Kentucky Counseling Center Intake Forms


Louisville, Lexington, Richmond, Frankfort, Covington, or London




Client Information

Full Name

Home Address on File with Insurance




SS #


Emergency Contact Name and Number



Insurance Company

Medicaid ID

Member ID



Insurance Company

Name and DOB of Policy Holder

Relationship to Client


Member ID

Group Number


Annual Deductible


Please complete this form if you would like our office to be able to communicate with your PCP



Client’s Name



I give Kentucky Counseling Center and my PCP office, listed above, permission to share my private health information with each other. This consent does not expire until I submit written request to terminate communication

 T A R G E T E D  C A S E  M A N A G E M E N T



Case Management provides community based assistance to Medicaid clients only; let us assist with your food, housing, transportation, legal, employment, educational, and various other needs. Many people are afraid to ask for help and we understand. We specialize in helping people find the supports they need to get their lives where they want it to be. We can meet you in your home, our office, or in the community to work towards your goals.


Once you’re signed-up for Case Management services, you will be contacted by your Case Manager within 48-hours. You will complete a short intake meeting, and then meet 2x per month. Most times your case manager will make sure to see you when you’re already in the office for therapy or medication, but they also work in-home, in the community, and in schools.

Do you want a Case Manager?


By signing this form, you agree to receive mental health services provided by Kentucky Counseling Center, LLC, and its independent contractors. We know that starting counseling is a big decision and you may have many questions. We will do our best to answer any questions or concerns. This form explains information about KCC policy, State and Federal Laws, and your rights about counseling. All KCC employees and contractors have met the highest level of education, certification, and licensing requirements set forth by Kentucky state law. Counseling practices, philosophy and plan limitations and risks will be discussed with you today.


It is the mental health professional’s responsibility to keep accurate records including Evaluations, Treatment Plans, and Progress Notes. By signing this document, you are consenting to the Treatment Plan that your provider creates and agree to any goals, objectives, and therapy techniques that may be used in your therapy process.


If you plan to use insurance to pay for services, claims will be sent to the insurance company based on information used at the time of service. Sometimes, insurance information may change or may not be up to date. If for any reason, inaccurate information related to deductibles, co-pays, or number of available sessions, etc. is retrieved at the time of service, KCC will bill the client for any additional costs associated with mental health services rendered. Additional services may not be provided until the client’s balance is current. If balances remain unpaid for 60 days, client information will be sent to a collection agency.

MISSED APPOINTMENT FEES Appointments will be cancelled and $25.00 fee will be assessed if client is 15 minutes late without notice. If client cancels appointment without a notice greater than 24 hours, KCC will charge the client $25.00. 

RETURNED CHECK FEE If your check is returned, your account will be assessed a $35.00 fee.

CREDIT CARD PAYMENTS You may choose to have KCC store your credit card information for future bills you may incur. Should you do so, KCC will automatically process all outstanding balances one time per month and will not provide any additional warning other than what is written in this section of the Informed Consent form.

CONFIDENTIALITY AND EMERGENCY SITUATIONS: Confidential information discussed in session is not discussed with anyone without your written permission except for:

1. Diagnosis and dates of service shared with your insurance company to process your claims

2. Information you tell KCC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services

3. Where you sign a release of information to have specific information shared

4. If you tell KCC you are in danger of harming yourself or others

5. Information shared with therapist’s clinical supervisor if applicable

6. When required by law.

If you need to contact us between counseling sessions please call 855-591-002. E-mail, text messages and social networking sites are not confidential and we may not be able to respond. In the event of an emergency please call 911.

Do you agree that you have read and accept our informed consent policy?


Right to request how we contact you

It is our normal practice to communicate with you at your home address and daytime phone number you gave us when you scheduled your appointment, about health matters, such as appointment reminders etc. Sometimes we may leave messages on your voicemail. You have the right to request that our office communicate with you in a different way.

Right to release your medical records

You may consent in writing to release your records to others. You have the right to revoke this authorization, in writing, at any time. However, a revocation is not valid to the extent that we acted in reliance on such authorization.

Right to inspect and copy your medical and billing records

You have the right to inspect and obtain a copy of your information contained in our medical records. To request access to your billing or health information, contact the office manager. Under limited circumstance we may deny your request to inspect and copy. If you ask for a copy of any information, we may charge a reasonable fee for the costs of copying, mailing and supplies.

Right to add information or amend your medical records

If you feel that information contained in your medical record is incorrect or incomplete, you may ask us to add information to amend the record. We will make a decision on your request with 60 days, or some cases within 90 days. Under certain circumstance, we may deny your request to add or amend information. If we deny your request, you have a right to file a statement that you disagree. Your statement and our response will be added to your record. To request an amendment, you must contact the office manager. We will require you to submit your request in writing and to provide an explanation concerning the reason for your request.

Right to an accounting of disclosures

You may request an accounting of any disclosures, if any, we have made related to your medical information, except for information we used for treatment, payment, or health care operational purposes or that we shared with you or your family, or information that you gave us specific consent to release. It also excludes information we were required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submit your request in writing to the Privacy Officer. We will notify you of the cost involved in preparing this list. Right to request restrictions on uses and disclosures of your health information. You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to our office manager. However, we are not required to agree to such a request.

Right to complain

If you believe your privacy rights have been violated, please contact us personally, and discuss your concerns. If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individual will not be retaliated against for filing such a complaint.



Kentucky Counseling Center, LLC has been and will always be totally committed to maintaining client confidentiality. We will only release healthcare information about you in accordance with federal and state laws and ethics of the counseling profession.

This notice describes our policies related to the use and disclosure of your healthcare information.

Your health information may be used for the purposes of providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allows us to use and disclose your health information for these purposes.

TREATMENT We may need to use or disclose health information about you to provide, manage or coordinate your care or related services. Which could include consultants and potential referral sources.

PAYMENT Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. We may bill the person in your family who pays for your insurance.

HEALTHCARE OPERATIONS We may need to use information about you to review our treatment procedures and business activity. Information may be used for certification, compliance and licensing activities. There are some instances where we may be required to use and disclose information without your consent. For example, but not limited to: Information you and/or your child or children report about physical or sexual abuse: then by Kentucky State Law, we are obligated to report this to the Department of Children and Family Services; If you provide information that informs us that you are in danger of harming yourself or others, we must report this also; Information may be used to remind you of /or to reschedule appointments or treatment alternatives; Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order; Clinical records, psychotherapy notes and other disclosures require a separate signed release of information. You have a right to or will receive notification of a breach of any unsecured personal health information. You have a right to restrict any disclosure of personal health information where you have paid for services out-of-pocket and in full.

METHOD OF CONTACT BY OFFICE We may send you appointment reminders by text message or phone call and leave a voice message.

I have read and received a copy of the Notice of Privacy Practices and Client Rights document

Consent to Release Information

I consent for Kentucky Counseling Center, LLC and those representing this group to share my private health care information with the following individuals and/or entities. KCC is permitted to send and receive information to and from the entities below if needed:


I understand that I have the right to revoke this authorization, in writing, at any time by sending notice to Kentucky Counseling Center, LLC. I understand that a revocation is not valid to the extent that Kentucky Counseling Center, LLC has acted in reliance on such authorization. This authorization does not expire until I submit a written request. A copy of this release shall have the same force and effect as the original.

NOTICE TO RECEIVING PROVIDER OR ORGANIZATION: You may not re-disclose any of this information unless the person who consented to this disclosure specifically consents to such re-disclosure.

I understand that there is a potential for disclosure of this information by the recipient and, if that occurs, federal law may not protect the information.





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Document name: Kentucky Counseling Center Intake Forms
Unique Document ID: 18a67866e9e0af1dc0ad85eed5a86eac92ee38dc
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September 3, 2018 11:22 pm ESTKentucky Counseling Center Intake Forms Uploaded by Matt Grammer - IP
November 14, 2018 6:54 pm ESTAmy Hale - added by Matt Grammer - as a CC'd Recipient Ip: