New Client Intake Form

Client Personal Information

  • If you are filling this out for somebody else, please complete fields that pertain to that person.
  • After entering your e-mail address as it was provided to our office staff and date of birth.  Click verify. If the next fields for first and last name do not fill in, make sure your e-mail address and DOB are entered correctly.

Family Information

  • Please list only the family members living in the home.
  • Click to Add Family Member

Spiritual / Religious

Legal

Counseling / Prior Treatment History

  • Information about client (past and present):

    Counseling
    Suicidal thoughts/attempts
    Drug/Alcohol treatment
    Hospitalizations

Notice of Privacy Practices

  • Please find attached a copy of our Notice of Privacy Practices. This is in compliance with the Health Insurance Portability & Accountability Act of 1996 (HIPAA). This Federal law requires that all health care professionals notify patients of how their health information is protected and how it may be used.

    Florida law regarding psychotherapy is much stricter than Federal guidelines. HIPAA allows stricter state laws to prevail where conflict between the two may exist.

    Please review the attached document and complete and sign the Acknowledgement of Receipt of Privacy Practices.

    If you have any questions regarding HIPAA or our privacy practices, please contact us or discuss it with your therapist.

    Privacy Practices for Gilstrap & Associates

    As of January 2015

    *THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. *

    The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually identifiable health information "protected health information" used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

    Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment and health care operations.

    Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. Examples of treatment would include psychotherapy, medication management, etc.

    Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be billing your insurance company for your services, or third party person responsible.

    Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would include a periodic assessment of our documentation protocols, etc.

    In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or provide you with information about treatment options or other health-related services. We will use and disclose your PROTECTED HEALTH INFORMATION when we are required to do so by federal, state or local law. We may disclose your PROTECTED HEALTH INFORMATION to public health authorities that are authorized by law to collect information; to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding; response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested. We may release your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. We may use and disclose your PROTECTED HEALTH INFORMATION when necessary to reduce or prevent serious threat to your health and safety or the health and safety of another individual or to the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

    Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

    You have certain rights in regards to your PROTECTED HEALTH INFORMATION, which you can exercise by presenting a written request to our Privacy Officer at the practice address listed below:

    The right to request restrictions on certain uses and disclosures of PROTECTED HEALTH INFORMATION, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

    The right to request to receive confidential communications of PROTECTED HEALTH INFORMATION from us by alternative means or at alternative locations.

    The right to request an amendment to your PROTECTED HEALTH INFORMATION.

    The right to receive an accounting of disclosures of PROTECTED HEALTH INFORMATION outside of treatment, payment and health care operations

    The right to obtain a paper copy of this notice from us upon request.

    We are required by law to maintain the privacy of your PROTECTED HEALTH INFORMATION and to provide you with notice of our legal duties and privacy practices with respect to PROTECTED HEALTH INFORMATION.

    We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all PROTECTED HEALTH INFORMATION that we maintain. Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office.

    You have the right to file a formal, written complaint with us at the address below, or with the Department of Health and Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.

    For more information about our Privacy Practices, please contact:

    Jessica M Gilstrap, MA, LMHC
    7601 Conroy Windermere Road Suite 202
    Orlando, FL 32835
    407-522-9919

    For more information about HIPAA or to file a complaint:

    The U.S. Department of Health & Human Services
    Office of Civil Rights
    200 Independence Avenue, S.W.
    Washington, D.C. 20201
    877-696-6775 (toll-free)

    Click here to open a copy of our practices for your records.

     

Legal Involvement

  • If your visit to our office requires our involvement in a legal proceeding (i.e., deposition, court-ordered evaluation, subpoena, court appearance, etc.), we cannot guarantee confidentiality. Although we will follow all statutory obligations to honor your privacy and your confidentiality, the court can order disclosure of confidential information under circumstances beyond our control. We will, however, assert objections to disclosure of confidences through our attorneys. Please consult with your attorney prior to your first session if you believe our services will involve the legal system.

    ALSO, please be aware that our fees for involvement in the legal process, including time spent raising objections to disclosure of confidential information, are $300.00 per hour, with a one (1) hour minimum. The legal process is time intensive and often requires us to cancel or reschedule appointments with other clients. Thus, we must charge these additional fees for our time. In addition, you are also responsible for any legal expenses we incur in connection with your counseling sessions, including, but not limited to, expenses incurred in opposing disclosure of confidential information. Your account must be current prior to our involvement in any legal proceeding.

    If the client is a minor, the individual signing below is responsible for the fees and expenses incurred as a result of legal proceedings, including attorney’s fees. If the individual signing below is not the minor’s parent or legal guardian, we must have legal documentation of financial responsibility on file prior to our first session with the child. Florida law gives minors privacy rights which our office may need to assert on behalf of the minor. The person signing below is responsible for the payment of all fees and expenses associated with our protection of the minor’s legal rights.

    The fees for our involvement in the legal process are neither billable to nor reimbursed by your insurance carrier. All such fees are your responsibility and are payable in advance. We will not balance bill third parties or attorneys. We accept cash, check, or credit card for these fees, and we must have a valid credit card number on file. A form for this purpose is attached at the end of this intake package for your convenience.

    We are not attorneys. For legal advice or information, please consult and follow the advice of a competent attorney. If your attorney requests information regarding your sessions with us, you will need to sign a waiver of confidentiality. Note that Jessica Gilstrap is professionally trained in Collaborative Family Law. Fees for reports, consultations, or recommendations in this field are your responsibility and are billed at the rate mentioned above.

    A total breakdown of our Legal Billing Fees can be further explained if applicable to you.

    As in all legal proceedings, final disposition is the responsibility of the court, and we will follow all court orders issued by judges with jurisdiction over our office.

Fee Structure

  • As of January 2014

    THIS FORM MUST BE SIGNED PRIOR TO THE FIRST SESSION

    *BY SIGNING THIS AGREEMENT, I ACCEPT RESPONSIBILITY TO PAY THESE FEES AS SERVICES ARE RENDERED. I FURTHER RECOGNIZE AND AGREE THAT SHOULD COLLECTION PROCEEDINGS BE NECESSARY UPON MY DEFAULT, I WILL BE RESPONSIBLE FOR ANY LEGAL FEES INCURRED AS A RESULT OF SUCH PROCEEDINGS. *

    IF YOU NEED TO MAKE SPECIAL ARRANGEMENTS FOR PAYING FOR OUR SERVICES, PLEASE SPEAK TO OUR OFFICE MANAGER AT THIS TIME. IF SPECIAL ARRANGEMENTS ARE MADE, THEY WILL BE INCLUDED WITH THIS SIGNED AGREEMENT AND WILL BECOME PART OF THE COUNSELING RELATIONSHIP. THE FOLLOWING PAGE DESCRIBES OUR FEE STRUCTURE AND SERVICES. THE FOLLOWING RATES ARE FOR LICENSED MENTAL HEALTH COUNELORS


  • IF YOU ARE USING INSURANCE, PLEASE BE AWARE THAT ANY DIAGNOSIS MADE BY YOUR THERAPIST BECOMES A PART OF YOUR PERMANENT MEDICAL RECORD.  FURTHER, BY SIGNING BELOW, YOU ACKNOWLEDGE AND AGREE THAT SHOULD YOUR INSURANCE CARRIER FAIL TO REMIT PAYMENT TO HEARTSPOKEN COUNSELING YOU WILL BE FINANCIALLY RESPONSIBLE FOR ANY CHARGES ON YOUR ACCOUNT INCLUDING BUT NOT LIMITED TO; SESSIONS FEES, LATE CANCEL/NO-SHOW FEES, LEGAL EXPENSES AND OTHER COSTS ASSOCIATED WITH YOUR TREATMENT.

Credit Card Information

  • By signing this form, you agree that any balance due will be charged to your credit card. If you have requested we provide you with the proper documentation for submission to your insurance company, we shall do so.

    Please note, your credit card information will be kept confidential and secure. You have the option to receive a receipt from our office reflecting the charges applied to your credit card. Charges will appear on your credit card statement under the name HeartSpoken Counseling, Inc.


    By signing this form, I certify that this is my credit card and that I am legally authorized to give permission for its use. My signature further authorizes Gilstrap and Associates/HeartSpoken Counseling, Inc. to charge my credit card an amount not to exceed the "agreed maximum amount" referenced above. I understand that I may incur additional charges if my card is declined. I will notify Gilstrap and Associates of any changes to my account.

    This authorization will remain in effect for one (1) year unless I cancel it through written notice to Gilstrap and Associates.

  • This form will check if that the credit card number you entered matches the proper format, but will not validate the card. If there is an issue with the card, we will contact you.

Consent to Treatment

  • PLEASE READ THE FOLLOWING COUNSELING AGREEMENT AND SIGN. IF THE CLIENT IS UNDER 18 YEARS OF AGE, THE AGREEMENT MUST BE SIGNED BY THEIR PARENT OR GUARDIAN.

    "I understand that I am entering into a confidential therapeutic counseling relationship. I understand that I have the right to terminate this relationship upon due notice to my therapist. I also understand that ALL fees, as outlined in the above section titled "FEE STRUCTURE" are due at the time services are rendered unless previous arrangements have been made. I UNDERSTAND THAT FAILURE TO CANCEL A SCHEDULED APPOINTMENT 24 HOURS IN ADVANCE WILL RESULT IN ME BEING CHARGED THE INFORMED AMOUNT FOR THAT SESSION. I understand that my therapist has the right to consult with other therapists within the association related to my services and care. Information concerning my treatment cannot be divulged to other parties without my prior written consent unless directed by Florida Law. Other conditions of confidentiality will be discussed during the initial session.I understand this agreement covers myself and any minor children I may include in therapy."