5524 So. Emerson Avenue
Indianapolis, IN 46237
(317) 781-1917
 

Application - Couples Therapy

INSTRUCTIONS: Please read all sections, then fill out the form as completely and accurately as possible. Provide your initials where requested to confirm your understanding and acknowledgement of my policies. Then submit the registration form when you are finished and I will respond as quickly as I can.

Welcome

I appreciate the investment you are making in turning to me for counseling. Starting treatment feels awkward for many people who have not been in counseling before. I’d like to assure you that any apprehension you might have at the outset is understandable, but that in all likelihood you will find the initial interview to be interesting and even pleasant. My goal is to help you understand and develop practical solutions to the emotional, interpersonal or family problems which brought you to me. I feel responsible for giving clear and concrete suggestions in a timely manner and I firmly believe that counseling does not have to be a prolonged or painful process.

Appointments and Availability

In light of the Coronavirus outbreak, I am currently offering counseling and diagnostic services exclusively via video conference. I routinely schedule appointments between 1:30 PM and 6:30 PM Tuesday through Friday. Appointments typically last 45 to 50 minutes. I can generally be counted on to start on time.

I answer my own phone and schedule my appointments personally. If I happen to be on the phone or with a client when you call, you’ll be asked to leave a message. Outside of office hours you can also leave non-urgent messages on the office voicemail (317-781-1917).

In the event of an actual emergency I am at your service 24 hours a day. Outside of office hours you should call me directly at my home (317-783-2399). You will get instructions for contacting me on my cell phone if I am not home when you call. For more routine matters, such as for rescheduling an appointment, please call the office and leave a message. I usually return such calls on the next business day.

Cancellations

On the rare occasion that an emergency or other unforeseen circumstance arises, and I need to cancel or change an appointment we have scheduled, I will notify you as soon as possible. In the event that I am unable to do so with at least 24 hours-notice, I will credit your account $45. If you have to cancel an appointment with less than 24 hours’ notice, I will charge you a Late Cancellation Fee of $45. Insurance does not pay for cancellation fees.

Please initial below to acknowledge your recognition and agreement of the $45 cancellation fee due when notice is given less than 24 hours prior to your appointment.

I agree:

Fees and Insurance

For those who have insurance coverage my fees are specified at varying rates in numerous contractual agreements. Your cost will depend, in turn, on the terms of your policy, which may specify that you are responsible for paying some or all of the cost of your services due to co-payments or unmet deductibles. You can find out more about your specific coverage by contacting the Customer Services number on your insurance card.

Confidentiality

In the interest of providing competent psychological services at reasonable rates I limit my routine record keeping procedures to the professionally responsible minimum. This allows me to spend more time directly serving you and less time on paperwork. In my experience there is rarely any legitimate need for other health professionals to request records regarding my patients’ treatment, especially when no psychiatric medications are involved. If for any reason you would like a written summary of your treatment sent to another professional, I would be happy to prepare a narrative at the time of your request.

Generally speaking, the confidentiality of your records is assured by state and federal law and cannot be released without a written authorization from you. Other State laws may override confidentiality and mandate that critical situations be reported to governmental agencies in the following specific cases: 1) if a patient expresses a serious intention to harm himself or others, or 2) if there is a substantial concern that children, or the elderly are being abused or neglected.

Apart from the mandatory reporting laws, confidentiality may be compromised if you are involved in litigation. If the Court becomes aware that you have been in counseling and finds that to be pertinent to the legal proceedings (e.g., child custody disputes, etc.) then the release of your records could be ordered by the Court. Also, in the event of non-payment of fees, after reasonable efforts to collect an outstanding debt have failed, I would turn the balance due over to a commercial agency for collection as an outstanding “medical expense” under the name of the patient or the responsible party.

Video Conferencing-Based Counseling

The security controls for the video conferencing platform I am utilizing are as secure as any in the industry. You are welcome, even encouraged, to record our sessions. I simply request that you obtain my permission before beginning the recording. For a list of common-sense considerations regarding online sessions, please refer to the American Psychological Association’s recommendations which are found on my website, JohnGallagherPhD.com, under Patient Information/Informed Consent.

If you have any questions or concerns regarding any of the information presented here, please bring them to my attention. I will be happy to discuss them with you.

Couple's Registration Application Form

Please provide the following information regarding yourself and your spouse or partner. We will need to discuss which individual would be appropriately designated as the patient of record, but for now, just pick one.

Patient Information

Preferred means of communication: Check one or more:

Spouse or Partner Information

Preferred means of communication: Check one or more:

Emergency Contact Information

Authorization to Bill Insurance

Insurance generally pays for video conference-based counseling services just as it does for in-person psychological services. However, your insurance may not pay all or even any of these claims due to copayments or unmet deductibles. I encourage you to call the customer service number on your insurance card to determine the extent of your coverage for “tele-health mental health services.”

If you have obtained an Employee Assistance Program (EAP) authorization for this service, please provide the following items:

I authorize Dr. Gallagher to submit health insurance claims on my behalf.

All items in this section must be completed to allow insurance claim submittal.

Financial Responsibility

By providing the following bank card information and signing below, I acknowledge that:

  • I have read and accept the policies outlined above.
  • I authorize Dr. Gallagher to release to my insurance company the information necessary to process claims on my behalf, and to receive payment from my insurance company for his services (if applicable).
  • I accept financial responsibility for the services provided by Dr. Gallagher for which my insurance does not pay. If I am not using insurance, I accept financial responsibility for the full cost of services received.
  • I authorize Dr. Gallagher to collect any residual amount owed using the following bank card information.