• Alba Wellness, Inc. Intake Form


    _____________________________________________
    Counseling – Transformation – Empowerment
    433 Kitty Hawk Rd. Suite 219 Universal City, TX 78148
    Phone (210 ) 566-1280 | Toll Free (855) 566-ALBA | Fax (210) 566-1289

  • Therapy Agreement

  • By signing this form, I understand and agree to the following fee schedule. I am responsible for the applicable service fees, if insurance does not pay.

  • LPC 60 min. Intake (initial assessment)
    LPC 45 min counseling
    LPC 30 min brief therapy
    LPC 60+min extended counseling
    LPC 60+min family/couples counseling
    LPC 45 min family/couples counseling
    LPC 15 min phone consultation
    LPC Group therapy (45-60 min)
    LPC legal/court rate
    Late cancellation(less than 24hr)/no show
    LPC intern 60min Intake (initial assessment)
    LPC intern 45min counseling
    LPC intern 30min counseling
    LPC intern 60+min family/couple counseling
    LPC intern 45min family/couple counseling
    LPC intern 15min phone consultation
    LPC intern legal/court rate
    Medical records/rsch/letters/reports (for simple reports and letters only)

  • $115.00
    $85.00
    $65.00
    $145.00
    $115.00
    $85.00
    $40.00
    $50.00
    $150
    $50.00
    $60.00
    $45.00
    $30.00
    $60.00
    $45.00
    $15.00
    $150.00
    $25.00 (for simple reports and letters only)

  • At AWI, we attempt to balance the client’s wellbeing with the need to create a comfortable working environment. It is a simple reality that there are times when life is challenging and paying for services is difficult. Our process for addressing this concern is as follows:

  • a. Client may qualify for a fee on a sliding scale.
    b. Client may see an intern for a reduced rate.
    c. Client may be considered a “pro bono” case.
    d. Client may be given

  • Insurance Information

  • By signing this intake form, I acknowledge that all the information above is correct to the best of my knowledge and I assume responsibility for charges not covered by insurance.

  • Cancellation Policy Details

  • Alba Wellness, Inc. Intake Form


    Cancellation Policy
    _____________________________________________
    Counseling – Transformation – Empowerment
    433 Kitty Hawk Rd. Suite 219 Universal City, TX 78148
    Phone (210 ) 566-1280 | Toll Free (855) 566-ALBA | Fax (210) 566-1289

  • Notice of Cancellation and No-show Policies

  • We understand that situations arise in which you must cancel your appointment. Therefore, it is requested that you must provide more than 24 hours notice to cancel or reschedule your appointment. This allows another person waiting to schedule in that appointment slot. Office appointments which are canceled or rescheduled with less than 24 hours notification are subject to a $50.00 cancellation fee. Patients who do not show up for their appointment without a call to cancel are considered as no show and subject to a $50 fee as well. Patients who No-Show twice in a 12 month period, are denied any future appointments unless no show fees are paid in full. If client cannot pay the fees, they are provided referrals to other agencies. The Cancellation, Reschedule, and No Show fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment. Our practice firmly believes that a good counselor/client relationship is based upon understanding and good communication.

    Thank You
  • Credit Card Details

  • Alba Wellness, Inc. Intake Form


    Credit Card Information
    _____________________________________________
    Counseling – Transformation – Empowerment
    433 Kitty Hawk Rd. Suite 219 Universal City, TX 78148
    Phone (210 ) 566-1280 | Toll Free (855) 566-ALBA | Fax (210) 566-1289

  • Required Credit Card Information

    We require credit card information in order receive services. Please fill out this portion, and note that in the unlikely event there is a late cancel or no show we will charge this card $50 as indicated on the service fee portion of this document. You will be provided a receipt upon request.

  • By signing this intake form, I acknowledge that all the information above is correct to the best of my knowledge.

  • Details of Statement of Informed Consent

  • Alba Wellness, Inc. Intake Form


    Intake Form
    _____________________________________________
    Counseling – Transformation – Empowerment
    433 Kitty Hawk Rd. Suite 219 Universal City, TX 78148
    Phone (210 ) 566-1280 | Toll Free (855) 566-ALBA | Fax (210) 566-1289

  • Statement of Informed Consent

    Upon entering into a counseling relationship, there are specific rights you should be aware of before consenting to treatment. Please review this document carefully and feel free to ask any questions you may have about its’ contents.

    Purpose, goals, and techniques

    Counseling is a professional relationship that empowers individuals to accomplish mental health, wellness, education, and career goals. To this end, your therapist will partner with you to identify specific problems you choose to address and help you develop solutions. This process involves discussions and activities identified by you and your therapist that explore the connections between your thoughts, emotions, and behaviors.

    Potential Risks of Counseling

    The discussion of sensitive issues may be part of the process and may put you in the position to experience some uncomfortable emotions/thoughts, as well as, face painful decisions about your life. Together you and your therapist will work through these thoughts and feelings

    Right to appropriate referrals

    You have a right to request referrals to other mental health professionals at any time. Your therapist is obligated to provide these referrals when:

    • Either you or your therapist determine, either individually or collaboratively, that the services provided are not meeting your needs.
    • When your needs are outside the therapist’s scope of practice
    • When you request referrals for any reason

    Provider Consultation

    Mental Health Professionals regularly seek consultation with their colleagues to ensure the highest quality of therapy for the clients and to analyze personal biases. Despite the extra expense to the therapist for this consultation, it is essential to maintain the highest standards for your care. All legal and ethical confidentiality laws and standards apply during these professional consultations.

  • Records

    Your medical records are property of Alba Wellness. Individual clients, legal guardians, and parents have a right to request copies of records. In cases, in which, a couple or a family is seen by a therapist, all adults have a right to those parts of records that pertain to themselves as a client (as well as a right to their children’s records). This does not mean that the individual has a right to the information in the record regarding the other partys. You may be given a copy upon request for a fee of $25.

    Right to Terminate Therapy

    While therapists strive to partner with clients to address important issues, there are understandable circumstances in which a client may need to terminate therapy. In most circumstances, you and your therapist will work together to determine when therapy should come to an end and how to make that transition as easy as possible. However, should you decide at any point to terminate this relationship it is your right to do so.

    Termination

    I understand that after the final session or in the event that I have not attended a therapy session in three months, the client/therapist relationship will be considered closed unless I initiate further contact. I further understand that I can reinitiate therapy after my case is closed.

    Rights of Confidentiality (limits of confidentiality)

    All information discussed in sessions is completely confidential, unless specified in writing on the Consent for the Release of Information form. There are three (3) conditions under which confidentiality is breached. These are:

    • Situations involving child or elder abuse

    • Situations involving abuse or exploitation of the disabled
    • 
    • Situations in which a client expresses suicidal/homicidal thoughts, plans, and a willingness to carry out those plans

    In situations when child or elder abuse is reported, it is our legal responsibility and policy to contact the appropriate state and local agencies. This requirement also extends to situations where there is reported exploitation or abuse of the disabled. Suicidal or homicidal thoughts when connected to a plan to carry out such actions, and a clear intention to follow through with such a plan legally require us to notify local crisis responders.

  • Adult Protective Services
    Child Protective Services
    San Antonio Police Department 911 or Non emergency (210)
    Universal City Police Department 911 or non emergency (210)
    Bexar County Sheriff's Department 911 or non emergency

  • 1(800)252-5400
    (800)252-5400
    207-7273
    658-5353
    (210) 335-6000

  • As outlined in the Alba Wellness Privacy Practices, insurance companies can request your medical records as part of treatment reviews and verification of services provided by an Alba Wellness Inc. provider. By signing below, I agree that I have read and understand the above information.

  • Notice of Privacy Practices

  • Alba Wellness, Inc. Intake Form


    _____________________________________________
    Counseling – Transformation – Empowerment
    433 Kitty Hawk Rd. Suite 219 Universal City, TX 78148
    Phone (210 ) 566-1280 | Toll Free (855) 566-ALBA | Fax (210) 566-1289

  • Notice of Privacy Practices

    You may find the Privacy Practices of Alba Wellness in the waiting room or online at www.albawellness.net. My signature below indicates that I have been informed where the Notice of Privacy Practices can be viewed. If you have any further questions, please ask a member of our staff or email us at info@albawellness.net.