Child Intake Packet
This packet is appropriate for individuals under the age of 14 and should be completed by their legal guardian.

*If there is joint custody, each parent/guardian need to complete a packet for their child.
Email address *
Hello!
Welcome to A New Hope Therapy Center, and thank you for allowing us to work with you!

Before your appointment, please read and complete the attached paperwork. Please initial and sign where indicated.

The forms included are:
* Statement of Client Rights, Responsibilities and Informed Consent
* Payment and Cancellation Policies
* Notice of Privacy Practices (HIPAA)
* Credit Card Authorization
* Consent for Release of Information for your Primary Care Physician (PCP)

It’s important that these forms are completed and turned in at your first appointment. We will be happy to discuss the details with you and answer any questions you may have before you begin your first session, however will we be unable to see you without these completed forms.

Along with these completed forms, please be sure to bring the following to your first appointment:
* Photo identification for client or parent, if applicable
* Insurance Cards
* List of all current medications including dosage and prescriber’s information
* Custody Order / Restraining Orders / Parental Rights Determination, if applicable

Your first appointment will be an evaluation and will take approximately one hour. Your following sessions will be scheduled for the length of time appropriate, determined by your therapist/provider.

Our address is 715 E Idaho - our entrance is located at 2B. We are located behind the Albertson’s on El Paseo in the office complex on the corner of Idaho and Mesquite. If you turn off of Idaho, onto Mesquite (towards Valley View Elementary School), take the second entrance to the parking lot on your immediate left. Head down the parking lot, towards the dumpster, and we are the last office on the right. Feel free to park in any empty space and come into the door marked with a B.

If for any reason you need to reschedule your first appointment, please contact the office at 575-556-9585 with at least 24 hours’ notice. Our office hours are 8-5 Monday through Friday.

As a reminder, A New Hope Therapy Center does not offer crisis services. We rely on and refer to our community crisis services as needed including:
* LC Cares Warm Line 575-527-9114 * Mobile Crisis 575-647-2800
* NM Crisis Line 855-662-7474 * Mesilla Valley Hospital 800-877-3500

Thank you and we look forward to working with you!
STATEMENT OF CLIENT RIGHTS, RESPONSIBILITIES AND INFORMED CONSENT
As a client of A New Hope Therapy Center you have the right:
1. To be treated with dignity and respect at all items.
2. To be given information about your rights and responsibilities relative to therapy services.
3. To receive timely response from A New Hope Therapy Center regarding therapy services.
4. To reasonable enjoyment of privacy and freedom of thought, conscience and religion.
5. To have your opinions heard and to be included, where possible and deemed therapeutically appropriate, in any decision made concerning your treatment.
6. To receive guidance, supervision and support.
7. To humane care.
8. To be protected from physical, emotional and sexual abuse, neglect and exploitation.
9. To review your clinical record at your request with your provider and legal guardian if applicable.
10. To be given information regarding anticipated transfer of services and/or termination of services.
11. To know the right of confidentiality. Information is held in the strictest confidence and will not be revealed without your written permission. Legal exceptions to confidentiality exist to protect you and others. The exceptions include:
1) If you threaten grave bodily harm to yourself or to another person, I am required to inform the necessary individual, the intended victim and others in order to prevent harm
2) If abuse, neglect of exploitation is suspected I am required to notify the centralized intake unit of the State of New Mexico Department of Health; Children, Youth and Families division; Protective Services Division
3) If a court of law issues a legitimate subpoena
12. To complete information, given in a way you can understand, about your treatment, including the risks and benefits as well as the cost of treatment.
13. The right to refuse treatment and an explanation of the risks involved.
14. To know the names, titles and professional qualifications of A New Hope Therapy Center staff members.
15. To file a Client Grievance.

As a client of A New Hope Therapy Center you have the responsibility to:
1. Give accurate, complete information concerning your past treatment, medications, allergies and other pertinent information.
2. Assist in developing and maintaining a safe environment
3. To give at least twenty-four (24) hours’ notice of need to cancel a scheduled appointment
4. Participate in the development and update of your plan of care
5. Adhere to your plan of care
6. Request information regarding anything you do not understand.
7. Give information regarding concerns, complaints and problems to Maria Laquerre, CEO, LMFT, RPT-S.

As a client of A New Hope Therapy Center you consent to and acknowledge:
1. I consent to receive calls, text messages, emails, faxes, from A New Hope Therapy Center for my protected healthcare and other services at the phone numbers below. I understand I may be charged for such communication by wireless carrier.
2. Computers and email communication have the potential to be accessed by unauthorized people and therefore could compromise the privacy and confidentiality of communication. Our computers are equipped with a firewall, a virus protection, and a password. If you communicate confidential or private information via email or via text, we will assume that you have made an informed decision, and will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters.
3. I hereby authorize A New Hope Therapy Center and its associates to use Doxy.Me or Google Meet as a means for telehealth psychotherapy. Doxy.Me and Google Meet are HIPAA compliant platforms for telecommunication.
4. I understand that I may revoke this authorization at any time by giving written notice, except to the extent A New Hope Therapy Center has already taken action in reliance on it. I may specify the date, event, or condition on which this consent expires. If none is stated, and if no prior notice of revocation is received, this consent will expire one year after the date it was initiated.
Typing your full name indicates consent and agreement: *
Today's Date *
MM
/
DD
/
YYYY
PAYMENT AND CANCELLATION POLICIES
Thank you for choosing us as your therapy provider. We are committed to providing you with quality and affordable care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have put together this payment policy for your review and agreement.

Insurance.
We participate in most insurance plans, including Medicaid. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

Co-payments and deductibles.
All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

Proof of insurance.
We must obtain a copy of your current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you will be responsible for the balance of a claim.

Claims submission.
We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

Coverage changes.
If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.

Nonpayment.
If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative care.

Missed appointments.
Our policy is to charge for missed appointments not canceled within 24 hours of your scheduled appointment time. These charges will be your responsibility and are required to be paid prior to continuing services. Please help us to serve you better by keeping your regularly scheduled appointment.

Cancellation and Missed Appointment Policy.
Our goal is to provide quality individualized care in a timely manner. "No-shows" and late cancellations inconvenience those individuals who need access to care in a timely manner. We would like to remind you of our office policy regarding missed appointments. This policy enables us to better utilize available appointments for our patients in need of services.

Cancellation of an Appointment.
In order to be respectful of the needs of other clients, please be courteous and call A New Hope Therapy Center or your therapist promptly if you are unable to show up for an appointment. This time will be reallocated to someone who is in need of treatment. If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely services
.
How to Cancel Your Appointment.
To cancel appointments, please call your therapist directly or the office at 575-556-9585. If you do not reach the therapist or the receptionist, you may leave a detailed message on our voicemail. If you would like to reschedule your appointment, please leave your phone number. We will return your call and give you the next available appointment time.

Late Cancellations.
A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24-hour advance notice.

No Show or Late Cancellation Policy.
A "no-show" is someone who misses an appointment without cancelling it in an adequate manner. A failure to be present at the time of a scheduled appointment will be recorded in your medical record as a "no-show." There will be a $50.00 No Show or Late Cancellation charge to be paid before your next appointment.

Payment options.
For ease of account reconciliation, we require keeping your credit or debit card on file as a convenient method of payment. Your card information is kept confidential and secure. Signing below indicates that you have read and agree to these terms.

Joint Custody/Responsibility.
We are happy to keep multiple cards on file to pay your deductible, copays or amounts owed. If you are splitting the cost of services for your child, for custody reasons, please note - we will not track who is responsible for the account balance, that is for you to track. If you do not pay at the time of service, the card on file will be charged. It is not our responsibility to track payments, only to collect at the time of service.

Payment Arrangements.
If you need alternate payment arrangements, those can only be done with our office staff. Please contact them for more details.

I have read and/or have been read my clients rights and responsibilities and have had any questions clearly explained to me. I understand my rights as a client and consent to treatment.
Typing your full name indicates consent and agreement: *
Today's Date *
MM
/
DD
/
YYYY
NOTICE OF PRIVACY PRACTICES
In 1996 the United States Congress passed the Health Insurance Portability and Accountability Act (HIPAA.) Among others, the Act applies to health care providers and hospitals; it is intended to standardize health care information as well as ensure privacy and security of patient information. As a result of this act, A New Hope Therapy Center would like to advise you of how we will protect the privacy of your medical record.

THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

WHO WILL FOLLOW THIS NOTICE:

A New Hope Therapy Center collects Protected Health Information (PHI) through interactions with you and your health care providers. Information is obtained through assessments, interviews, billing and other forms. PHI may be obtained in writing, in person, by telephone and electronically. Examples include: the collection of information such as your name, address, telephone number, social security number, date of birth, medical, education, developmental, and psychiatric histories, diagnosis, treatment provider identification and treatment information, financial responsibility and payment information and emergency contact information.

OUR COMMITMENT REGARDING PHI:

We understand that PHI about you and your health is personal. A New Hope Therapy Center is committed to protecting PHI about you. We create a record of the care and services you receive (Client Chart.) We need this record to provide you with complete and comprehensive care and to comply with certain legal requirements. This Notice applies to all of the records your care generates at A New Hope Therapy Center.

This Notice tells you about the ways in which we may use and disclose PHI about you. It also describes your rights and certain obligations we have regarding the use and disclosure of PHI.

We are required by law to:
* ensure that PHI that identifies you is kept private.
* give you this Notice of our legal duties and privacy practices with respect to PHI about you; and
* follow the terms of the Notice currently in effect.

HOW WE MAY USE AND DISCLOSE PHI ABOUT YOU:

The following categories describe different ways the law allows us to use and disclose PHI. Not every use or disclosure in a category will be listed. However, all of the categories in which we are permitted to use and disclose information will fall within one of these categories.

Permitted Use or Disclosure Without Your Authorization:

For Treatment.
We may use Protected Health Information (PHI) about you to provide you with therapy treatment or services.

For Payment.
We may use and disclose PHI about you to your insurance plan or other parties who help pay for your care.

More Restrictive State and Federal Laws.
The State law of New Mexico is sometimes more restrictive than the Health Insurance Portability and Accountability Act (HIPAA). State law is more restrictive when the client may be entitled to greater access to records than under HIPAA and when under state law the records are more protected from disclosure than under HIPAA. Certain federal laws also are more stringent than HIPAA. A New Hope Therapy Center will continue to abide by whichever law is more restrictive. The federal laws include applicable Internet privacy laws, such as the Children’s Online Privacy Protection Act and the federal laws and regulations governing the confidentiality of health information regarding substance abuse treatment. State law covers genetic and HIV testing and disclosure consents for those areas remain in place.

Appointment Reminders.
We may contact you to remind you about your appointment for therapy services.

Business Associates.
There may be some activities provided for our organization through contract with outside businesses. Examples include bookkeeping and collection agencies. Under such contracts, we may disclose your health information to these businesses to perform the job we have asked them to do. These contracts also require business to protect the health information we disclose to them.

Permitted Use or Disclosure With an Opportunity for You to Agree or Object

Individuals Involved In Your Care.
We may disclose PHI about you to a family member or friend whom you have appointed or who qualifies to be your decision maker according to New Mexico law. If you are not present or able to object, then we may use our professional judgment determine whether the disclosure is in your best interest.

Research.
We may use and disclose PHI about you for research purposes. We will only use and disclose your information for a research project if we obtain your permission or if the need to obtain your permission has been waived by a designated review committee that meets Federal requirements.

To Avert A Serious Threat to Health and Safety.
We may use and disclose PHI about you when necessary to prevent a serious threat to your health and safety or the health and safety of others. Disclosure will only be to persons who could help prevent the threat.

Use or Disclosure Permitted by Public Policy or Law Without Your Authorization

Military.
If you are a member of the armed forces, we may disclose PHI about you as required by military command authorities. We may also disclose PHI about foreign military personnel to the appropriate foreign military authority.

Workers Compensation.
We may disclose PHI about you for workers’ compensation or similar program to the extent necessary to comply with laws relating to workers’ compensation or other similar programs established by law. These programs provide benefits for work-related injuries or illness.

Public Health Risks.
As required by law, we may disclose PHI about you for public health activities. For example, we may undertake these activities:
To prevent or control disease, injury or disability;
To report child abuse or neglect
To notify the appropriate government authority if we believe a client has been the victim of abuse, neglect or domestic violence. We will only make this disclosure subject to certain requirements when mandated or authorized by law.

Health Oversight Activities.
We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure surveys. These activities are necessary for the government monitor the health care system, government programs, compliance with civil rights laws, and to improve client care.

Lawsuits and Disputes.
If you are involved in a lawsuit or a dispute, we may disclose PHI about you in response to a court or administrative order. We may also disclose PHI about you in response to a subpoena, discovery request, or other lawful process.

Law Enforcement.
We may disclose PHI if asked to do so by a law enforcement official:
* In response to a court order, subpoena, warrant, summons or similar process;
* To identify or locate a suspect, fugitive, material witness or missing person;
* About the victim of a crime, if under certain limited circumstances, we are unable to obtain the person’s agreement
* About suspected criminal conduct while under our direct care
* In emergency circumstance to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime

National Security.
We may disclose PHI about you to authorized federal officials for purposes of national security.

YOUR RIGHTS REGARDING PHI ABOUT YOU:
You have the following rights regarding PHI we maintain about you:

Right to Access, Inspect and Copy.
* You have the right to inspect and have copied PHI used to make decisions about your care, including clinical and billing records, but does not include some records such as psychotherapy notes.
* To inspect and have copied PHI used to make decisions about you, you must submit your request in writing to A New Hope Therapy Center. There will be a fee associated with the processing of your request.
* If you provide authorization to use or disclose PHI about you, you may revoke that authorization in writing at any time. If you revoke your authorization we will no longer use or disclose PHI about you for the reasons covered by your written authorization. We are unable to take back any disclosure we have already made with your authorization and we are required to retain records of the care that we have provided you.
* Under very limited circumstances, your request may be denied if a copy of the information would risk the health, safety, security, custody or treatment of you or others.

Right to Amend.
* If you feel that PHI we have about you is incorrect or incomplete, you may ask us to amend the information. If we do not agree to your request, we must tell you why. You have the right to request an amendment of your record for as long as the information is kept by or for A New Hope Therapy Center.
* To request an amendment to your record, your request must be made in writing and submitted to A New Hope Therapy Center. In addition, you must provide a reason that supports your request. We may deny your request for an amendment your record if it is not in writing or does not include a reason to support the request. We may deny your request if you request amendment to information that:
* Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
* Is not part of the records used to make decisions about you
* Is not part of the information which you are permitted to inspect and copy; or
* Is accurate and complete

Right to an Accounting of Disclosures.
You have the right to receive a list of the disclosures of you PHI. This list may not include all disclosures made. For example, we are not required to tell you we made disclosures for treatment, payment, or health care operations disclosures made prior to 2003 or disclosures you specifically authorized. To request this list, submit a request in writing to A New Hope Therapy Center.

Right to Request Restriction.
You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or in the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide emergency treatment. To request restrictions, make your request in writing stating: 1. The information you want to limit; 2. Whether you want to limit A New Hope Therapy Center use, disclosure or both and 3. To whom you want the limits to apply.

Right to Request Confidential Communications.
You have the right to request that we communicate with you about clinical matter in a certain way or at certain locations. Make your request in writing to A New Hope Therapy Center. We will accommodate all reasonable requests.

Right to a Paper Copy of the Notice.
You may ask for a paper copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this notice.

REVISIONS TO THIS NOTICE
A New Hope Therapy Center may revise this Notice periodically to reflect changes in our privacy practices. We reserve the right to make the revised or changed Notice effective for PHI we already have about you as well as for any information we receive in the future. We will post a copy of the current Notice in the locations where you receive services.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint to:
Maria Laquerre-Diego, CEO
A New Hope Therapy Center
715 East Idaho Suite 2B
Las Cruces, New Mexico 88001
Phone (575) 556-9585 Fax (575)-556-9456
Please provide as much information as possible so your complaint may be properly investigated. There can be no penalty for filing a complaint.

RECORDING POLICY
A New Hope Therapy Center is committed to protecting the confidential and proprietary information of their clients and the freedom of its employees to communicate without the fear of being secretly recorded without their consent. Many state laws also prohibit the audio recording of others without the consent of all those participating in the conversation and many clients prohibit smart phones in work areas.

Therefore, in order to maintain confidentiality with all information and records, no person, including but not limited to, A New Hope Therapy Center employees, visitors, clients, contractors, or a representative acting on behalf of A New Hope Therapy Center, should record conversations of another without his or her prior knowledge and consent. Recordings include audio and/or video, by any means including smart phones. The devices used to record via audio or video that are prohibited are inclusive of, but are not limited to, phones, voice recorders of any kind, video cameras of any kind, and microphones.

Any individual requesting to record via audio or video any interaction with any persons associated with A New Hope Therapy Center, will need to inform A New Hope Therapy Center CEO of their intention and obtain authorization. A New Hope Therapy Center CEO reserves the right to refuse such request, in their sole discretion. Furthermore, all A New Hope Therapy Center employees and contractors may refuse to be recorded and at such time may end the conversation if the asking party refuses to speak without a recording device.

A New Hope Therapy Center Staffing and their clients reserve the right to install and use security cameras for the purposes of safety and monitoring worker performance. However, nothing in this policy is intended to prevent A New Hope Therapy Center employees from making recordings for concerted activity purposes or as otherwise protected by law.

A violation of this policy may result in disciplinary action, up to and including immediate termination of services.
Typing your full name indicates consent and agreement: *
Today's Date *
MM
/
DD
/
YYYY
Treatment Agreement
We, the parents of the minor child named are bringing our child to A New Hope Therapy Center for therapy. We understand that the purpose of this therapy is to provide a neutral professional with whom our child can talk openly about personal difficulties. We understand that in order for a child to benefit from these sessions, they must be private and confidential. In order to protect this confidentiality, we agree to the following rules and expectations:

1) The sessions between our child and the Therapist will be confidential under the same rules that apply in adult psychotherapy as described in the Ethical Standards for Professional Counselors.
2) Neither of us will ask the Therapist to participate in any court proceedings regarding custody, time-sharing or other Family Court matters regarding our child.
3) We will not submit the Therapists name as a witness in any such proceeding, nor ask that he/she be subpoenaed. We understand that A New Hope Therapy Center will quash any subpoena and request legal fees for any costs involved in this attempt.
4) A release of information to provide treatment by another professional must be signed by both of us, and will be honored by A New Hope Therapy Center only if the child’s confidentiality will be maintained.
5) We understand that the Therapist will inform us only of the following:
a. Information leading to a suspicion that a child is being abused or neglected, that is, subject to unfit care by a parent or other adult. Such information will be referred to the New Mexico Children, Youth and Families Department for investigation, as required by law.
b. Information that the child is a danger to herself/himself/themselves or to others.
c. Information that the child has been brought to sessions, when and by whom.
d. Information that the child agrees that the Therapist should reveal to one or both parents, and that the Therapist believes is in the best interests to reveal.
6) We further agree to support the confidentiality of the sessions by not asking the child the about the content of their sessions, and by saying that it is not necessary to reveal such information if brought up voluntarily.
Typing your full name indicates consent and agreement: *
Today's Date *
MM
/
DD
/
YYYY
Next
Never submit passwords through Google Forms.
This form was created inside of A New Hope Therapy Center. Report Abuse