Patient Registration Form     

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Patient Registration Form (Page 1 of 2)

(Please Type or Print)

Last Name __________________First Name_____________________ MI___________

Address _____________________________________________________________

City/State/Province/County ___________________________Zip/Post Code___________

Social Security # _____Date of Birth (mm/dd/yyyy) _______Gender: Male______ Female _____

Marital Status _____ Home Phone ____________ Day Time Phone ____________________

(Single, Married, Divorce, Living Together with a Significant Other)

Cell Phone _______________ E-Mail _______________________________________

Church You Attend ______________________________Religious Preference __________

Employee Name _______________________________________________________

Employee Address ______________________________________________________

City/State/Province/Country______________________________________________________

HOW DID YOU LEARN ABOUT US? (Check all that apply)

Friend/Family Yellow Pages Physician Counselor Other_________

                                                                                                        (Please specify)

Referring Physician/Counselor Name _________________________________________

RESPONSIBLE PARTY INFORMATION (If different from Patient)

Last Name _________________________________First Name___________________

Address _____________________________________________________________

City/State/Country____________________________ Zip/Post Code _______________

Patient Relationship _________SS# __________Phone # __________Birth Date_________

Employer Name ________________________________________________________

Employer Address ______________________________________________________

City/State/Province/Country _________________________Zip/Post Code ____________

Patient Registration (Page 2 of 2)

EMERGENCY CONTACT - NOT LIVING WITH YOU (i.e. Friend or relative)

Last Name ________________________ First Name __________________ MI ______

Address ___________________________________________ Zip/Post Code________

BRIEFLY TELL US WHY YOU HAVE COME TO SEE US

_____________________________________________________________________________

______________________________________________________________________________

WHAT DO YOU EXPECT TO ACHIEVE

______________________________________________________________________________

______________________________________________________________________________

PAYMENTS

Our Heart's desire is to assist you with the help of the Lord, the Word of God, and our professional training and life experience. To keep organization running for you and others, we call your attention to the financial matter. Our fee schedule for evaluation, counseling and testing are below the national average. Our counseling fees begin at a low of $60.00 and if a Temperament Analysis Profile is needed the charge is $30.00. A complete fee schedules is available upon request. Additionally there are miscellaneous charges including mileage and travel expenses if sessions are held other than at our office location. We reserve the right to charge $25.00 for a broker appointment of less than 24 hours' notice. If you are unable to pay for the total charges for counseling at this time please discuss the matter with your counselor at the start of your appointment.

Please check this box if you are unable to pay the full costs prior to the session.

Please indicate how you plan to pay for this and future sessions.

Cash                Check              Visa          Master Card            Discover              PayPal

I have read and understand the information contained in this form.

Signature _______________________________________ Date _________________

Office Policy (Page 1 of 2)

Following are our office policies. Please read thoroughly, initial at the bottom and sign on page 2 of this form.

I UNDERSTAND AND/OR AGREE THAT:

The office does not extend credit to any person, company, or institution and that payment is expected to be received by office personnel prior to seeing the doctor or counselor.

I am responsible for payment in full for all services at the time they are rendered. I accept this ultimate responsibility whether or not or in case that third parties cover, do not cover, deny, pre-certify, pre-authorize, or authorizes tests, services, or payment.

I will be reimbursed by the Center for Christian Counseling for any third party payment to the office for services for which I have already paid.

If I am unable to keep an appointment I will contact the Center at 915-239-0196 at least 24 hours prior to the appointment.

Failed appointments, failed counseling compliance, failed office policy compliance, and/or failed therapeutic alliance will result in being subject to termination by mutual consent and referral to another Counselor if requested followed by two weeks coverage for counseling emergencies. There is a $25.00 charge for failed appointments unless 24 hours’ notice has been given payable prior to the next scheduled appointment.

Please note that all counseling notes are the property of the counselor and copies of the files will be provided upon request and consent of all parties involved in the counseling.

If a member of the counseling team of the Center for Christian Counseling is subpoenaed to testify in court on my behalf it is understood the charge will be $100.00 per hour for preparation and from the time the counselor leaves the Center to go to court until he/she returns to the Center after court. A $500.00 deposit will be expected 24 hours prior to the court date. Yahweh Counseling has a right to refuse services to you if you are intoxicated, smoking or using tobacco products, boisterous or using inappropriate language, offensive or aggressive gestures while on our premises.

I will not video or audio record any sessions whether in the office or via telephone, SKYPE or other technology.

I am required to pay prior to the beginning of each session.

We accept Cash, check, MasterCard, Visa, Discover. Payments may also be made on our website at

http://www.yahwehcounseling.org using PayPal.

Make checks payable to: (Yahweh's Counseling for Mission Studies).

Please note: there is a $35.00 charge for returned checks.

Patient: Please Initial Page 1 _________ (Continue with page 2)

Office Policy (Page 2 of 2)

If you have any questions concerning payments, please direct your questions to Angela Edwards our Administrative Assistant. She is available Monday through Thursday 9:00am to 3:00pm EST.

ACTIVE YCMS MEMBERS*

As you may know, we are a completely independent and financially self-supporting, stand-alone ministry of YCMS. Sessions are given at a reduced rate of $30.00 per one-hour session. The above requirement of 24 hours’ notice still applies.

INACTIVE YCMS MEMBERS*

The first session is $30.00. Thereafter it will be $60.00 per one-hour session.

*Active or inactive membership as determined by the Administrative Assistant office.

I have read and understand the information on these two pages of the office policy.

______________________________________________ _____________

Patient/Representative Signature                                                             Date

______________________________________  _____________________

Witness Signature                                                                                       Date

Informed Consent Form (Page 1 of 2)

I/we, _____________________________________________________________, have been informed that the Yahweh

Counseling is a ministry and that any counseling provided will be spiritual counseling from a Biblical perspective and also that:

1. Dr. Ophelia Phillip-Alleyne is an ordained of a Non-denominational minister and remain accountable to the Pastor and leadership of _________________. Dr. Ophelia Phillip-Alleyne is a licensed Clinical Christian Counselor (Advanced Certification), licensed by the National Christian Counselors Association and not by the State of Florida.

2. As a members of the clergy Dr. Ophelia Phillip-Alleyne will report or cause a report to be made and cannot keep silent on the grounds of confidentiality or privileged communication, the following:

- When a disclosure indicated a counselee may cause danger to self

      - When a disclosure indicated a counselee may pose a danger to others

- In case of suspected child abuse and/or neglect as required by law

3. A free exchange of information between appropriate staff members of Yahweh’s Counseling For Mission Studies Inc. regarding my evaluation and treatment may take place as necessary. Otherwise my file will be treated with strict confidentiality. PLEASE NOTE: all notes are the property of the counselor and Yahweh’s counseling for Mission Studies and copies of files will be provided upon request and consent of all parties involved in the counseling. If copies of notes are requested and approved the counselee must sign a release.

4. The counselee desires to take advantage of the Counselor’s services and training, and understands the Bible will be the foundational basis for all counseling.

5. As Dr. Ophelia Phillip-Alleyne and Yahweh Counseling for Mission Studies is a ministry, I agree never to make demands, threaten to sue, or actually litigate any matter whatsoever relating to or resulting from this Agreement. I understand that making demands, threatening to sue or actually litigating a matter against Yahweh Counseling for Mission Studies Inc. clearly violates Biblical teaching and practice and shall constitute sufficient grounds for immediate termination of counseling services.

I understand that retaining or instructing an attorney to contact the ministry with regard to a potential claim or dispute will be interpreted as a threat to sue. Accordingly, the parties agree to resolve all potential claims, disputes or causes of action through binding arbitration using the procedures outlined in the Center’s officially adopted Christian arbitration procedures.

6. A staff member has explained fully to me, the counselee, all of the above prior to entering into any counseling or disclosure.

Patient: Please Initial Page 1 _________ (Continue with page 2)

Informed Consent Form (Page 2-0f 2)

7. I freely and willingly accept and agree to abide by this informed consent as presented.

___________________________________________ _____________________

Conselee Signature                                                                                                     Date

______________________________________________         _______________

Parent/Legal Guardian Signature Relationship                                                      Date

_______________________________________________     _______________

Witness                                                                                         Date

Counselee Name __________________________ Birth Date _____________________

Counselee Address _____________________________________________________