James M. Reinach, LMHC, CAP, SAP

Congratulations on your decision to begin counseling. Please take a few minutes and read and fill out the online form below. The therapy session will be 45-50 minutes in length. Please be aware that I will make every effort to be available at your appointment time. Thank you.

Client Information

Full Name
      Email   
Address
City
      State          Zipcode   
Home Phone
      Work Phone          Cell Phone   
Age
      Date of Birth          Sex   
SS Number
      Education      (Last grade completed) 
Marital Status
Occupation
      Company   
Emergency Contact
      Relationship   
Home Phone
      Work Phone          Cell Phone   

Billing Information

Insurance Company
Address
Phone Number
     This insurance policy lists you as
Relationship
Primary employee’s name (if different from Client)  
SS Number
      Employer   
Member ID or Policy Number     You were referred by  

Procedure for Telephone Contact

Please note that it is sometimes necessary to notify you of a change in appointment time. Please be assured that your confidentiality is very important at these times and if you cannot be reached a message will be left with only a first and last name and phone number.


 

Notice of Therapist Availability

Please be advised that I am not available at all times. I will attempt to return phone calls in a timely manner for brief conversations between sessions when needed.

In the event that you cannot reach me at any given time (day, evening, weekend, holiday) and you feel it is an emergency, go to any emergency room for a psychological consultation, or call 911. Keeping yourself safe is your responsibility and if you are unable to do this you must contact me, your Primary Care Physician, or 911.

I agree

Agreement for Service/Informed Consent

  1. I have chosen to receive psychotherapy services. My choice is voluntary and I understand that I may terminate at any time.
  2. I understand that there are no assurances that I will feel better. Because psychotherapy is a cooperative effort between me and my therapist, I will work with the therapist in a cooperative manner to resolve my difficulties.
  3. I understand that during psychotherapy, material may be discussed which will be upsetting in nature and that this may be necessary to help me resolve my problems.
  4. I have read and had explained to me the basic rights of an individual receiving mental health treatment. These rights include:
    • The right to be informed of the various steps and activities involved in receiving services.
    • The right to confidentiality under federal and state laws relating to the receipt of services.
    • The right to make an informed decision whether to accept or refuse treatment
  5. I understand that each individual appointment is scheduled for approximately 45-50 minutes. If I am unable to keep the appointment, I will call Jim Reinach at (813) 251-2922 to cancel twenty-four hours before the appointment.
I agree

Financial Responsibility

I, , understand that I am responsible for any service rendered, regardless of whether this service is covered by insurance. I further understand that it is my responsibility to give James M. Reinach 24 hours notice if I am going to cancel my appointment. Failure to notify may result in a charge commensurate with the total session fee, up to $50.00.
I agree

Consent For Use And Disclosure Of Health Information

SECTION A: CLIENT GIVING CONSENT
Name
Address
Phone
Date Of Birth
SECTION B: TO THE CLIENT — PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

James M. Reinach, LMHC, CAP, SAP
806 West DeLeon Street, Suite 101
Tampa, FL 33606-2731
Phone: (813) 251-2922
Fax: (813) 886-1332

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to James M. Reinach, LMHC, CAP, SAP at the address above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I, , have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.
I agree

Notice Of Privacy Practices

I, , have been provided a copy of this office's Notice of Privacy Practices.
I agree
Yes, I would like to receive a copy of this form at this email address: