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Counseling Associates of Southern Illinois

Registration and Policy.

Please complete BOTH sections.

1. New Client Registration

You can avoid a mound of paper and save lots of time by registering online and completing our electronic form. Everything is sent directly to your provider. Go Here to REGISTER NOW!

2. Counseling Associates Online Policy Forms

These are POLICY forms that require signature before your session can begin. You can read and digitally sign the documents from this app instead of downloading, filling out, and printing paper copies.

1Insurance Policy Statement

2CASI Financial Policy

3Consent to Treat Minor

4CASI Privacy Policy

Name*
Name of Adult Completing this Form. This is the person responsible for decisions and payment
First Last
Is the client a Child?*
- Yes
- No
Client Birthdate*
DD dash MM dash YYYY
Email*
Insurance Policy Statement

Due to recent changes in insurance company policies, we are making this strong recommendation. Often, Mental Health Benefits are different than your medical benefits. The majority of patients DO need pre-authorization for their visits. We urge you to contact your insurance company and make sure you know your benefits. Make sure you read and understand your Explanation of Benefits you get in the mail. We call your insurance company as a courtesy, however: Ultimately, it is your responsibility to understand your benefits and your responsibility for payment of services rendered. Many times we have gotten the wrong quotes for benefits from the insurance company when we have called them. We are only passing on the information they give us. Sometimes, we can get different quotes by talking to two different people. This is not our fault... it is your insurance company's fault... Therefore, we urge you to get involved in the process, understand, and know your deductible and benefits. Our staff is more than happy to help you with any questions you may have. Please don't hesitate to ask.

Thank You
CASI Staff

CASI Financial Policy

The staff at Counseling Associates of Southern Illinois (CASI) is committed to providing caring and professional mental healthcare to all of our clients. As part of the delivery of mental health services we have established a financial policy which provides payment options to all clients. The financial policy of the clinic is designed to clarify the payment policies as determined by the management of the clinic.
Your insurance policy, if any, is a contract between you and your insurance provider. As a service to you, the clinic will bill insurance companies, but cannot guarantee such benefits or the amounts covered. We do not bill Auto Insurance or Workman's Compensation. In some cases insurance companies may consider certain services as unreasonable or unnecessary and may determine that services are not covered. In such cases the person responsible for payment of account is responsible for payment of these services. Our clinic charges the usual and customary rates for our area. Clients are responsible for payments regardless of any insurance company's arbitrary determination of usual and customary rates. We will only resubmit your claim one time. If after one re-submission your claim is still denied, the balance will become your responsibility.

The person responsible for payment of account is financially responsible for paying funds not paid by insurance companies after 60 days. Payments not received after 90 days are subject to collections.

Insurance deductibles and co-payments are due at time of service. Although it is possible your deductible has been met elsewhere, this amount will be collected by the clinic until an Explanation of Benefits is received from your insurance company. All insurance benefits will be assigned to this clinic (by insurance company) unless the person responsible for payment of account pays the entire balance at each session.

Clients are responsible for payment at the time of service. The adult accompanying a minor is responsible for payments at time of service. Unaccompanied minors will be denied non-emergency service unless charges have been pre-authorized to an approved credit plan, charge card, or payment is made at time of service.

Agree to the following statements by selecting the checkboxes.
Missed Appointment Terms*
- Missed appointments or cancellations less than 24 hours prior to the appointment will be charged at the current rate
Credit Card Authorization Terms*
- All clients will be required to fill out and sign the credit card payment guarantee form to receive services.
Acceptable Credit Terms*
- Accepted payment methods include HSA, HRA, Check, Cash, Visa, MasterCard, and Discover.
Initial Here*
I have read and understand the Insurance and financial policies

Consent to Treat A Minor
If the client is a child, we need signatures from the Parents/Guardians
The involvement of children and adolescents in therapy can be highly beneficial to their overall development. Very often, it is best to see them with parents and other family members; sometimes, they are best seen alone. I will assess which might be best for your child and make recommendations to you. Obviously, the support of all the child’s caregivers is essential, as well as their understanding of the basic procedures involved in counseling children.

The general goal of involving children in therapy is to foster their development at all levels. At times, it may seem that a specific behavior is needed, such as to get the child to obey or reveal certain information. Although those objectives may be part of overall development, they may not be the best goals for therapy.

Again, I will evaluate and discuss these goals with you. Because my role is that of the child’s helper, I will not become involved in legal disputes or other official proceedings unless compelled to do so by a court of law. Matters involving custody and mediation are best handled by another professional who is specially trained in those areas rather than by the child’s therapist. The issue of confidentiality is critical in treating children. When children are seen with adults, what is discussed is known to those present and should be kept confidential except by mutual agreement. Children seen in individual sessions (except under certain conditions) are not legally entitled to confidentiality (also called privilege); their parents have this right. However, unless children feel they have some privacy in speaking with a therapist, the benefits of therapy may be lost. Therefore, it is necessary to work out an arrangement in which children feel that their privacy is generally being respected, at the same time that parents have access to critical information. This agreement must have the understanding and approval of the parents or other responsible adults and of the child in therapy.

This agreement regarding treatment of minors has provisions for inserting individual details, which can be supplied by both the child and the adults involved. However, it is first important to point out the exceptions to this general agreement. The following circumstances override the general policy that children are entitled to privacy while parents or guardians have a legal right to information.

Confidentiality and privilege are limited in cases involving child abuse, neglect, molestation, or danger to self or others. In these cases, the therapist is required to make an official report to the appropriate agency and will attempt to involve parents as much as possible. Minors may independently enter into therapy and claim the privilege of confidentiality in cases involving abuse or severe neglect, molestation, pregnancy, or communicable diseases, and when they are on active military duty, married, or officially emancipated. They may seek therapy independently for substance abuse, danger to self or others, or a mental disorder, but parents must be involved unless doing so would harm the child.

Agree to the following statements by selecting the checkboxes.
Confidentiality Statement 1*
- Confidentiality and privilege are limited in cases involving child abuse, neglect, molestation, or danger to self or others. In these cases, the therapist is required to make an official report to the appropriate agency and will attempt to involve parents as much as possible.
Confidentiality Statement 2*
- Minors may independently enter into therapy and claim the privilege of confidentiality in cases involving abuse or severe neglect, molestation, pregnancy, or communicable diseases, and when they are on active military duty, married, or officially emancipated. They may seek therapy independently for substance abuse, danger to self or others, or a mental disorder, but parents must be involved unless doing so would harm the child.
Confidentiality Statement 3*
- Any evaluation, treatment, or reports ordered by, or done for submission to a third party such as a court or a school is not entirely confidential and will be shared with that agency with your specific written permission. Please also note that I do not have control over information once it is released to a third party
Now that the various aspects surrounding confidentiality have been stated, the specific agreement between you and your child/children follows. Please complete the statements
1. Parent/Guardian*
First Last
1a. Relationship*
- Mother
- Father
- Legal Guardian
2. Parent/Guardian
First Last
2a. Relationship to Child
- Mother
- Father
- Legal Guardian
1. Child Name*
First Last
Name of Child Client
2. Name of an additional child that will/may be seen
First Last
3. Name of an additional child that will/may be seen
First Last
I agree the child(ren) listed above should have privacy in his/her/their therapy sessions, and I agree to allow this privacy except in extreme situations, which I will discuss with the therapist. At the same time, except under unusual circumstances, I understand that I have a legal right to obtain this information. To increase the effectiveness of the therapy, I agree to the following

I will do my best to ensure that therapy sessions are attended and will not inquire about the content of sessions. If my child prefers/children prefer not to volunteer information about the sessions, I will respect his/her/their right not to disclose details. Basically, unless my child/children have been abused or is/are a clear danger to self or others, the therapist will normally tell me only the following:
- Whether sessions are attended
- Whether or not my child/children are generally participating
- Whether or not progress is generally being made
The normal procedure for discussing issues that are in my child’s/children’s therapy will be joint sessions including my child/children, the therapist, and me and perhaps other appropriate adults. If I believe there are significant health or safety issues that I need to know about, I will contact the therapist and attempt to arrange a session with my child/children present. Similarly, when the therapist determines that there are significant issues that should be discussed with parents, every effort will be made to schedule a session involving the parents and the child/children. I understand that if information becomes known to the therapist and has a significant bearing on the child’s/children’s well-being, the therapist will work with the person providing the information to ensure that both parents are aware of it. In other words, the therapist will not divulge secrets except as mandated by law, but may encourage the individual who has the information to disclose it for therapy to continue effectively.
Parent or Guardian 1 Signature*
Parent or Guardian 2 Signature

CASI Notice of Privacy Practice

Please download and read the CASI Privacy Notice
We provide to our clients a copy of Counseling Associates of Southern Illinois Notice of Privacy Practices, which describes your mental health information privacy rights. We encourage you to thoroughly review this document and become familiar with how your personal mental health information will be used and safeguarded, as well as your rights regarding the protection of your personal data. The information in this notice became effective April 14, 2003

I hereby acknowledge reciept of the Counseling Associates of Southern Illnois Notice of Privacy Practices. I received and reviewed a copy of this notice on the date indicated below. I understand the limits of confidentiality, privacy policies, my rights, and their meanings and ramifications. I understand that if I have questions about this notice, I may contact Counseling Associates of Southern Illinois at 1669 Windham Way, Suite B, O'Fallon, Illinois 62269 or by phone at (618) 622-2579
Signature*
Please sign and submit.

OR.. If you prefer mounds of paper.

You can manually download, Print, fill these out, and bring them with you at your first appointment.

Policy Only Statements
Policy Statement with Adult Client Intake
Policy Statement with Child Intake and Consent to Treat

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