Minor Client Information Form - Centerpoint Counseling Page 4
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4Client/Child Name: ______________________________
Therapist:_______________________
Insurance for Mental Health Services- CenterPoint Counseling
Insurance Considerations: The filing of an insurance claim requires that we provide a diagnosis to your
insurance company. There have been occasions when a clinical diagnosis to your insurance has resulted in
persons experiencing difficulty in obtaining life, medical or disability insurance.
Insurance Information: There are numerous insurance companies that offer mental health benefits as part of
their coverage. We suggest you check with your insurance provider to determine the requirements for
insurance coverage. Your insurance company will want to know the credentials of the Provider of Service. You
will want to ask your insurance company about deductible requirements, authorization requirements,
percentage of co-payment, number of sessions per year and “In-Network” vs. “Out-of Network” benefits.
Contracting with insurance companies is the decision of each individual therapist. CenterPoint Counseling will
be glad to assist you by providing and filing the necessary information for insurance reimbursement. Be aware
that if you are seeing a provider who is not licensed or out-of network, filing for insurance may not be an
option and efforts to obtain reimbursement are provided as a courtesy. You are ultimately responsible
for any charges not covered by insurance for any reason.
Insurance Pre-Certification/Authorization of Services: Many insurance companies now require pre-
authorization of services. Please know that it is your responsibility to obtain authorization of services for an
out-of-network provider if needed. You will be responsible for any charges not covered by insurance due
to lack of precertification/authorization for an out-of-network provider.
Medicare/Medicaid Considerations: Please be aware that CenterPoint Counseling and its contracted
therapists are not approved providers through Medicare or Medicaid. Therefore, CenterPoint will not file any
claims on your behalf to these entities. If you have supplemental Medicare coverage, we will attempt to help
you file for reimbursement as a courtesy. However, you are ultimately responsible for any charges not covered
for any reason.
Insurance With Regards To Our Cancellation Policy: We understand that illness and other unforeseen
events are inevitable. Therefore, CenterPoint Counseling grants one missed appointment as a show of grace.
After the first missed appointment, cancellations received with less than 24 hours notice will be charged a $50
missed appointment fee. Unfortunately, because missed appointments cannot be billed to insurance, you
are responsible for the full cost of this fee. Please discuss situations with your therapist that you think
warrant further consideration.
Authorization to Release Information: If I choose to file with insurance, I authorize CenterPoint Counseling
to release my clinical diagnosis, prognosis and treatment request information acquired in the course of my
examination or treatment to my insurance carrier. I am also aware that payment is ultimately my responsibility
and should my insurance fail to pay for services for any reason, I am required to pay CenterPoint Counseling
for services and reconciling with insurance is my responsibility.
Do you plan to file for possible insurance reimbursement?
____Yes
____No
(If yes, a copy of your insurance card must be provided)
I have read and understand the policies of CenterPoint Counseling provided in this document as it relates to
filing insurance for mental health services.
Parent/Guardian Signature ___________________________________________Date____________________
Parent/Guardian Signature __________________________________________Date_____________________
(If Applicable)
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