ZIP Code:
Best number to contact you?
Alternate Number:
E-Mail Address:
You are scheduled to see Melynda Madrid, LPCC.
(MM-dd-yyyy)
Date of Birth: 
Social Security Number:
Marital Status:
Spouse Name:
Payment Structure:
Emergency Contact:
Phone:
Relationship?
Patient Employer:
Work Phone:
Primary Care Doctor:
Phone Number:
Payment Information
Credit Card #:
Expiration Date:
I hereby authorize Encouraging Heart Counseling to use the above credit card information to cover
any copays, coinsurance or self-pay amounts or amounts not
covered by my insurance for payment.
Please type your full name to indicate your electronic
signature:
Type Full Name:
Responsible Party
Information
INSURANCE INFORMATION
Have you contacted your insurance company about this
appointment?
Primary Insurance Co.
Phone:
Address:
City:
State:
ZIP Code:
Name of Insured:
Insured Id #:
Group #:
SSN of Insured:
(MM-dd-yyyy)
Date of Birth:
Secondary Insurance Co.
Phone:
Address:
City:
State:
ZIP Code:
Name of Insured:
Insured Id #:
Group #:
SSN of Insured:
(MM-dd-yyyy)
Date of Birth:
Is this an Employee Assistance Program Visit (EAP) ?
Auth #:
# of visits:
If you will be using your commercial insurance once your
EAP visits have been exhausted, please fill out insurance information above.
How did you hear about us?
Reason for seeking care?
Medical History
Do you have any drug allergies:
What medicines are you allergic to?
What type of reaction do you have?
What medications, including dosages, are you currently
taking?
Past hospitalizations?
Are you sexually active?
Are you pregnant or trying to get pregnant?
Do you currently smoke?
How much do you smoke?
Have you quit smoking?
When did you stop smoking?
ACKNOWLEDGEMENT OF RECEIPT
OF PRIVACY NOTICE
I have been presented with a
copy of Encouraging Heart Counseling's Notice of Privacy
Policies, detailing how my
information may be used and
disclosed as permitted by federal and state law. I understand the contents of
the Notice, and I request
the following restriction(s)
concerning the use of my personal medical information:
Restrictions:
Please type your full name here to acknowledge receipt of
Privacy notice:
PATIENT -THERAPIST AGREEMENT
If at any time you have questions or concerns about any aspect of your therapy,
please talk about them with your therapist.
Services: Melynda Madrid, MA, LPCC, provides counseling and psychotherapy to individuals, children, adolscents,
and adults. Sessions are usually held weekly, but may be more or less frequent depending on your needs.
You and your therapist will identify your needs and concerns. Together you will develop goals and plans for your treatment.
Confidentiality: Your therapist will follow the Code of Ethics of the American Counseling Association, as well as the
state and federal laws which protect your privacy. These laws are explained in the NOTICE OF PRIVACY PRACTICES.
Process of Psychotherapy: Participation in therapy can result in a number of benefits to you, including improvement
of interpersonal relationships and resolution of the specific concerns that led you to seek therapy.
Working toward these benefits, however, requires effort on your part.
Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts,
feelings and/or behavior. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or
thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc.,
or experiencing anxiety, depression, insomnia, etc. Attempting to resolve issues that brought you to therapy in the first
place, such as personal or interpersonal relationships may result in changes that were not originally intended.
Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or
relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another
family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating.
There is no guarantee that psychotherapy will yield positive or intended results.
Therapeutic Approach/Scope of Practice: During the course of therapy, Melynda Madrid, LPCC is likely to draw on
various psychological approaches according, in part, to the problem that is being treated and her assessment of what
will best benefit you. Melynda Madrid, LPCC does not provide custody evaluation or recommendation; nor medication or
prescriptions recommendation, nor legal advice, as these activities do not fall within her scope of practice.
Fees: The full fee is $120.00 per 45-minute session. There is no charge for telephone calls of less than 15 minutes.
You and your therapist will discuss the details of your financial arrangements during initial phone calls and at the first
therapy session. Therapy is also available for those who cannot afford the full fee based on availability.
Adjusted fees are based on family income and family size.
Payment: Payment is due at the time of service, unless other arrangements have been made. Payments may be made by
cash or credit card. In order to devote more time to your counseling needs, please leave a credit or debit card on file
with my billing department. They will charge your co-pay/payment to your account after each session and send you a receipt.
I am currently in the process of contracting with most major insurance companies. If you have insurance, please contact my
billing staff at 384-7352 to determine if I can accept your insurance.
If payment is not made when due and other arrangements are not made, the necessary billing information may be released to a
professional collection agency. If that occurs, you will be responsible for paying all costs for collection, including
attorney fees.
Please discuss any questions or concerns about payment with your therapist.
Missed Appointments: If you must cancel a scheduled session, please call your therapist as soon as possible.
You will not be charged for a session that you cancel 24 or more hours in advance. You will also not be charged for a
session that has been canceled by your therapist. You may be charged for sessions canceled with less than 24 hours notice
or for missed appointments.
Emergencies: If you have an emergency when the office is closed, you may call the phone number on the
card your therapist has given you. Your therapist will either speak with you directly or return your call as
soon as possible. You may also contact the Crisis Unit of the University of New Mexico Mental Health Center at 272-2920.
If the emergency is immediately life-threatening, call 911 or go to the nearest emergency room.
Licensure: Your therapist holds a masters' degree and is licensed by the State of New Mexico as a Licensed Clinical
Mental Health Counselor (LPCC).
Please check here to accept the terms of the Encouraging Heart Counseling's Consent to Treatment
Please type your full name here to indicate your electronic
signature: