Sharon Montcalm New Adult Patient
  • New Patient Information

  • Insurance Information ( Primary Only Please )

    Please give your insurance card and drivers license to your counselor.
  • In case of emergency, name of local friend or relative (not living at the same address)
  • I understand that I am financially responsible to all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. JVC 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 6 months from the date below.
  • By entering your name here, you are digitally signing this online form.
  • Health Information

  • Authorizations

    I/We consent to counseling:
  • By Entering your name here, your are digitally signing this online form.
  • This office is a Christian counseling facility but we also respect your individual beliefs. Please indicate below your preference.

  • Policies

    Please initial above each policy to acknowledge that you have read and agree.
  • This office does not provide assistance to such patients wishing to obtain paperwork for any type of disability and/or time off of work. This office does not diagnose for ADHD, nor make any judgements for disability in conjunction with such diagnoses.
  • 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 hour notice, there will be a $120 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 $120.
  • 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 $120.
  • All patient information including all psychotherapy notes and any other patient information is the property of Jodi Valentine Counseling, Inc. In order to ensure quality care, all patient charts are subject to audits by assigned staff members of Jodi Valentine Counseling, Inc.
    If at any time a patient requests any type of documentation, if the original counselor assigned to the patient is no longer available to assist in this matter, patients release staff of Jodi Valentine Counseling to obtain any such applicable information.

  • Should the patient choose to transfer to a different counselor or should the office and/or counselor need to transfer a patient's care to another counselor at Jodi Valentine Counseling, the patient releases the originally assigned counselor to release all information (verbally and electronically) to the newly assigned counselor.
  • All appointments are booked over the phone and confirmed in an email to you by office staff at our Corporate Office. Due to limited availability with counselors and due to an excessive volume of calls received daily, only office personnel will rebook appointments and will rebook several appointments in advance. Once you have less than 3 sessions scheduled, office staff will call you to rebook several additional sessions in conjunction with the recommended frequency of counseling the counselor notes. Please make sure to rebook these appointments with office staff prior to your appointment or your counselor, before your session begins, must take a few minutes from your regularly scheduled appointment and have you speak with our office staff to rebook these sessions. Please make it a habit to always return phone calls from the corporate office in order to avoid any time being taken away from your sessions.
    Once you receive an email confirmation denoting the dates and times of your appointments, if you feel that the dates and/or times are not accurate, you must contact the office greater than 24 hours in advance of the appointment times listed or you will be assessed fees if you cancel or do not show for the appointment that you feel is inaccurate.
    Please make sure the email you list is the best email address to reach you. If you do not receive your email, though we will have copies of all emails sent to you, it is still your responsibility to either attend your sessions or reschedule/cancel your appointments within the time frame detailed regarding avoiding the fees.
    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 emailed to the email account on file. Methods of acceptable payment include credit cards and debit cards.
  • 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. We will contact your insurance provider to determine your benefits and will notify you with this information before the initial evaluation; however, all insurance benefits quoted to us 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.
  • 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 Jodi Valentine Counseling'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.

    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.

  • By entering your name here, you are digitally signing this online form.
  • To be signed and dated by counselor
  • Patient Financial Responsibilites

    You are responsible for ensuring that services are paid in full. You are ultimately responsible for payment of your bill even if insurance is filed on your behalf. If your insurance carrier denies any part of your claim, you are responsible for the remaining balance. You are also responsible for any deductibles, co-insurance, co-payments, etc as determined by your insurance plan.
  • A credit card on file is required for all new patients to secure an appointment and for any existing patients to schedule future appointments.

    By signing this form, you agree to the financial responsibilities stated above and authorize Jodi Valentine Counseling Incorporated 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) Appointments that are missed for any reason;
    3) Appointments that are cancelled for any reason 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.
    6) Credit card authorizations in the sum of one cent before the first appointment, before future appointments and randomly as needed to confirm the authenticity of the card.
  • Please add your personal credit card information below and not a Health Savings Card

    his form is submitted over a secure connection.
  • (CVC- 3 digit code on back of card)
  • You will receive an email receipt for any charges applied to your credit card unless otherwise requested. A super bill can also be provided for insurance purposes.
  • Please type your name as you would sign on your card.
  • Declaration of Practices and Procedures

    Sharon Montcalm, LPC

    Qualifications: I earned a Master of Education Degree in Counseling in December 1999. I am licensed as a Professional Counselor (LPC) # 69693 with the Texas State Board of Examiners of Professional Counselors, Mail Code 1982, P O BOX 149347, Austin , TX 78714, Phone 512-834-6658.

    Counseling Relationship: I see counseling as a process in which you, the client, and I, the counselor, having to come to understand and trust one another, work as a team to explore and define present problem situations, develop future goals for an improved life and work in a systematic fashion toward realizing those goals.

    Areas of Expertise: A variety of formats are undertaken in which I am involved with conducting individual and family counseling with persons of all ages.

    Fee Scales: An Initial Evaluation, the first session, is $170 and sessions thereafter are $120.

    Services offered and Clients Served: I am a Christian Counselor and approach counseling from a cognitive-behavioral perspective in that patterns of thoughts and reactions are explored in order to better understand the client’s problems and to develop solutions. A variety of formats are undertaken in which I am involved with conducting individual and family counseling with children, adolescents and adults.

    Code of Conduct: All counseling conducted in this center will adhere to the Texas Code of Ethics for Licensed Professional Counselors established by the Texas State Board of Examiners and the Texas Code of Ethics for Licensed Professional Counselors established by the Texas State Board of Examiners of Professional Counselors. A copy of this code is available upon request. Counseling services are available for any client, unless it is determined that a referral to another mental health professional or agency is in order.
  • Privileged Communication: Discussions between you and me, and even the fact that you are in counseling with me, are confidential. For this reason, if I see you in public, I will protect your confidentiality be greeting you only if you greet me first.
    Material revealed in counseling will remain strictly confidential except under the following circumstances in accordance with state law:

    1) The client signs a written release of information indicating informed consent of such release.
    2) The client expresses intent to harm himself/herself or someone else.
    3) There is reasonable suspicion of abuse/neglect against a minor child, elderly person (65 or older), or a dependent adult.
    4) A subpoena or other court order is received directing the disclosure of information. It is my policy to assert privileged communication on behalf of the client and the right to consult with the client if at all possible, except during an emergency, before mandated disclosure. I will endeavor to apprise client of all mandated disclosures as conceivable.
  • Certain types of litigation (such as child custody suits) may lead to the court-ordered release of information without your consent. Also note that if you use third party insurers, such as health insurance policies, HMO or PPO plans, or EAP programs, you must sign a release of information and all information will be disclosed.

    When working with couples, families or groups, I can not disclose any information outside of the treatment context without a written authorization from all individuals competent to sign such authorization. For example, I can not release any information about either or both spouses I have seen for marital therapy to an attorney without signed authorizations from both spouses.

    In the event of marriage or family counseling, material obtained from an adult client individually may be shared with the client’s spouse or other family members only with the client’s permission. Any material obtained from a minor client may be shared with the client’s parents or guardian.
  • Emergency Situations: 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 hospital emergency rooms. Local emergency numbers are:

    1) Baylor Grapevine - 817-783-4173
    2) Methodist Southlake - 817-865-4400
    3) Cook Children's – Fort Worth - 682-885-4000
  • Client Responsibilities: You, the client, 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 these with me so that we can make the necessary adjustments. If it is determined that you have been receiving counseling services from another mental health professional, I ask you to grant me permission so that we may coordinate our services to you.

    Physical Health: Because of the complicated nature of mental health in its interrelationship with the psychological, it is recommended that clients have a complete physical evaluation and list any medications you are now taking.

    Potential Counseling Risks: As a result of mental health counseling, the client may realize that they have additional issues to resolve which they were not aware before the beginning of the counseling relationship. For example, when dealing with a substance abuse problem, the client may experience strained relationships in the family as the client attempts to make constructive changes in his or her life.

    I have read and understand the above information and give permission for Sharon Montcalm , LPC 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.
  • By entering your name here, you are digitally signing this online form.
  • To be signed and dated by clinician
  • By entering your name here, you are digitally signing this online form.
  • Acknowledgement of Receipt of Privacy Notice
    And Release of Information
  • I have been presented with a copy of Jodi Valentine Counseling’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. If you were referred to our office by your physician please include his/her name. By law, we cannot discuss anything without you placing their name on
  • By entering your name here, you are digitally signing this online form.