Adult Intake Form

    In the event of emergency do you give NSCG permission to contact? YesNo

    Self Pay YesNo

    Financial Policy

    NorthStar Counseling Group39 E. Hawley St.Mundelein, IL 60060(847) 400-02232Financial Policy Insurance and Claims: If you have health insurance it may provide some coverage for mental health treatment. NorthStar Counseling Group (“NSCSG”) will bill insurance companies on your behalf. By signing this document, you certify that you have active and valid insurance as noted above and authorize insurance payment directly to NCSG. You are authorizing NCSG to exchange private healthcare information with your insurance company to verify insurance benefits, obtain treatment authorizations, process claims and/or engage in a collection process. Insurance coverage is determined at the time the claim is processed by insurance carrier. As such, insurance carrier (s) and/or provider cannot guarantee coverage. You will remain responsible for any balance that your insurance does not cover. Your contract with your health insurance company requires that you authorize NCSG to provide it with information relevant to the services that have been rendered. Typically, insurance companies require a clinical diagnosis toassist in reimbursement, and your insurance company may require additional clinical information such as treatment plans or summaries, or copies of your clinical record. In such situations, we will make every effort to release only the minimum information necessary for the purpose requested. This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank.

    Payment: NCSG charges a fee of $150 per session. If you will not be using insurance you will be expected to pay for each session at the time it is held, unless you and your therapist have made other arrangements. If insurance will be used, you will be expected to pay your co-insurance, co-pay, or deductible at the time of service, unless you and your therapist have made other arrangements. Returned checks will be charged a $30 fee for insufficient funds. In the event that insurance does not cover billed claims, whether in part or wholly, you will be liable for all incurred charges. NCSG does not bill secondary insurance. By signing this document, you will be the responsible party and will be billed on behalf of the client. If you feel someone else should be the responsible party/financial guarantor, please speak with your provider on how to proceed. Please note that NCSG will not bill multiple parties for services rendered. In the event that full payment for services is not received, NCSG shall be entitled to recover, in addition to the principal balance remaining, interest at the rate of 1.5% per month along with all costs incurred in collection efforts, including but not limited to court costs and reasonable attorneys’ fees.

    Cancellations/Missed Appointments: Appointments that are not cancelled 24 hours in advance will be charged a fee of $100. Please note that insurance companies do NOT reimburse for missed appointments and the fee will become the sole responsibility of the client or parent/guardian.

    Telephone Contact Permission Form/Electronic Communications Agreement

    What number do you prefer to be contacted at?

    Texting okay? YesNo
    May we leave a voice message at this number? YesNo
    In the event that someone else answers the phone, may we leave a message with them? YesNo

    May we leave a voice message at this number? YesNo
    In the event that someone else answers the phone, may we leave a message with them? YesNo

    May we leave a voice message at this number? YesNo
    In the event that someone else answers the phone, may we leave a message with them? YesNo
    May we contact you via Email? YesNo

    I agree to release NorthStar Counseling Group from any legal responsibility resulting from the unintended use of or inadvertent release of my protected healthcare information when such information has been exchanged by means of any electronic communication including but not limited to computers, handheld devices (such as texting), e-mails, faxes, cellular telephones, land-line telephone, voice mail and answering-machines.

    Any private, personal and/or clinical information that I share electronically with therapist is solely my choice and therefore I assume complete liability for any information contained in said electronic means of communication, as well for its disclosure, copying and/or distribution. NorthStar Counseling Group will make reasonable and professional efforts to protect all private healthcare information.

    I understand that electronic communications are used for making, changing and confirming appointment times and NOT to be used for emergencies and discussing clinical information. I understandthat if I am experiencing an emergency, it is my responsibility to contact the Emergency Medical System (EMS) by calling 9-1-1 or immediately securing transportation to the nearest emergency room.

    Coordinating Care with Your Primary Care Physician

    I hereby authorize NorthStar Counseling Group to exchange information with my primary care physician for the purposes of coordinating or continuing care.

    I agree to the following exchange of information:
    Any information pertinent to coordinating careI do not have a PCPI decline consent to coordination of care with my PCP

    NorthStar Counseling Group is being given authorization to release records effective from the date of this authorization until 12/31/2020.

    Alternative time period if applicable:

    Outpatient Services Agreement

    Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you bring forward. There are many different methods used to deal with the problems that you hope to address. Psychotherapy calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things you and the therapist talk about both during your sessions and at home.Psychotherapy can have benefits and risks. Since therapy 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 havesignificant benefits for people who are willing to put the effort in and engage the process long enough to reap the benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.

    Your provider is not always immediately available by telephone. Please leave a message on the office voicemail with your name, number, time of call, and purpose of call. The messages are received and answered at the therapist’s earliest convenience. Since this is an outpatient practice, emergency services are not available. Therefore, in case of emergency please contact either 9-1-1 or go to the nearest hospital emergency room. Emergencies may include, but are not limited to, being harmful to self or others, family or personal crisis. Please know that although technology is wonderful, voicemails, cell phones, etc. cannot be guaranteed to be confidential. IN AN EMERGENCY, DO NOT WAIT TO TALK TO THERAPIST. IT IS YOUR RESPONSIBILITY TO ACTIVATE EMERGENCY MEDICAL SERVICES BY CALLING 9-1-1 OR GO TO YOUR NEAREST EMERGENCY.

    LIMITS ON CONFIDENTIALITY (please see Privacy Practices for more information):
    The law protects the privacy of all communications between a patient and a behavioral health treatment provider. In most situations, NorthStar Counseling Group can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and/or Illinois law. However, in the following situations, no authorization is required: your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During aconsultation, the therapist will make every effort to avoid revealing the identity of the patient. The other professionals are also legally bound to keep the information confidential. If you do not object, the therapist will not tell you about these consultations unless she feels that it is important to your work together. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.

    If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the therapist-patient privilege law. We cannot disclose any information without a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your treatment provider to disclose information.

    If a government agency is requesting the information for health oversight activities, NorthStar Counseling Group may be required to provide it for them.

    If a patient files a complaint or lawsuit against a treatment provider, that treatment provider may disclose relevant information regarding that patient in order to provide defense.

    If you file a worker’s compensation claim, and your therapist is rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, she must, upon appropriate request, provide a copy of your record to your employer or his/her appropriate designee.There are some situations in which we are legally obligated to take actions, which she believes is necessary to attempt to protect others from harm. We may have to reveal some information about a patient’s treatment.

    If NorthStar Counseling Group has reasonable cause to believe that a child under 18 known to her in a professional capacity may be an abused child or a neglected child, the law requires that the therapist file a report with the local office of the Department of Children and Family Services. Once such a report is filed, your therapist may be required to provide additional information.If your therapist has reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that the therapist file a report with the agency designated to receive such reports by the Department of Aging. Once such a report is filed, your therapist may be required to provide additional information.If you have made a specific threat or acted violently or plan to act violently against another or if we believe that you present a clear, imminent risk of serious physical harm to another, she may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your hospitalization.If we believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, she may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you.

    If such a situation arises, your therapist will make every effort to fully discuss it with you before taking any action, and the therapist will limit the disclosure to what is necessary.While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you and your therapist discuss any questions or concerns that you may have now or in the future.

    In accordance with protected healthcare information laws and professional ethical standards, healthcare providers are bound to maintain the confidentiality and privacy of their clients. While clients have the right to privacy, some courts have held that if an individual intends to cause harm or danger toward themselves or another person(s), it is the practitioner’s duty and obligation to share privileged communications to warn and/or protect the client him/herself and/or other persons who might suffer the results of client’s threats to cause harm. In such cases, emergency medical professionals, other healthcare professionals and any other person may be contacted to maximize the safety for the client and/or others. Client’s will be informed as soon as possible should clinicians “duty to warn” obligation be invoked.

    I, as client (and/or legal guardian) acknowledge receiving, reading, discussing (as needed) and agreeing to abide by the terms of the Outpatient Services Agreement. In commencing therapy, I have been provided informed consent for treatment

    Public Health Information



    Your health record contains personal information about you and your health. This 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, including the Health Insurance Portability and Accountability Act ("HIPAA"), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights reguarding how you may gain access to and control your PHI.

    We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.


    For Treatment.Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

    For Payment.We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

    For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

    Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

    Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

    As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization.The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.

    Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

    Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

    Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

    Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

    Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

    Health Oversight. If required,we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.

    Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

    Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosurelaws and the need to prevent serious harm.

    Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

    Public Safety. We may disclose your PHI ifnecessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

    Research. PHI may only be disclosed after a special approval process or with your authorization.

    Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.

    Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

    With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except tothe extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice ofPrivacy Practices.

    YOUR RIGHTS REGARDING YOUR PHI You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to North Star Counseling Group:

    ● Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.
    ● Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.
    ● Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
    ● Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.
    ● Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.
    ● Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
    ● Right to a Copy of this Notice. You have the right to a copy of this notice.

    If you believe NorthStar Counseling Group has violated your privacy rights, you have the right to file a complaint in writing with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. NorthStar Counseling Group will not retaliate against you for filing a complaint.

    The effective date of this Notice is September 23, 2013.

    Verification of Receipt of Privacy Practices & Client Rights (HIPPA)

    HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that your treatment provider amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about NorthStar Counseling Group procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. The therapist is happy to discuss any of these rights with you.I have read and understand the, Notice of Privacy Practices and Client Rights document.

    I have also been given the opportunity to ask any questions as to its contents and/or receive a copy.