Please print this form. Complete the form and bring it with you to your initial visit with Ms. Gleason, at

Boerne Counseling and Consultant Service. Directions to the facility are found in section: Driving Directions

                                         CLIENT INFORMATION-REGISTRATION

 PATIENT NAME ___________________________ DATE _____________________, 20____

DATE OF BIRTH ____/____/________ AGE ____ yrs. TEL (____) _____-________  message __

SOCIAL SECURITY NUMBER ______-_____-_______ DL & ST __________________- _______  

HOME ADDRESS ________________________________________ ZIP CODE ____________

EMPLOYER  & ADDRESS ______________________________________ HOW LONG _______

SCHOOL & CITY _____________________________TEL (____) _____-________Grade _____

CURRENT MEDICATION*

Name: ____________________ Dose: _________   Name: _________________Dose: ________   

Name: ____________________ Dose: _________   Name: _________________Dose: ________ 

Name: ____________________ Dose: _________   Name: _________________Dose: ________

PRIMARY CARE PHYSICIAN* ________________________________T (___) _____-_________

LIST CHRONIC HEALTH ISSUES*__________________________________________________

CURRENT MENTAL HEALTH DIAGNOSES*___________________________________________

CURRENT STRESSORS _________________________________________________________

GOALS FOR THERAPY* _________________________________________________________

___________________________________________________________________________

PREVIOUS THERAPY ~ NAME of THERAPIST _________________________________ Helpful  Y  N

WHO MAY WE THANK FOR THE REFERRAL __________________________________________

RESPONSIBLE PARTY (if different from above)

NAME _____________________________ GENDER __ M __ F   RELATIONSHIP ______________

DATE OF BIRTH ___/___/_______ AGE _____  EMPLOYER ______________________________

HOME ADDRESS _______________________________________________________________

                                             Number and Street                                City & State                                        Zip Code

TEL H (____) _____-________ CELL (____) _____-________ TEL W (____) _____-________          

                                                                                                    -   -   -   -

IN CASE OF EMERGENCY NOTIFY (if other than above)

NAME _______________________________ RELATIONSHIP ________________ Gender _ M _ F

DOB ____/____/_______ TEL (____)_____-_______ ADDRESS _______________________________  

PRIMARY INSURANCE  Have you pre-certified any visits?   __ Y __ N __ Unsure

Insured’s Name ____________________________ Date of Birth ___/___/______ Gender __ M __ F

Social Security No. _____-____-______ ID Number ____________________Group Number ____________

Insured’s Employer ________________________ Employer Address _____________________________

Carrier ___________________Tel (___) ____-______ Claims Address: ___________________________  

SECONDARY INSURANCE (IF ANY) 

Insured’s Name _____________________________ Date of Birth _____/_____/_________ Gender  M  F

Social Security # ______-_____-________ ID Number ___________________Group Number _____________

Insured’s Employer __________________________ Employer Address ______________________________

Carrier ___________________Tel (___) _____-________ Claims Address: ___________________________  

PAYMENT AGREEMENT

I AGREE TO THE FOLLOWING PAYMENT PLAN TO COVER MY PORTION OF THE CHARGES:

_________ I do not have insurance and will pay in full at the time of service.

_________ I will file my own insurance and will pay in full at the time of service.

_________ Please conduct a courtesy billing to my insurance. The reimbursement for services will be directed to me.     

I understand that if problems arise in obtaining payments to practitioner/ therapist from my insurance company, 

I will be responsible to pay the balance of the bill and settle with my insurance carrier unless the practitioner/ therapist 

has otherwise contracted with my insurance company. Furthermore, I agree to pay off any balance on my account 

within 30 days unless I have made other arrangements with practitioner/ therapist. I understand that my account 

may be sent to a collection agency if I do not pay my bill according to this document. If use of a collection agency is 

necessary I will be charged a 10 % Interest Fee on the balance of my account in addition to a $25 collections fee.         

Responsible Party Signature ____________________________ Date ___________________, 20___                          

MEDICAL RELEASE OF INFORMATION

I authorize release of information to Kathleen Gleason LPC-S ~ Boerne Counseling and Consultant Service,

to share my information with referral sources for the purpose of diagnosis, treatment, consultation, 

and professional communication. I release information to the following peron(s) or agency/business:

1. ________________________  2. ________________________ 3. _______________________

If I am an insured client, I further authorize the release of information for claims, certification, case management,

quality improvement benefit administration and other purposes related to my health plan. 

I understand that this medical release of information is valid from one year of the signature date.                  

Signature __________________________ Signed on the ___ day of ____________________, 20 ___

                                                                                            -   -   -   -

FINANCIAL TERMS/ FEES

INSURANCE COVERAGE                                                                              □ N/A

You are responsible for obtaining prior authorization for treatment from your insurance carrier. We can conduct a 

courtesy billing upon request. Thus, reimbursement for services will be directed to you. If your insurance accepts 

us as an in-network or out-of-network provider you are responsible for co-payment amounts, deductibles and full 

payment fees.                                                                        Initial here: _____           

FEES 

            Additional costs incurred for additional time 

Initial Visit: $160/ 60 minutes

Individual Therapy: $145/ 50 minutes; $175.00/ 60 minutes

Two or more Individuals: $175/ 50 minutes

Family Therapy: $200/ 50 minutes

Drug and alcohol classes: $200.00-Initial Evaluation; $135 per class-6 week series with Certificate

Letter or Report Preparation: $450.00

Texts/ Emails: $ 15.00  (message via text or e-mail unauthorized by therapist)

Legal Testimony: $1100.00 ½ day, PLUS per diem, travel and mileage expenses

The retainer of $1100.00 must be paid in cash, one week in advance

Court: $ 375.00 per hour with a minimum of (3) hours. Payment must be made within one week of the slated 

court date                                                                                                                                                     Initial here _____

SAME DAY CANCELLATION/ MISSED APPOINTMENTS  $135.00

Scheduled appointment times are reserved especially for you. Late day and evening appointments are in high demand.

If an appointment is missed or canceled with less than 24 hours notice, you will be billed according to the scheduled fee. 

Missed appointments are not covered by your insurance and the charges associated with them are your responsibility. 

Repeated "no-show" appointments or “same day” cancellation could result in referring you to another practitioner. 

I acknowledge and agree with the above fees.                                                                                       Initial here: ______                        

RETURNED CHECK POLICY

A $50.00 fee will be assessed in addition to the bank charge, the amount of check and other incurred fees. It is the 

responsibility of the patient to pay this fee. Non-payment of returned checks will result in filing with the Kendall

County Prosecutor's Office and sanctions may apply.  Initial here: ______

EMERGENCY ACCESS

After-hour calls are to handle emergencies ONLY. A $25.00 fee for the first 5-minutes and an additional $5 charge

for every 5 minute increment for telephone consult. This is the patient's responsibility.         Initial here: ______

I have read and agree to the Financial Terms and Fees as indicated above.        

                                                                                                                                                                        Initial here: ______