Adult Intake Form
Elizabeth Vivian, LPC, PMH-C
Client's Full Name
Date of Birth
Transgender Male/Trans Man/FTM
Transgender Female/Trans Woman/MTF
Genderqueer, neither exclusively male nor female
Additional gender category or other
Choose not to disclose
Lesbian, gay, homosexual
Straight or heterosexual
Choose not to disclose
Full Time/Part Time Student
State / Province / Region
Postal / Zip Code
May I leave a voice message?
How did you hear about Elizabeth Vivian LPC, PMH-C?
Employer Name and Occupation
Please note that I only accept certain insurance plans at this time. If I am not credentialed with your insurance provider I am happy to offer reduced rate fees. If you have health insurance please select the carrier below.
Blue Cross/Blue Shield
Emergency Contact Information
Notify (name & relationship to client)
Health & Medical History
Primary Care Physican
Psychiatrist (if applicable)
Please list any medical problems and current medications
Have you previously sought outpatient counseling? If yes, please provide the name of previous provider(s), length and frequency of treatment.
Have you ever been hospitalized for mental health treatment? If yes, please provide the name of hospital and dates of treatment.
What areas are you struggling with that brought you to counseling?
Please initial each policy to acknowledge that you have read and agree.
If for any reason you need to cancel and/or reschedule an appointment, please notify the office immediately. For all cancellation or reschedule notices received with less than a 24 business hour notice, there will be a $125 fee assessed to the card on file. If for any reason you do not attend your session, you will be charged the full session fee of $125. If you arrive 15 minutes or more late to your appointment, your appointment will be considered missed and your card on file will be charged the full session fee of $125.
Cancellation/No Show/Late Arrival Policy
The card you provide on file will be assessed any applicable copays/deductibles/fees and will be processed in less than 24 hours of all scheduled appointments. A receipt for the paid session/fee will be provided upon request. Methods of acceptable payment include credit cards, debit cards,personal check and cash.
If you are requesting an insurance provider to be billed for services, you will be expected to pay all charges not paid in full by the insurance provider. It is your responsibility to contact your insurance provider to determine benefits before the initial evaluation; however, all insurance benefits quoted from your provider are not a guarantee of payment. While remaining HIPPA compliant, our office operates electronically in regards to all patient information including filing claims in order to bill insurance companies.
Billing Services through your Insurance Provider
This office does not provide assistance to patients wishing to obtain paperwork for any type of disability and/or time off of work. This office does not make any diagnoses judgements for disability in conjunction with such diagnoses.
For any and all legal matters (subpoenas, court appearances, depositions, any and all written and/or typed materials requested or any other such legal matter), please contact the office directly. Please provide at least a one month notice for any such request. Rates for any such legal matters are $300 per hour and if travel is mandatory, all travel expenses are to be paid in full. For any court appearance or deposition, a $1500 retainer must be paid in full at least 2 weeks prior to the scheduled date. If the fees for the service total less than the $1500 retainer, such monies will be reimbursed within one month. If the fees for the service total more than the $1500 retainer, payment will be expected in full at the time such services are rendered. If a deposition and/or court appearance is scheduled, but for any reason was cancelled and/or such services are no longer requested, the $1500 retainer will be reimbursed in full as long as an appropriate two week notice (10 regular business days) is given. If such a notice is given in less than two weeks, but at least one week (5 business days), then $1000 will be reimbursed. Any notice given under 48 hours will be assessed the full $1500 in which the $1500 retainer fee will not be reimbursed. If the above information is not addressed accordingly, such legal matters will be sent directly to Elizabeth Walters LPC LLC's attorney.
Requests for documentation of counseling services will simply be a brief summary in which the dates of services and a very brief, maybe one sentence general statement regarding the reasons for attending counseling will be provided. Only the adult patient themselves or the legal guardian who has permission for such information may be provided with this summary.
If you are requesting documentation of services for legal purposes, only the same summary above will be provided and only provided to the same parties as detailed above. A $25 fee will be assessed to the card on file for such a summary. A notice of at least 5 business days must be provided for such a summary.
To be processed with the card on file, there shall be a fee of $25.00 assessed for all phone conferences and other communications initiated by the patient and/or guardian with the counselor outside the office setting. You are highly encouraged to make an appointment if you need to speak with the counselor. Your insurance provider cannot be billed for this service and it will be your responsibility to pay this charge.
To be processed with the card on file, all detailed reports and correspondence will be assessed a rate of $150/hour. Detailed reports require a 30 day notice and payment in full before documents will be sent.
Our office is HIPPA compliant in regards to policies and procedures. While remaining HIPPA compliant, our office operates electronically in regards to patient information such as filing claims and charting sessions. Session notes are filed and stored with a fully encrypted data center.
My (digital) signature below signifies that I have read and agree to the policies listed above.
I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Elizabeth Vivian, LPC, PMH-C may use my healthcare information and may disclose such information to my insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits of the benefits payable for related services. This consent will end when my current treatment plan is completed or 12 months from the date below.
By entering your name here, you are digitally signing this online form.
A credit/debit card on file is required for all new clients and existing clients. Please note that it will be required at the time of your initial session.
By signing this form, you agree to the financial responsibilities stated above and authorize Elizabeth Walters, LPC LLC to charge the credit card or debit card on file for: 1) Any applicable copays/deductibles for all appointments scheduled and to be processed within 24 hours or less of scheduled appointments; 2) Missed appointments; 3) Appointments that are cancelled with less than a 24-hour notice; 4) Non-payment of any outstanding claims of 30-days or greater; 5) A returned check by your bank. Credit card will be charged for cost of service as well as any applicable bank fees. There is a minimum $30 NSF per returned check.
Declarations of Practices and Procedures for Elizabeth Vivian LPC, PMH-C
Qualifications I earned a Master of Arts Degree in Mental Health Counseling from Southern University A&M in 2009. I am a Licensed Professional Counselor (LPC #3689) with the Licensed Professional Counselors Board of Examiners, which is located at 8631 Summa Avenue, Suite A, Baton Rouge, LA 70809 (phone 225-765-2515). I am a Certified Perinatal Mental Health Specialist with Postpartum Support International. Counseling Relationship I see the counseling relationship as one that must be based on mutual trust, respect, and honesty. I use a variety of theoretical approaches in attempt to match client’s needs. I primarily use techniques based in Cognitive-Behavioral Theory in which strategies are used to help modify patterns of thought and actions to promote mental health, wellness, and personal growth. Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Areas of Expertise My focus includes working with individuals and couples to address issues with infertility, loss/grief and perinatal mental health from pre-conception to twelve months postpartum. I also see adolescents and young adults when presenting issues are within my scope of practice. Issues include, but not limited to, depression, anxiety, relationship and family of origin issues, and high risk behaviors such as substance use/abuse. Fee Scales Initial sessions are $150 and follow up sessions are $125. I also offer reduced rate fees of $75-$100 per session. Services Offered and Clients Served I work with clients in a variety of formats, including individual, group, and family therapy. I see clients of all backgrounds with ages ranging from five to fifty five years. Code of Conduct As a Licensed Professional Counselor, I adhere to the Louisiana State Code of Conduct for Licensed Professional Counselors as required by state law. A copy of this code is available upon request.
In general, the privacy of all communications between a client and a therapist is protected by law, and I can only release information about our work to others with your written permission. There are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I must file a report with the appropriate state agency or contact law enforcement. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action. I may occasionally find it helpful to consult other professionals about a case. During a consultation, I do not reveal identifying information about my client. The consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
Emergency services are not provided. Clients may leave a message during normal work hours and those calls will be returned as soon as possible. If an emergency situation should arise, you may seek help at the nearest emergency room. Otherwise call 911; the COPE Team at Our Lady of the Lake Hospital (225)765-8900 or (800)864-9003; or the Baton Rouge Crisis Intervention Center at (225)924-3900 or (800)437-0303.
I see counseling as a collaborative process, meaning you are a full partner in counseling. Your honesty and effort is essential to success. If as we work together you have suggestions or concerns about your counseling, I expect you to share those with me so that we can make the necessary adjustments. If it develops that you would better be served by another mental health provider, I will help you with the referral process. If you are seeing another mental health professional, please inform me so that with your permission I may contact the other professional and develop a collaborative professional relationship.
Physical health can be an important factor in the emotional well-being of an individual. If you have not had a physical examination in the last year, it is recommended that you do so. Additionally, medications, both prescription and non-prescription, may have significant side effects that may impact the counseling relationship. I expect full disclosure from you regarding any and all medications that you are currently taking and may ask permission to discuss them with your physician/medical doctor.
Potential Counseling Risk
You should be aware that counseling poses potential risks. In the course of working together additional problems may surface of which you were not initially aware. If this occurs, you should feel free to share these new concerns with me. Since counseling often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.
I am often not immediately available by telephone. I will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents.
Email and Online Therapy
I do not provide therapy via text, email, Skype, or telephone. Phone calls are not a substitute for in-person therapy, and I will not discuss therapeutic issues via email or text. With the exception of calling to notify me of an emergency and the need to meet in person, you acknowledge that phone calls/emails are not to be used for suicidal thoughts, thoughts of harming others, or other life-threatening emergencies, hallucinations/dissociative disorders, intimate partner violence, or child abuse issues. You agree to take responsibility for maintaining the confidentiality of any emails you send/keep on your computer and any phone conversations.
Consent to Treatment:
I have read and understand the above information and give permission for Elizabeth Vivian, LPC, PMH-C to conduct counseling with me (as the patient and/or the parent/legal guardian of the patient), my minor child (if applicable) and any other minor children that I am legally able to give consent on their behalf that may enter the counseling session. I understand that I may stop such treatment or services at any time.
Acknowledgement of Receipt of Privacy Notice And Release of Information
I have been presented with a copy of Elizabeth Vivian, LPC, PMH-C's Notice of Privacy Policies detailing how my information may be used and disclosed as permitted under federal and state law. I also have the opportunity to take home a copy of the policy. I understand that no one, including family members, will be allowed access to any information regarding my treatment or billing information, to include but not limited to, my diagnosis, prognosis, attendance, any and all progress/treatment notes, information regarding compliance with counseling, recommendations for future counseling services and any other information necessary for such coordination of care and any other information requested from person/agency/other to whom information is to be released, unless I include them on the below list. I understand that this office cannot accept my verbal permission to release my information. I also understand that I can change this list at any time
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