Instructions: Please fill out the following five form sections and click on the green submit button located at the bottom of the last box.

Patient Information

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Insurance Information

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Health History

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  • Psychiatric Hospitalization:

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Emergency Contact Information

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Policy Agreement

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Confidentiality Policy

In general, the privacy of all communications between a patient and a licensed Professional Clinical Counselor are protected by law, and I can only release information about our work to others with your written permission. But 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. In terms of Distance Counseling, laws vary from state to state, but it is my responsibility, as a NBCC Certified Distance Counselor, to make online communications as private and confidential as state-of-the-art technology will facilitate.

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 may be required to file a report with the appropriate state agency. If I believe that a patient is threatening serious bodily harm to another, I may be required to take protective actions.

These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient 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 very 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.

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. Where inter-state or Distance Counseling is being provided, you should consult the laws of your particular state in this regard, because I can only be responsible to the laws of the State of Ohio.

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Financial Policy

Thank your for choosing me as a health care provider. I am committed to your treatment being successful. The payment of your bill is considered a part of your commitment to treatment. The following is a statement of my financial policy.

I accept cash, check, or credit cards. Please pay your fees in full at the time of the appointment. Distance Counseling fees will be paid at the initial consultation and after via PayPal.

Regarding Insurance. For those plans where I am considered to be a participating or accepted provider, all co-pays and deductibles are due at the time of treatment. Please understand that your insurance plan is a contract between you and your insurance company to which I am not a party. Therefore, please recover any insurance payments yourself. Before becoming my client, please check with your insurance company to be sure about what is and what is not going to be covered, what kind of deductible you may have, whether you have to have pre-authorization, or whether you need a referral slip from a primary physician.

I will provide minimal assistance for you to file your own insurance claims. I have accepted in- and out-of-network insurance reimbursement and will continue to do so with some exceptions. I will provide an explanation of services that are basic to your filing claims. I am a preferred provider for some plans, but with newer, more restrictive plans, newer policy limits, fees and charges, such as deductibles, I am increasingly "out of network," meaning, your insurance company may reimburse me, but they may charge you extra for not seeing a provider "in-network."

Rates: I charge what is usual and customary for this geographical area. Face to face counseling: $125.00 per 60 minute session. Distance Counseling (On-line, e-mail or phone): $100 per 60 minute session. Occasionally a session is longer than 1 hour, never less than 60 minutes, so I charge by the session, not by the hour.

Unusual Circumstances or situations can be discussed directly with me. Other financial arrangements may be negotiated on a limited basis, if there is hardship.

Cancellation Policy

It is very important that you keep your appointments and arrive on time, both for yourself and for the good of other potential clients. Because I cannot use your time for another client, I must maintain a strict cancellation policy. A full session fee is charged for missed appointments or cancellations with less than a 24-hour notice, unless it is due to illness or emergency.

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Marlene Talbott-Green, Ph.D
36 W Short Street, Worthington, OH 43085
(614) 846-8880, MTGPHD@aol.com
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