Prospective Client Data Form (online version) Date: BreakThru Counseling and Consulting, P.C. WELCOME!! Please share with us the following information. We can then help you determine if it would be a good fit to work with Dr. Warner. If you have any questions you can contact us at: (678) 775-6704. You have a choice in how you send us this form. You can complete it online and then email it back to us or, you can download the form and fax it to (678) 954-6616 or, mail it to: Breakthru Counseling & Consulting, P.C., 6340 Sugarloaf Parkway, Ste. 200, Duluth, Georgia, 30097. Also, we need to alert you, if you choose below to communicate with us by electronic transmission (text, phone, faxes and/or emails) you assume the risk this may pose to client confidentiality. In this day and age of hackers, there is no 100% guarantee of confidentiality for any of us via electronic transmission. Thus, privacy of electronic transmissions cannot be assured. However, we’ll do our utmost to preserve your confidentiality on our end. Upon receipt and review of your information, we’ll contact you to discuss setting up an appointment. Please make sure you give us a day and night time phone number. We look forward to serving you! Information on person filling out this form: OK to leave voicemail at...? Home: ---YesNo Cell: ---YesNo Office: ---YesNo Email OK to send? ---YesNo Who referred you to BreakThru? What is your relationship to the prospective BreakThru client? Prospective Client Information: OK to leave voicemail at...? Home: ---YesNo Cell: ---YesNo Office: ---YesNo * Client's Sex: ---MaleFemale * Marital Status: ---MarriedSingleDivorcedSeparatedWidowed Client a US Citizen? ---YesNo If not a US Citizen, explain status: Prior Counseling: * Type of Counseling sought? ---For MyselfMaritalFor My ChildPremaritalOther * Description of reason client(s) seek counseling: * Will you be planning to pay through your insurance? ---YesNo If so, please give us the information requested below, as a courtesy service, we’ll verify coverage before your appointment and let you know your benefits. If you plan to pay without using insurance, please go now to the "3rd Party" or "SELF PAY" section, whichever applies. If you want to use your EAP program for payment, please complete the "Insurance/EAP" Section. You’ll then need to provide the requested info. for BOTH your EAP & your major medical insurance. INSURANCE/EAP INFORMATION: Do you want to use: InsuranceEAPBoth If you want to use both EAP and your major medical insurance and they are managed by two different insurance companies, please complete this form for each of the different insurance/EAP products you have. Do you have any secondary insurance? ---YesNo If so, please complete this form for each insurance company. Name of the family member the insurance is under (Insured): Some insurance companies will give a separate phone # on their cards labeled: “Mental Health /Alcohol and Substance Abuse phone #”. Please give us that # if your card has one: Prospective Client's Insurance Information (if different from above) The cost of the initial session will be $175.00 and following sessions will cost $150.00. Please be advised that any deductible and/or co- payment will be due at each session. Payment accepted is cash and/or check only. No credit, debit or medical spending cards accepted. As a courtesy to you we will file your insurance claim for you. However, the client, not the insurance company, is ultimately responsible for full payment of all fees owed. Other 3rd Party Information: If someone other than an insurance company or the client has agreed to pay for the client’s counseling, give us all contact information necessary to verify and bill for payment please. SELF PAY: If you plan to not use your insurance or other third party payers or do not have insurance, please be advised that the cost of the first session will be $175.00 and that following sessions will be charged $150.00 per forty- five minute session. Payment is due at each session. Payment forms accepted are cash or check. Credit, debit and/or medical spending account cards are not accepted.