New Client Form


Today's Date *
Today's Date
We understand that your personal information is sensitive. Please be advised that any secure information obtained will only be used for the services intended and will NOT be shared with any third party entities.
Client Information
Please be sure to complete all fields.
Name *
Name
Address *
Address
Contact Number *
Contact Number
Date of Birth *
Date of Birth
Gender *
Emergency Contact Information
Name *
Name
Contact Number *
Contact Number
Alternate Contact Number
Alternate Contact Number
Insurance Information
Responsible Party *
Responsible Party
Responsible Party Address *
Responsible Party Address
Contact Number *
Contact Number
Please list your primary form of payment (i.e. insurance, EAP referral/authorization number). Missing or incorrect information may result in the cost of services rendered to be deferred to the client/responsible party.
Subscriber Name *
Subscriber Name
Subscriber DOB *
Subscriber DOB
Insurance policy, EAP Authorization, Reference, or Referral # is acceptable.
Insurance Address
Insurance Address
Insurance Contact Number
Insurance Contact Number
Please indicate any additional forms of payment to be billed for services rendered. If utilizing EAP benefits as your primary form of payment, no further cost will come to you. For those utilizing insurance as their primary, any remaining balance following processing of your insurance benefits will become the patient's responsibility.
Subscriber Name
Subscriber Name
Subscriber DOB
Subscriber DOB
Insurance policy, EAP Authorization, Reference, or Referral # is acceptable.
Insurance Address
Insurance Address
Insurance Contact Number
Insurance Contact Number
Reason for Your Visit
Give dates as best as you can remember.
Please indicate when/where. If not applicable please indicate N/A.
Medication Name + Dosage + Frequency
Please outline any use, misuse, or abuse concerns.
Confidentiality/Informed Consent Form
I hereby consent to engaging in services with Stephanie A. Jones, LCSW of Lifestyle Management Counseling Center, LLC. for the purpose of counseling and supportive services. I understand that this includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using real time interactive audio, video, and/or data communications. I understand that this also involves the communication of my medical/mental/financial information, both orally and visually to be shared only by written release of information as well as to health care practitioners in and outside the states of Florida and Georgia for treatment purposes only. I understand that I have the following rights: (1) I have the right to withhold or with or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. (2) The laws that protect the confidentiality of my medical information are also applicable to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential except in instances of mandatory action including but not limited to reporting child, elder, and dependent abuse; expressed threats of violence towards self or others; and where subject to subpoena for legal proceedings. I also understand that the dissemination of any personally identifiable information from interaction to researchers or other third party entities shall not occur without my written consent. (3) I understand that there are risks and consequences from telemedicine use, including, but not limited to despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. In addition, I understand that when using telemedicine based services my care may not be as complete as face-to-face services. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I may elect to convert to this service or I will be referred to a psychotherapist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not be improve, and in some cases may even get worse. (4) I understand that I may benefit from psychotherapy, but that results can never be guaranteed or assured. (5) I understand that I have a right to access my medical information with a written request and copies of medical records in accordance with Florida or Georgia law will be provided. I have read, understand, and agree to the information provided above.
Please type your name as acknowledgement and acceptance of these terms. *
Please type your name as acknowledgement and acceptance of these terms.
Today's Date
Today's Date
Explanation of Services
Counseling provided with Lifestyle Management Counseling Center, LLC is both a short-term, long term, and non-medical in nature. We utilize both traditional and non-traditional methods of counseling to work with problems. If it is determined that your problem requires more extreme therapy or medical management, you will be referred to another provider in your local community. The goal of counseling is to understand problems and identify solutions to those problems. Q. Is counseling Confidential? A. Counseling sessions are confidential and State and local laws protect the content. Exceptions include suspected child abuse and neglect, safety, National Security, spouse abuse, homicide, and suicide. Q. What are the credentials of the LMCC Counselor? A. Stephanie A. Jones is a Master’s level counselor. She is credentialed by state licensing bodies in both Florida and Georgia. All license verification may be performed through either the Georgia Secretary of State or the Florida Department of Health. Q. Who is eligible for services at Lifestyle Management Counseling Center? A. Any person who resides within the states of Florida or Georgia in which the counselor holds state licensure. Q. How long are scheduled appointments? A. In general, appointments last 50-60 minutes. Some may be longer or shorter, depending upon circumstances. Q. Who do I speak with if I’m dissatisfied with any service provided by Lifestyle Management Counseling Center? A. If at any time you have complaints or concerns regarding your experience at Lifestyle Management Counseling Center please feel free to acknowledge your concerns with your counselor. Please Do Not leave LMCC if you feel unhappy with any of the services. We need your input to help our programs grow and be a valuable resource to you. Q. What are the hours of operation? A. LMCC is available Monday through Friday 5:00 pm - 8:00 pm and Saturdays and Sundays by appointment only. If you should have an emergency during the times we are closed you should contact 911.
Please type your name as acknowledgement and acceptance of these terms. *
Please type your name as acknowledgement and acceptance of these terms.
Today's Date *
Today's Date
CANCELLATION AND NO SHOW POLICY
We understand that situations arise in which you must cancel your appointment. It is therefore requested that if you must cancel your appointment you provide more than 24 hours notice. This will enable for another person who is waiting for an appointment to be scheduled in that appointment slot. With cancellations made less than 24 hours notice, we are unable to offer that slot to other people. Office appointments which are cancelled with less than 24 hours notification may be subject to a $50.00 cancellation fee. Clients who do not show up for their appointment without a call to cancel an office appointment will be considered as NO SHOW and may be subject to a $50.00 no show fee. Clients who No-Show two (2) or more times in a 12 month period, may be dismissed from the practice thus they will be denied any future appointments. The Cancellation and No Show fees are the sole responsibility of the patient and must be paid in full before the client’s next appointment. We understand that special unavoidable circumstances may cause you to cancel within 24 hours. Fees in this instance may be waived, but only with counselor approval. LMCC firmly believes that a good counselor/client relationship is based upon understanding and good communication. Questions about cancellation and no show fees should be directed to Stephanie A. Jones, LCSW at 888-443-2713 ext. 1 or sjones@lifestylemanagementcounselng.com. Please complete this section to indicate that you have read, understand and agree to this Cancellation and No show Policy.
CREDIT CARD '"on file" AUTHORIZATION
Cardholder Name *
Cardholder Name
(as imprinted on credit card)
LMCC is authorized to maintain credit card payment information in our confidential files. This form is being provided for you to supply LMCC with information for the purpose of “No Show/Same Day Cancellation” fee deduction ONLY from the credit card below.
(as associated with this card)