule please call or text me as soon as possible. I ask that phone calls for other purposes be limited to under 10 minutes. In the event that phone calls exceed 10 minutes, charges may apply and this will be added to your bill.

I look forward to meeting you and helping you achieve your therapy goals.

Sincerely,

Nicole Noyes

mailto:[email protected]

http://www.nicole-noyes.com/


Kennewick, WA 99336 760 774 9142


Counselor Disclosure Statement

Nicole Noyes, LMHC

My name is Nicole Noyes and I have been in the Tri-Cities for the better part of the last eight years. I have been involved in the mental health/social services field since 2002. I received my Master’s Degree in Psychology with an emphasis on Marriage and Family Therapy from Chapman University in 2005. I am a Licensed Mental Health Counselor.

I have considerable background working with individuals with the following problems: Anxiety, Depression, PTSD, Relationship Problems, Marriage Issues, Behavioral Problems in children, Stress, and Substance Abuse.

My therapeutic orientation is eclectic, and it is my goal to be sensitive to the needs and interests of the person coming for counseling services. I have a background in several kinds of therapy including Eye Movement Desensitization Reprocessing (EMDR), Mindfulness based therapy, Cognitive Behavioral Therapy (CBT), and Trauma Focused Cognitive Behavioral Therapy (TF-CBT).

My therapeutic philosophy is centered in the belief that everyone has the innate capacity for transformation. Each person’s journey is unique and I am honored to be a guide during this valuable process. It is my intent to be an attentive listener while offering you supportive and reflective feedback. The process of self-examination can be challenging and I appreciate and respect your willingness to explore your thoughts, feelings, and behaviors as a way of gaining greater self-understanding.

I accept clients from ages 4 and up. When working with children ages 12 and under, I prefer to meet with the parents for the initial session. This allows me to get to know your perspective on your child as well as what methods you have attempted thus far. Effective communication between parents and myself throughout the therapeutic process can enhance the child’s progress.

During our first session we will determine and agree upon plan of action. You have the responsibility of choosing a provider and treatment method that best meets your needs. You have the right to refuse any treatment approach and I encourage you to be open about what is working or not working for you. If you are not satisfied with your services, you may contact: Washington State Department of Health, Health Systems Quality Assurance, Complaint Intake, P.O. Box 47857, Olympia, WA 98504-7857. I am licensed as a Mental Health Counselor and my number is 60525051. The completion of your treatment is completely up to you. If you feel you are not making the progress you desire or have questions regarding the process of treatment, please feel free to discuss these concerns with me. Meeting your treatment goals is my priority and if I am unable to assist you in a way that feels effective to you, I will gladly refer you to someone who may be better suited for your needs.

As issues discussed in the course of therapy are strictly confidential: by law, information concerning treatment or evaluation may only be released with a written consent of treatment of the person being treated or such person’s parent or guardian. In the case of marital, or family therapy, sharing of the information will require written consent of all parties involved. In certain cases courts may subpoena records or insurance companies may request access to records. If coordination of care with other professionals or agencies is required, a release of information will also be necessary. As a mental health professional, I am a mandated reporter and am obligated by law (RCW 71.05 and RCW 26.44) to report




Kennewick, WA 99336 760 774 9142


to proper authorities, information related to the following: suspicion of child or elderly abuse or neglect, potential harm to self or to others, or the inability to care for one’s basic needs.

I believe that in order to have successful treatment, you have to practice what we discuss in session. At the end of each counseling session, homework may be assigned. Homework can include practicing a particular behavior, journaling, keeping a log of your thoughts, etc. I understand that life gets busy however completing your homework will help you in your treatment and therefore improve the quality of your life.

Counseling appointments will be 50 minutes long unless otherwise specified. Counseling appointments may be weekly, biweekly, or monthly depending on your progress, schedule, and stability. It is essential for your successful treatment that you follow through with your counseling appointments.

As a client, you have the right to:

Know the method and course of treatment. Receive accurate information about the services. Know the cost of services and billing practices. Be informed of confidentiality practices. Know the complaint process. Terminate services that are not satisfactory.

Client signature/ Date

_____________________________________________

Parent or Guardian/ Date

_____________________________________________

Nicole Noyes, LMHC/ Date

_______________________________________________




Kennewick, WA 99336 760 774 9142


Intake / Referral information

Name: ___________________________________________Birth Date: ______ /_____/_______

(Last) (First) (Middle Initial)

Address: _________________________________________________Gender: □ Male □ Female

(Street and Number)

______________________________________________________________________________

(City) (State) (Zip)

Name of parent/guardian (if under 18 years):

______________________________________________________________________________

(Last) (First) (Middle Initial)

Home Phone: ( ) _____________________ May we leave a message? □Yes □No

Cell/Other Phone: ( )__________________ May we leave a message? □Yes □No

E-mail: ___________________________________ May we email you? □Yes □No *Please note: Email correspondence is not considered to be a confidential medium of communication.

Marital Status:

□ Never Married □ Domestic Partnership □ Married □ Separated □ Divorced □ Widowed

Insurance information:

Name of insured

_______________________________________________________________________

Last Name First Name Relationship

_______________________________________________________________________

DOB Social Security number

_________________ ______________________________________________

Insurance ID number Group number

_______________________________________________________________________

Insured place of employment

_______________________________________________________________________

Name and phone of insurance

_______________________________________________________________________

Insurance Address City State Zip

Comments:____________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Please attach copy of insurance card.




Kennewick, WA 99336 760 774 9142


Emergency Contact Information:

Name: _____________________________________________

Relationship: ________________________________________

Phone number: ______________________________________

Reason for Referral (symptoms/concerns):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Person making referral:

Name: ____________________________________________

Phone Number: _____________________________________

Please answer the following questions:

1) Are you currently experiencing suicidal thoughts? □Yes □No

2) Have you ever attempted suicide? □Yes □No

3) Have you ever been psychiatrically hospitalized? □Yes □No

4) Are you seeking treatment for substance use? □Yes □No

5) Are you currently using any type of substances? □Yes □No

6) Are you currently applying for Social Security Disability? □Yes □No

7) Are you currently involved with an L&I claim? □Yes □No

8) Are you currently involved with the legal system? □Yes □No

If yes, under what capacity? _________________________________________

*Please see Consent for services form regarding services not provided.

9) Are you currently seeking weight loss or other cosmetic surgeries? □Yes □No

Notes

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________




Kennewick, WA 99336 760 774 9142


Financial Policy

INSURANCE VERIFICATIONS - Before the initial office visit, the client’s insurance company will be contacted to determine specific benefits. We will inquire if there is a deductible, copay, coinsurance, what services are covered, and whether a referral or prior authorization is necessary.

PAYMENT ARRANGEMENTS – Should clients need to make special payment arrangements, please speak with me. I will do my best to accommodate you if possible.

PRIVATE BILLINGS - For clients without insurance coverage, full payment is due at time of service. All clients are quoted a fee for the office visit and are expected to pay at the time of the appointment. My financial policy does offer a fee at time of service rate if you do not have insurance or do not wish to utilize your insurance.

FORMS OF PAYMENT – Cash or check can be used for payment of services. There will be a $35.00 fee for checks returned for insufficient funds.

COLLECTION NOTICE – I understand that any and all accounts that become 90 days delinquent are subject to collections and may incur a $25.00 collection fee.

Insurance Company: ID#: Subscriber Name: Group#:

I certify that I am eligible for benefits under my prepaid health benefit plan. If I am later found to be ineligible or in

consideration of being treated without proof of eligibility, I agree to pay for all services provided by my individual

practitioner based upon regular fees then in effect.

I understand that all Co-pays will be due at the time of service and that all non-covered, co-insurance, and Deductible

amounts must be paid within 30 days of receipt of notice from my insurance.

I authorize the release of any medical or other information necessary to process my claims.

I authorize payment of medical benefits to Nicole Noyes, LMHC directly from my insurance carrier.




Kennewick, WA 99336 760 774 9142


CLIENT FEE SCHEDULE Initial Assessment- $200

Session Fee (90 min) $200



No show or Late Cancellation- $50-150 See cancellation policy

Forms and letters outside of appointment $150.00/hour, billed in increments of 15 min. Letters for attorneys billed at separate rate $250.00/hour Clerical fee for searching/handling records, per WAC $24.00 Pages 1-30 (copying fee), per WAC $1.09 per page Pages 31+ (copying fee), per WAC $0.82 per page Editing of confidential information, per WAC $150.00/hour Returned check fee, plus original amount due $35.00 Collection Fee $25.00

I have read and understood the above information and have been provided with a copy at my request. Patient Signature or Parent/Guardian: _______________________________ Date:_____________________ Client Name: ____________________________________ DOB:_____________________




Kennewick, WA 99336 760 774 9142


CONSENT TO SERVICES / RIGHTS ACKNOWLEDGEMENT I hereby request and consent to services for myself/dependent which includes therapy, diagnostic assessment, case coordination, consultation, and other treatment/services recommended and considered necessary by Nicole Noyes, LMHC. I understand that developing a treatment plan with my therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by my therapist. I am aware that I may stop my treatment with my therapist at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment (for example, if my treatment has been court ordered, I will have to answer to the court). I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatment I receive at this clinic. I understand that if payments for the services I receive at this clinic are not rendered, then the clinic may stop my treatment. I understand and have been informed that Licensed Professional Counselor – Interns may be involved with my treatment and sessions. I have been informed that any information regarding services through Nicole Noyes, LMHC are subject to release only by my informed and written consent or by subpoena and/or court order. I have also been informed that patient identifying information about me may be exchanged between office staff and other designated/contracted providers for continuity of care purposes. I authorize Nicole Noyes, LMHC to release any medical information necessary to process claims for the services provided. I authorize payment of governmental/medical benefits to this clinic for services provided. I understand that I remain responsible for any and all charges not met by my insurance company. It is my policy to not get involved in custody or legal matters. This includes, but is not limited to, court hearings, custody battles,

placement recommendations, provision/support letters, visitation schedules, etc. Additionally, therapy sessions will not be utilized for supervised visitations of any kind. If requested, I will be happy to provide you with recommendations for alternative

agencies that are designed to meet this need.

____________ Initials CONSENT FOR TREATMENT OF MINOR I authorize this clinic to provide services for ___________________________________________. I agree to follow-up with phone conversations regarding progress in therapy and to participate in therapy as recommended. ____________________________________________________________ Client Signature/Date ____________________________________________________________ Parent or Representative Signature (relationship)/Date




Kennewick, WA 99336 760 774 9142


THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU

CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. / USES AND DISCLOSURES:

TREATMENT – Your health information may be used by our providers and staff members or may be disclosed to other health

care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment.

PAYMENT – Your health information may be used to seek payment from your health plan, other sources of coverage such

an automobile insurer, or credit card companies that you may use to pay for services. For example, your health plan may

request and receive information on dates of service, the services provided, and the medical condition being treated.

HEALTH CARE OPERATIONS – Your health information may be used as necessary to support the day-to-day activities and

management of “YOUR NAME HERE”. For example, information on the services you received may be used to support

budgeting and financial reporting and activities to evaluate and promote quality to ensure that our practice is meeting state

and federal guidelines and laws designated to protect your health care information.

LAW ENFORCEMENT – Your health information may be disclosed to law enforcement agencies, without your permission, to

support government audits and inspections, to facilitate law enforcement investigations, and to comply with government

mandated reporting. For example, any known or reasonably suspected cases of child abuse or neglect, any known or

suspected intentions of harming oneself (suicide), and/or any known or suspected intentions of harming others.

PUBLIC HEALTH REPORTING – Your health information may be disclosed to public health agencies as required by law. For

example, our practice is required to report certain communicable diseases to the State of Washington Department of Health.

BUSINESS ASSOCIATES – The following companies may have access to your Protected Health Information for the purpose

of carrying out Treatment, Payment, and/or Health Care Operations: Prestige Medical Billing Company, Inc./ My Clients Plus

(Electronic Medical Records)

OTHER USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION – Disclosure of your health information or its use for

any purpose other than those listed above requires your specific written authorization. If you change your mind after

authorizing a disclosure or use of your information, you may submit a written revocation of the authorization. However, your

decision to revoke your authorization will not affect or undo any disclosure or use that occurred before you notified this

practice of your decision.

ADDITIONAL USES OF INFORMATION:

APPOINTMENT REMINDERS – When applicable, your health information will be used by our staff to call / send you

appointment reminders.

________ PLEASE CHECK HERE IF IT IS OKAY TO LEAVE MESSAGES AT YOUR CONTACT NUMBER(S)

PROVIDED OR EMAIL.

INFORMATION ABOUT TREATMENT – Your health information may be used to send you information on the treatment and

management of your health condition that you may find of interest. We may also send you information describing other

health-related goods and services that we believe may interest you.

INDIVIDUAL RIGHTS - YOU HAVE CERTAIN RIGHTS UNDER THE FEDERAL PRIVACY STANDARDS. THESE INCLUDE:

The right to request restrictions on the disclosure and use of your protected health information; The right to receive

confidential communications concerning your medical condition and treatment; The right to inspect and copy your protected

health information; The right to request an amendment or to submit corrections to your protected health information; The

right to receive an accounting of how and to whom your protected health information has been disclosed; The right to

receive a printed copy of this notice.

PROVIDER / OFFICE DUTIES – We are required by law to maintain the privacy of your protected health information and to

provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are

outlined in this notice.

RIGHT TO REVISE PRIVACY PRACTICES – As permitted by law, we reserve the right to amend or modify our privacy policies

and practices. These changes in our policies and practices may be required by changes in federal and state laws and




Kennewick, WA 99336 760 774 9142


regulations. Whatever the reason for these revisions, we will provide you with a revised notice at your next office visit. These

revised policies and practices will be applied to all protected health information we maintain.

RIGHT TO INSPECT PROTECTED HEALTH INFORMATION – As permitted by federal regulation, we require that requests to

inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your

records by contacting your individual practitioner or the front office. If you request a copy of your records, the following

fees will be assessed: $24 Clerical fee, $1.09 per page fee for the first 30 pages and then $0.82 per page for any pages 31

and over. This fee must be paid prior to the copies being released.

COMPLAINTS AND CONTACT PERSON – If you would like to submit a comment or complaint about our privacy practices or

obtain additional information about our privacy practices, you can do so by sending a letter outlining your concerns to the

person listed below. You will not be penalized or otherwise retaliated against for filing a complaint. OR YOU MAY ALSO

CONTACT: Office for Civil Rights-U.S. Dept of Health and Human Services 701 Fifth Avenue, Suite 1600, MS – 11, Seattle,

WA 98104 Voice Phone (800) 368-1019 FAX (206) 615-2297

Please sign to acknowledge receipt of the Privacy Policy.*

Patient Name: _____________________________________ DOB:_____________________________

Signature:_________________________________________ Date:_____________________________




Kennewick, WA 99336 760 774 9142


Credit Card Authorization

Client Name_______________________________DOB________________________________

The undersigned authorizes Nicole Noyes, LMHC to make the following charges to their credit card for

payment of services rendered. By signing, the undersigned agrees to make the following payment. Co-

insurance and co-pays are due at the time of service. Any fees not paid by the undersigned’s insurance

company or at the time of service will be automatically billed to the credit card on file.

____________________________________________________________________________________

CARD TYPE (circle one) VISA MasterCard Discover AMEX

CREDIT CARD NUMBER____________________________ EXPIRATION DATE_______________

3 DIGIT CODE __________NAME AS IT APPEARS ON CARD_______________________________

ADDRESS THE CARD STATEMENTS ARE MAILED TO (including zip code)

_____________________________________________________________________________________

SIGNATURE OF CARD

HOLDER__________________________________ DATE_____________

I understand my credit/debit card will remain on file ___________________________

Please Initial

This information must match the card or we will not process. We request that you notify our office as

soon as possible if any of this information changes. This agreement will remain in effect until this

agreement is cancelled in writing. We REQUIRE 24 hours notice of cancellation or late charges may

apply.

____________________________________________________________________________________

SIGNATURE DATE




Kennewick, WA 99336 760 774 9142


CANCELLATION POLICY I look forward to working with you. Our appointment sessions are approximately 50 minutes long. It is my strict policy to stay on time for all scheduled appointments. Therefore, if at all necessary, your wait time is kept to a minimum. Due to the length of time provided for each appointment, it is critical that you arrive on time for your appointments. If you are more than 20 minutes late, I will reschedule your appointment and you will be responsible for the fees of a no show. In order to avoid paying no show fees, I require at least twenty-four (24) hour notice for all cancellations, unless your appointment is on Monday, at which time cancellation needs to be before 3pm on the prior THURSDAY. Insurance companies will not pay for “No Shows or Late Cancellations,” therefore you will be responsible for the $50 fee for a missed appointment at the first no show or late cancellation. After the second no show or late cancellation, you are responsible for the entire fee of $100 to $150 and to continue scheduling, you will have to pre-pay the third session at $100 to $150. After 3 cancellations or no shows, you will not be able to schedule another appointment and will be referred to another provider. If you have arranged with your therapist to have standing appointments, then after the first no show, all appointments will be removed from the schedule and will have to arrange appointments weekly. I have read and understand the cancellation policy. _____________________________________________ Client Signature / Date

_____________________________________________ Parent or Representative Signature (relationship)/ Date



nicole noyes 6855 w clearwater ave ste b kennewick, wa ......kennewick, wa 99336 760 774 9142...

Documents