Restoring Clarity Counseling, LLC

Restoring Clarity Counseling, LLC Cristina Smugala, M.A., L.P.C 141 N. Meramec Ave., Suite 25 Clayton, MO 63105 314-888-5212 Fax# 314-727-1808 [email protected] www.traumaemdrtherapystlouis.com Office Policies & Informed Consent

CLIENT INTAKE FORM Please provide the following information for our records. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality as our therapy.

Name: First______Last______Middle Initial______

Name of parent/guardian (if you are a minor): ______First, Last

Address: Street______Apt.#______City______Zip______State______

Email: ______

Phone Number: ( )______Is it okay to leave a message: [] Yes [] No

Birth Date: ______/______/______Age: ______Gender: □ Male □ Female □ Other, preferred Gender Pronouns______

Insurance Provider and Plan Type: ______

Insurance Member ID: ______

Group #______SSN ______-_____-______

Please indicate how you were referred for services: ______

What are the concerns for which you are seeking assistance? ______YOUR MARITAL STATUS:

[ ] Single [ ] Married [ ] Divorced [ ] Separated [ ] Cohabitating [ ] Widowed [] Other

1. Who do you live with currently? ______

Cristina Smugala, MA, LPC 141 N. Meramec Ave. Clayton, MO 63105 Restoring Clarity Counseling, LLC Cristina Smugala, M.A., L.P.C 141 N. Meramec Ave., Suite 25 Clayton, MO 63105 314-888-5212 Fax# 314-727-1808 [email protected] www.traumaemdrtherapystlouis.com Office Policies & Informed Consent

______

PHYSICAL DESCRIPTION A. Do you have any physical impairments or disabilities? If so, explain: ______

B. Do you have any physical health illnesses? Explain: ______

EMPLOYMENT A. Are you currently employed? [ ] Yes [ ] No If yes, [ ] Full time [ ] Part time [ ] Seasonal B. Position: ______

SPIRITUAL INFORMATION Is spirituality an area of support or strength for you? [ ] Yes [ ] No RELIGION: [ ] Catholic [ ] Jewish [ ] Islamic [ ] Protestant [ ] Other:______

SUBSTANCE USE A. Do you use illegal or unprescribed drugs including alcohol? [ ] No [ ] Yes If yes, explain which drugs, amount and frequency: ______

B. Is drug or alcohol use an area of concern: [ ] No [ ] Yes If yes, explain: ______

Emergency Contact: Emergency Contact’s Address: ______

Emergency Contact’s Name: ______

Emergency Contact’s Phone______

I give Cristina Smugala permission to speak with my emergency contact about treatment recommendations and psychological diagnosis, and the nature of the emergency in the event that my life is in danger:

Print Name: ______

Signature: ______Date: ______

List ALL MEDICATIONS: List all current prescriptions:

______

Medical and Emotional Difficulties (Check all that apply)

Anorexia □ Binge eating □ Bulimia □ Wild Mood Swings: □ Rapid Speech: □ Extreme Anxiety: □ Panic Attacks: □ Phobias: □ Sleep Difficulties: □ Hallucinations: □ Unexplained losses of time: □ Unexplained memory lapses: □ Alcohol/Substance Abuse: □ Frequent Body Complaints: □ Eating Disorder: □ Body Image Problems: □ Repetitive Thoughts (e.g., Obsessions): □ Repetitive Behaviors (e.g., Frequent Checking, Hand-Washing): □ Homicidal Thoughts: □ Suicide Attempt: □ Asthma □Diabetes □Fainting/Dizzy □Hearing Problems □Heart Disease □High/Low Blood Pressure □High/Low Blood Sugar □ OB/GYN Problems □Obesity □Seizures/Epilepsy □Stomach or Intestinal Problems □Thyroid Problems □Ulcer □ Vision Problems □Extreme depressed mood: □ Decreased Motivation: □ Infertility: □

Have you experienced physical, sexual, emotional abuse or Intimate Partner Violence? [ ] No [ ] Yes describe:______

Cristina Smugala, MA, LPC 141 N. Meramec Ave, Suite 300, Clayton, MO 63105

Notice of Privacy Practices ______

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. ______I am required by law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices, legal obligations, and your rights concerning your health information ("Protected Health Information" or "PHI"). I will follow the privacy practices that are described in this Notice. If I amend this Notice, I will provide you with the amended Notice for your information and signature. For more information about my privacy practices, or for additional copies of this Notice, please let me know your questions as soon as they arise. ______

I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

A. Permissible Uses and Disclosures Without My Written Authorization. I may use and disclose your PHI without your written authorization for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures of your mental health information that are legally permissible.

1. Treatment: I may use and disclose your PHI to other clinicians involved in your care in order to better provide integrated treatment to you. For example, I may discuss your diagnosis and treatment plan with your psychiatrist or nurse practitioner. In addition, I may disclose your PHI to other health care providers in order to provide you with appropriate care and continued treatment.

2. Payment: I may use or disclose your PHI for the purposes of determining coverage, billing, claims management, and reimbursement. For example, a bill sent to your health insurer may include some information about our work together so that the insurer will pay for the treatment. I may also inform your health plan about a treatment you are going to receive in order to determine whether the plan will cover the treatment.

3. Health Care Operations: I may use and disclose your PHI in connection with health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities. For, example, I may disclose disguised information about our work for training purposes.

4. Required or Permitted by Law: I may use or disclose your PHI when I am required or permitted to do so by law. For example, I may disclose your PHI to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. In addition I may disclose your PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access your PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; disclosures for workers’ compensation claims, and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions as authorized by law.

B. Permissible Uses and Disclosures That May Be Made Without My Authorization, But For Which You Have An Opportunity to Object. 1. Fundraising: I may use your PHI to contact you in an effort to offer you new services. I may also disclose PHI to any foundation with which I am connected so that the foundation may contact you in an effort to raise money for its operations. Any fundraising communications with you will include a description of how you may opt out of receiving any further fundraising communications.

2. Family and Other Persons Involved in Your Care. I may use or disclose your PHI to notify, or assist in the notification of (including identifying or locating) your personal representative, or another person responsible for your care, location, general condition, or death. If you are present, then I will provide you with an opportunity to object prior to such uses or disclosures. In the event of your incapacity or emergency circumstances, I will disclose your PHI consistent with your prior expressed preference, and in your best interest as determined by my professional judgment. I will also use my professional judgment and my experience to make reasonable inferences of your best interest in allowing another person access to your PHI regarding your treatment with me.

3. Disaster Relief Efforts. I may use or disclose your PHI to a public or private entity authorized by law or its charter to assist in disaster relief efforts for the purpose of coordinating notification of family members of your location, general condition, or death.

C. Uses and Disclosures Requiring Your Written Authorization.

1. Psychotherapy Notes. I will not disclose the records of our work that I keep separate from the medical record for my personal use, known as psychotherapy notes, except as permitted by law.

2. Marketing Communications; Sale of PHI. I must obtain your written authorization prior to using or disclosing your PHI for marketing or the sale of your PHI, consistent with the related definitions and exceptions set forth in HIPAA.

3. Other Uses and Disclosures. Uses and disclosures other than those described in this Notice will only be made with your written authorization. For example, you will need to sign an authorization form before I can send your PHI to your life insurance company or to your attorney. You may revoke any such authorization at any time by providing me with written notification of such revocation.

II. MY INDIVIDUAL RIGHTS

A. Right to Inspect and Copy. You may request access to your medical records and billing records maintained by me in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, I may deny access to your records. I may charge a fee for the costs of copying and sending you any records requested.

B. Right to Alternative Communications. You may request, and I will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.

C. Right to Request Restrictions. You have the right to request a restriction on your PHI that I use or disclose for treatment, payment or health care operations. You must request any such restriction in writing addressed to Cristina Smugala, MA, LPC, 141 N. Meramec Ave, Suite 109, Clayton, MO 63105. I am not required to agree to any such restriction you may request, except if your request is to restrict disclosing your PHI to a health plan for the purpose of carrying out payment or health care operations, the disclosure is not otherwise required by law, and the PHI pertains solely to a health care item or service which has been paid in full by you or another person or entity on your behalf.

D. Right to Accounting of Disclosures. Upon written request, you may obtain an accounting of disclosures of your PHI made by me in the last six years, subject to certain restrictions and limitations.

E. Right to Request Amendment: You have the right to request that I amend your PHI. Your request must be in writing, and should explain why the information should be amended. I may deny your request under certain circumstances. F. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to Cristina Smugala, MA, LPC, 141 N. Meramec Ave, Suite 109, Clayton, MO 63105 at any time.

G. Right to Receive Notification of a Breach. I am required to notify you if I discover a breach of your unsecured PHI, according to requirements under federal law. H. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that I have violated your privacy rights, please contact me at 314-888-5512. You may also file a written complaint with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. I will not retaliate against you if you file a complaint.

III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE

A. Effective Date. This Notice is effective on ______.

B. Changes to this Notice. I may change the terms of this Notice at any time. If I change this Notice, I may make the new notice terms effective for all PHI that I maintain, including any information created or received prior to issuing the new notice. If I change this Notice, I will post the revised notice in the waiting area of my office and on my website at www.traumaemdrtherapystlouis.com. You may also obtain any revised notice by asking me directly.

Client Signature:______Date:______(**For Minors Only) I herby grant permission to______Cristina Smugala, MA, LPC to counsel/assess my child______(Minor’s name).

Parent Signature______Printed Name______Date:______

Counselor Signature______Date: ______Restoring Clarity Counseling, LLC Cristina Smugala, M.A., L.P.C 141 N. Meramec Ave., Suite 25 Clayton, MO 63105 314-888-5212 Fax# 314-727-1808 [email protected] www.traumaemdrtherapystlouis.com

In order to make our work together more productive, I would like you to have a clear understanding of my policies and procedures. Please read these policies carefully and ask me about anything that you may need clarification on. By signing below, you acknowledge that you have received this information and understand it. First, let me tell you about my professional training. I am a Licensed Professional Counselor in the state of Missouri. I received my Master of Counseling from St. Louis University and have received training in a variety of modes of therapy including EMDR Therapy, Internal Family Systems Therapy, Dialectical Behavioral Therapy and Cognitive Behavioral Therapy. I am not a physician, so I am not able to prescribe medications, nor do I admit to hospitals. If these services are needed, I will provide you with referrals. Our first session or two will be spent getting to know each other. I

Cristina Smugala, MA, LPC 141 N. Meramec Ave. Clayton, MO 63105 Restoring Clarity Counseling, LLC Cristina Smugala, M.A., L.P.C 141 N. Meramec Ave., Suite 25 Clayton, MO 63105 314-888-5212 Fax# 314-727-1808 [email protected] www.traumaemdrtherapystlouis.com Office Policies & Informed Consent will need to gather necessary information such as family history, why you are pursuing therapy at this time and possible risks. I will also discuss confidentiality, the limits of confidentiality and payment or insurance information and my cancelation policy. After our first meeting I will provide initial impressions about what our work will include. You should use this information to determine whether or not you think that working with me would be a good fit for you. Therapy involves a large commitment of time, money and energy so you should be careful in selecting a therapist. If you have any questions or concerns about how I work, we should discuss them as they arise. If you would like to pursue a second opinion, I would be happy to help you arrange that. Psychotherapy can have benefits and risks. Since therapy may involve discussing distressing aspects of your life, you may experience uncomfortable feelings. However, psychotherapy has also been shown to have benefits for those who engage in it.

OFFICE POLICIES

Session Start/End Time

Appointments last 50 minutes unless we have made other arrangements. If you arrive late, only the remainder of your session will be available so that I will be able to stay on schedule. If I am running late with a prior appointment for some reason, you will still receive your full session time. Thank you for being mindful and respectful of this policy ______INITIAL

Late Arrival to Session

If you arrive late for a scheduled appointment, only the remainder of the session will be available so that I will be able to stay on schedule. If I am running late with a prior appointment for some reason, you will still receive your full session time. I will contact you directly if I am unable to be in the office for any reason and a phone session will be necessary. (i.e. weather, illness etc.) ______INITIAL

Fees and Payment

My fee is $125 per fifty- minute session. Payment is expected at the time of the session and must be paid by cash, check or credit card. If checks return for non-payment, you will be responsible charged $30 plus any resulting fees charged by the bank. I evaluate my fees twice per year and reserve the right to change my rate. I will provide four weeks notice prior to any fee increase. If you are unable to afford my hourly rate and do not have insurance that will cover my services, then we can discuss payment options. ______INITIAL

A credit card will be kept on file for all clients. All information will be kept confidential in a locked cabinet with other client files or in a HIPAA-compliant encrypted computer file. All clients must agree to maintain a credit card on file for payment of all missed appointment fees and any balances 60 days past due. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, the outstanding balance will be charged to the credit card you keep on file with me. ______INITIAL

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, workmen’s compensation, injuries, lawsuits, etc…) neither you (client’s) nor your attorney’s nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon. If you do become involved in litigation requiring your therapist’s participation, you will be expected to pay $175.00 per hour for professional time including travel time even if your therapist is compelled to testify by another party. ______INITIAL

Copying and mailing records will be charged at a rate of $30.00 plus $.54 per page. ______INITIAL

EMAIL/Text: Please initial here if I have your permission you contact you via email and/or to respond to email messages sent to me. Please note that email is not HIPPA compliant, or is not guaranteed as a confidential way to communicate and that I cannot guarantee confidentiality via the internet communications. Additionally, processing therapy information is not appropriate via email and it is best to save this information for your session. I cannot ensure the confidentiality of any forms of communication through electronic media. You are advised that any e-mail sent to me via computer in a work- place environment is legally accessible by an employer. You are advised that Cristina Smugala cannot protect information you send electronically and you do so at your own risk. I do not always check e-mail daily. Cristina Smugala will not respond to text messages, please call. It is very important to be aware that computers and unencrypted e-mail, texts, and e- faxes communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all e-mails, texts and e-faxes that go through them. While data on Cristina Smugala's laptop is encrypted, e-mails and e-fax are not. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers I understand that email is not privacy protected and provide Cristina Smugala, MA, LPC permission to use email for communication purposes. ______INITIAL

Sick Child Policy: For parents who have to stay at home sick with a child we will conduct a session via phone. Payment is expected at the time of the session. Please be aware that insurance companies do not pay for missed sessions or counseling via the phone. ______INITIAL

Therapy Fee: My standard fee is $125 per session. In the event that insurance coverage lapses or changes clients are responsible for paying my full fee until their coverage resumes. Please notify me if any changes occur with your insurance coverage in order to avoid paying full fee for sessions.

Insurance Reimbursement

I am a provider for a few insurance companies and will accept payment from them. You are responsible for your copay at the time of services provided. It is your responsibility to contact your insurance company to determine the extent of

Cristina Smugala, MA, LPC 141 N. Meramec Ave. Clayton, MO 63105 Restoring Clarity Counseling, LLC Cristina Smugala, M.A., L.P.C 141 N. Meramec Ave., Suite 25 Clayton, MO 63105 314-888-5212 Fax# 314-727-1808 [email protected] www.traumaemdrtherapystlouis.com Office Policies & Informed Consent your coverage and the copay amount. It is also your responsibility to provide me with any updated insurance information as soon as it has changed. Insurance verification is not a guarantee of payment and insurance companies deny coverage for many reasons. If a claim is denied, you are responsible for all charges. I reserve the right to charge any outstanding balance on the client’s credit card on file if balances are not paid within 60 days of service rendered. ______INITIAL

If I am not in the network of your insurance company, you will be responsible for paying my fee at the time of services rendered. You can then file a claim for reimbursement from your insurance company. ______INITIAL

Cancellation Policy: 48 hours advanced notification is the cancellation policy.

My clients have always been very respectful of their appointment time, other clients’ appointment times and my time and it is rare that clients cancel, but due to my current schedule, and in order to support other clients who are on the waiting list who will need enough time to schedule off from work or set up childcare, if you must cancel the appointment for any reason, you are required to notify me at least 48 hours in advance so that therapy time may be given to another client. For example, if your session is scheduled on Tuesday at 2pm, you will need to cancel NO LATER THAN 2pm the prior Sunday. If you are ill or contagious we can conduct session via phone. INSURANCE COMPANIES DO NOT PAY FOR MISSED SESSIONS OR PHONE SESSIONS. It is the client’s responsibility to remember and manage their sessions and cancellation. Please give as much notice as possible for cancelled or rescheduled appointments. Since there is always a waiting list, I am able to fill cancellations with other clients in need of help. If you miss the appointment or cancel with less than 48 hours notice, you will be charged $125, as I am not able to absorb the lost income and it isn’t fair to the clients who want to get in but cannot. Please note that insurance companies do not cover/reimburse for missed appointments. As a result, these charges are the entire responsibility of the client. I will charge missed appointment on the date of the missed session to your credit card on file. You may cancel an appointment without charge, 48 hours in advance by calling 314-888-5212 and leaving a voice mail message or sending an email to [email protected]. ______INITIAL

Session Reminders

As a courtesy to my clients I offer an optional service of reminder texts that generally arrive 48 hours before the appointment. However, it is up to each client to schedule their appointments on their own calendar and to keep track of session dates whether they receive a reminder or not. If for any reason, you do not get a text, you are still responsible for keeping the appointment and paying the missed appointment fee of $125. ______INITIAL

Wait List/Individual Therapy Attendance

Individual therapy space has been saved each particular client and I am dedicated to my clients’ well-being and healing. It is understandable that on rare occasions you may need to cancel your appointment due to a life emergency or illness that will not permit a phone session. My current schedule does not accommodate frequent cancellations. If there are more than 3 cancellations during a 6 month period, even within the 48-hour cancellation policy, you will be placed on the waiting list and the session time will be opened up to another client in need. ______INITIAL

Contacting Me

I can be reached at 314-279-9455. I am often not immediately available by phone but you may leave a voicemail message. I will return your call as soon as possible. I do not answer my phone while I am in session. I will make every effort to return your phone call within 24 hours of your call except holidays and weekends. If it is an emergency or there is a risk to yourself or others and you are unable to reach me, call 911 or go to the nearest emergency room. You may also contact Life Crisis Services at 314-647-4357. If I will be unavailable for an extended period of time, my voicemail message will provide instructions regarding how to contact the therapist covering for me. ______INITIAL

Please do not use messaging on social networking sites such as Facebook, Twitter or Linkedin to contact me. These sites are not secure and I may not read these messages in a timely manner. My primary concern is for your privacy and engaging with me in this way could compromise your confidentiality. It may also create the possibility that these messages become part of your medical record and will need to be documented and archived in your chart. This is also the case for email messages. If you need to contact me between sessions, the best way to do this is my office phone at 314- 279-9455. Direct email at staff@traumaemdrtherapystlouiscom is best for quick administrative issues such as changing appointment times. I do not use texting for these issues. Please do not email or text me about your therapy because these modes of communication are not completely secure or confidential. Please be aware that all emails are retained in the logs of your and my internet service providers and the contents of your emails may be documented in your chart. If you have any questions about this topic please ask me about them when we meet. ______INITIAL

Confidentiality

In general, the privacy of our communication is protected by law and I can only release information about our work with your written permission. There are a few exceptions to confidentiality. I am a mandated reporter of child, disabled person or elder abuse. If I believe that someone is at risk of hurting themselves or someone else, I may have to take protective actions which may include seeking hospitalization for a client, contacting the potential victim or family members, the Division of Family Services, Division of Aging or a physician. ______INITIAL

Minors

A parent or legal guardian must accompany minors to the first session even if the parent or guardian remains in the waiting room during session. If you are under 18 years old, please be aware that the law may provide your parents the right to review your records. For older teens it is my general policy to request an agreement from parents that they give up access to the treatment records. If they agree, I will provide them with only general information about our work

Cristina Smugala, MA, LPC 141 N. Meramec Ave. Clayton, MO 63105 Restoring Clarity Counseling, LLC Cristina Smugala, M.A., L.P.C 141 N. Meramec Ave., Suite 25 Clayton, MO 63105 314-888-5212 Fax# 314-727-1808 [email protected] www.traumaemdrtherapystlouis.com Office Policies & Informed Consent together unless I feel that there is high risk that you will seriously harm yourself or someone else. In this case, I will notify you of my concern. Before giving them any information, I will discuss this matter with you. ______INITIAL

Life Threatening Emergency: If you are experiencing a life-threatening emergency, you may not be able to reach me right away. Please call 911 for immediate support of Life Crisis Services at 314-647-4357 ______INITIAL

Risks: In, counseling major life decisions involving separation within families, development of other types of relationships, changing employment settings and changing lifestyles. The decisions are a legitimate outcome of the counseling experience as a result of an individual calling into question many of their beliefs and values. Furthermore, symptoms may be intensified and the emotional experience may be too intense to deal with at this time. I will be available to discuss any of your assumptions or possible negative side effects in our work together. There is no guarantee of what you will experience in counseling. ______INITIAL

By signing this document, I understand that I am responsible for all charges regardless of insurance coverage. I agree to receive psychotherapy services from Cristina Smugala, M.A., LPC. I am aware that I may terminate at any time. I have received a copy of these policies and any questions I had have been answered to my satisfaction.

I give permission for Cristina Smugala, MA LPC, to release any information to insurance companies and medical billing services for the purposes of determining benefits, obtaining payment for services, and obtaining authorizations. The permission remains in effect unless specifically revoked by me.

My signature below indicates that I have read and understood the information in this document and agree to the terms during our professional relationship including the 48-hour cancellation policy and associated fees.

______Client (if age 13 or above) Date

______Parent or legal guardian of minor client Date

______Witness Date

Cristina Smugala, M.A., LPC Licensed Professional Counselor 141 N. Meramec Ave., Suite 300 Clayton, MO 63105 314-888-5212 Fax# 314-727-1808 [email protected] Cancelation Policy Credit Card Authorization Since the scheduling of an appointment involves the reservation of time specifically for you, if you must cancel the appointment for any reason, you are required to notify me of the cancelation at least 48 hours in advance so that the therapy time may be given to another client. My clients have always been very respectful and it is rare that clients cancel, but due to my current schedule, and in order to support other clients who are on the waiting list who will need enough time to schedule off from work or set up childcare, if you must cancel the appointment for any reason, you are required to notify me at least 48 hours in advance so that therapy time may be given to another client. Please give as much notice as possible for canceled or rescheduled appointments. Since there is always a waiting list, I am able to fill cancelations. If you miss the appointment or cancel with less than 48 hours notice, you will be charged $125, as I am not able to absorb Cristina Smugala, MA, LPC 141 N. Meramec Ave. Clayton, MO 63105 Restoring Clarity Counseling, LLC Cristina Smugala, M.A., L.P.C 141 N. Meramec Ave., Suite 25 Clayton, MO 63105 314-888-5212 Fax# 314-727-1808 [email protected] www.traumaemdrtherapystlouis.com Office Policies & Informed Consent the lost income and it isn’t fair to the clients in need of help who want to get in but cannot. Please note that insurance companies do not cover/reimburse for missed appointments. As a result, these charges are the entire responsibility of the client. I will charge missed appointment on the date of the missed session to the credit card on file. You may cancel an appointment by calling 314-888-5212 and leaving a voice mail message or sending an email to [email protected]. I do not use text messaging in my practice and will not accept a text as an acceptable form of communication for cancelations.

A credit card or debit will be kept on file for all clients. All information will be kept confidential in locked cabinets. All clients must agree to maintain a credit card on file for payment of all missed appointment fees and any balances 60 days past due.

Credit Card Information (Required of all clients regardless of billing or payment arrangements).

Client’s Name:______

Name on the Credit Card ______

Type of Credit Card: MasterCard Visa Discover AmEx

Card Number: ______

Expiration Date: (month/year)______

Security Code: (last 3 numbers on back of card)______Zip Code of billing address______

I, ______authorize Cristina Smugala to process the above credit card as “Signature on File” for any balance due on my account. I understand this authorization will expire upon conclusion of care.

______Signature Printed Name

______Witness Signature Witness Printed Name

Cristina Smugala, MA, LPC 141 N. Meramec Ave. Clayton, MO 63105