Minor Intake/Agreement Forms

Thank you for choosing Brighter Pathways, LLC. To register and complete your intake, please fill in the information below.

Patient Information

How did you hear about us? *

First Name *

Middle Initial

Last Name *

Birth Date (MM/DD/YYYY) *

Address *

Suite, Apt, Etc.

City *

State *

Zip Code *

Emergency Contact Person *

Telephone # *

Daytime Phone

Email Address

Have you had previous mental health treatment/Diagnosis before? *

Yes

No

If yes, what was your diagnosis?

Current Issues/Symptoms/ Problems

Current Problem * 🛈

Medical issues? *

Yes

No

Are you prescribed Medication? *

Yes

No

Do you have allergic/adverse reactions to anything? *

Yes

No

Appointment Information

Which services are you in need of? *

Primary preferred appointment time *

Alternate Preferred Appointment Time *

Insurance Information

Do you have medical Insurance *Please check with office to ensure we are provider's in your network or if you have out-of-network benefits :Please also note payment, if required, is expected at the time services are rendered. * Some groups are not covered under insurance. *

Yes

No

Primary Insurance *

Relation to the insured

Secondary Insurance

Relation to the insured

Agreement for Service

Rights and Risk of Therapy: You are urged to be fully involved in your care. You can terminate therapy at any time you wish. You have the right to divulge only what you want to be included in your records.You are urged to open an honest.Your care may involve emotionally provoking subjects and scenarios. You are urged to challenge and push yourself towards change and healing. Therapists are warned against dual relationships. Gift giving is discouraged, please refrain when possible. *

I have read and agree

Rights and Risk of Therapy: You are urged to be fully involved in your care. You can terminate therapy at any time you wish. You have the right to divulge only what you want to be included in your records.You are urged to open an honest.Your care may involve emotionally provoking subjects and scenarios. You are urged to challenge and push yourself towards change and healing. Therapists are warned against dual relationships. Gift giving is discouraged, please refrain when possible. *

I have read and agree

Confidentiality: We will not share your personal information or information about your treatment unless in the following situations: You provide permission, which you can revoke at any time. Your records are subpoenaed by the courts/attorney You threaten harm to yourself or someone else. Information is provided to indicate abuse/neglect of children and vulnerable adults. You decide to take legal action against me or the practice. Even if the patient is a minor, confidentiality is still held to the highest regard. Discretion will be made for serious/life-threatening events to break confidentiality. All efforts will be made to maintain your confidentiality when possible. *

I have read and agree

Appointments All office visits are by appointment, scheduled with your regular Therapist. You are urged to be on time, most sessions will last 45 to 60 minutes. If you are more than 15 minutes late, your appointment may be cancelled. Most of the time you will receive an appointment reminder. Please confirm. Note you cannot text us back but are welcome to call or email to notify us. You are required to cancel your appointment at least 24 hours in advance to avoid cancellation fee. Insurance companies will not pay for no-show/cancellation charges. After1 month of inactivity, your case will be considered for closure. Your therapist will contact you to attempt to re-engage you at least once and will close your case automatically if you do not respond or reengage. Once closed, you are more than welcome to re-enter therapy when you are ready, provided your therapist is currently accepting new clients during that time. *

I have read and agree

Fees: The client portion of fees is expected at the time of service. You are responsible for any unpaid portions after insurance. Accounts become delinquent after (30) days. Accounts more than 90 days in arrears will be terminated. I agree to discuss any changes to my financial situation. There will be a $25 fee added to return checks We accept Visa, MasterCard, & American Express. The card must be in your name or permission form sign by responsible party for you to use their card.

Current Fee Schedule: *Initial interview:- $155.00
*Individual Therapy Sessions: (30minutes): $40.00 (45minutes):$95.00 (60minutes):$115
*Family Therapy Sessions: $110.00 *Cancellation/No show: $25 *Crisis Session: $40.00/15minutes

* Specialty groups- Price vary per group * Completing documents: $25.00 ea

*

I have read and agree

Handling of Crisis/Emergency Situations: In a crisis situation, you have the option of reaching a counselor on call. The on-call counselor may or may not be your primary counselor but is here to help you through your crisis. You may call 803-708-7990, Ext 2 In a crisis situation after hours, if a counselor cannot be reached, you may call the 24 hour Mental Health Crisis 1-800-273-TALK ( 8255), 1-800-SUICIDE (1-800-784-2433) Line or go to your local Emergency Room for immediate assistance. Please note there is a charge for crisis calls. *

I have read and agree

Assignments of Benefits: I assign directly to Brighter Pathways, LLC all insurance benefits, if, any, otherwise payable to me for services rendered. I understand I am financially responsible for all charges not paid by my insurance as well as collection fees or interest that may be added if the account should be placed with an outside collection agency. I authorize the use of my signature on all insurance submissions. The above name facility may use my healthcare information and my disclose such information to the named insurance company or companies and their agents for the purpose of obtaining payment for services and determining benefits or the benefits payable for related services. This consent will expire 1 year after I have been discharged from brighter Pathways, LLC. *

I have read and agree

My or my representative's signature below indicates I have read/reviewed the policies and agree to receive services with Brighter Pathways, LLC.

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Date * +

Printed Name *

Relationship to Patient *

Parent

Other Other

Minor Consent to treatment

1.Consent to Evaluate/Treat:
I voluntarily consent that my child will participate in a mental health (e.g. psychological or psychiatric) evaluation and/or treatment by staff from Brighter Pathways, LLC I understand that following the evaluation and/or treatment, complete and accurate information will be provided concerning each of the following areas:

The benefits of the proposed treatment
Alternative treatment modes and services
The manner in which treatment will be administered
Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).
Probable consequences of not receiving treatment

The evaluation or treatment will be conducted by a Licensed Professional Counselor , Licensed Professional Counselor- Supervisor, Licensed Clinical Socialworker, or an individual supervised by any of the professionals listed. Treatment will be conducted within the boundaries of South Carolina Law for Social Work, Professional Counseling, or Marriage and Family Counseling.

2. Benefits to Evaluation/Treatment: Evaluation and treatment may be administered with psychological interviews, psychological assessment or testing, psychotherapy, medication management, as well as expectations regarding the length and frequency of treatment. It may be beneficial to my child, as well as the referring professional, to understand the nature and cause of any difficulties affecting my child’s daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. Possible benefits to treatment include improved cognitive or academic performance, health status, quality of life, and awareness of strengths and limitations.

3. Charges: Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. I will be responsible for all charges. Fees are available to me upon request.

4. Confidentiality, Harm, and Inquiry: Information from my child’s evaluation and/or treatment is contained in a confidential medical record at Brighter Pathways, LLC, and I consent to disclosure for use by Brighter Pathways, LLC, staff for the purpose of continuity of my child’s care. Per South Carolina mental health law, information provided will be kept confidential with the following exceptions: 1) if my child is deemed to present a danger to himself/herself, or others; 2) if concerns about possible abuse or neglect arise; 3) if a court order is issued to obtain records.

5. Right to Withdraw Consent: I have the right to withdraw my consent for evaluation and/or treatment of my child at any time by providing a written request to the treating clinician.

6. Expiration of Consent: This consent to treat will expire 12 months from the date of signature, unless otherwise specified.

I have read and understand the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment of my child. I also attest that I am the legal guardian and have the right to consent for the treatment of this child. I understand that I have the right to ask questions of my child’s service provider about the above information at any time. *

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Date * +

Printed Name *

Relationship to Patient *

Parent

Other Other

Depression	Anxiety	Grief/Loss
Behavioral Issues	Relationship/Family	Anger
Trauma	Substance Abuse	Other Other

Assessment Only	Individual Therapy	Family Therapy
Group Therapy	Employee Assistance Program(EAP)	Other