The Counseling Center of New England

One Main Street * Nashua, NH 03064 * (603) 883-0005
8 Auburn Street * Nashua, NH 03064 * (603) 883-0005
15 Trafalgar Square * Nashua, NH 03063 * (603) 883-0005
148 Coolidge Avenue * Manchester, NH  03102 * (603) 627-3111
294 D.W. Highway * Merrimack, NH  03054 * (603) 883-0005
77 Gilcreast Rd * Suite 3000 * Londonderry, NH  03053 * (603) 432-3033
45 Main Street * Peterborough, NH  03458 * (603) 924-3331
414 State Street * Unit 2 * Portsmouth, NH  03801 * (603) 334-2533
24 Front Street * Suite 100 * Exeter, NH 03833 * (603) 778-2005  
16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222
53 Baxter Boulevard * Portland, ME 04103 * (603) 883-0005
61 NH Route 27, Unit 10 * Raymond, NH 03077 * (603) 689-7602
319 Whittier Highway * Suite 8 * Center Harbor, NH 03326 * (603) 546-6178 
Fax all locations: 603-883-0007


~~ Please Note:  Only complete this form if you have spoken to our Intake Department and have already scheduled your first appointment. If you have not, please complete the Request Appointment Form for an Adult or Child/Teen ~~
(If yes, please add us to your contact list - 603.689.7890 & 603.881.9311)
OK to leave message at: (please check all that apply)
Ok to email appointment reminders? *
Ok to email billing information? *

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as is minimally necessary for the task of appointment scheduling or addressing billing and account related information.  This release will be in effect unless otherwise cancelled in writing.
I understand that my typed initials shall have the same legal and binding authority as my handwritten initials.

Terms of Insurance Coverage, Authorizations, and Payment Consent Form

1.  I agree to pay for each covered service according to my plan benefits, including any deductibles or copayments, at the time of each visit.  I understand that I have the option to leave a credit or debit card on file to facilitate regular payments at the time of services rendered to avoid any monthly finance charges that may result from unpaid balances. Please click the link below if you wish to securely leave a credit card payment on file.

2.  I authorize The Counseling Center to bill my insurance company to obtain direct payment for any insurance due balances, and in the event of nonpayment, I authorize The Counseling Center to file a complaint with the NH Department of Insurance on my behalf to ensure payment according to the terms of my insurance plan.  Because my health insurance policy is a contract between my insurance company and me, I understand that it is my responsibility to:

         i)  Pay for any balance on my account should the insurance payments differ from what was
              expected, not to exceed any contracted rates The Counseling Center accepts from your 
              carrier for covered services.  I understand that any/all information provided to you about
              expected insurance coverage is only a "quote" of benefits and is not a guarantee of
              payment.  An authorization only guarantees that if coverage under your insurance plan
              exists, and services are deemed medically necessary by your insurance plan, that payment
              will be made in accordance with the terms of your insurance contract.  If you have any 
              questions about what your plan covers or what they consider medically necessary services,
              please contact your insurance company directly for confirmation of coverage.

          ii) To obtain, when required, an authorization for service prior to my first visit, unless The
              Counseling Center has confirmed doing that for me, and to work with my provider to 
              ensure all my subsequent visits are authorized by my insurance company (if applicable).  
               I recognize that any change in my insurance policy may require a new authorization, 
               which I am responsible for obtaining from my new carrier prior to any visits at The
              Counseling Center, and that if I do not a $15 administrative charge may be billed for The
              Counseling Center doing this on my behalf.  I also recognize that if my authorization has
              an expiration date that I am responsible for tracking that date and obtaining a new
              authorization after it expires.  I understand that I may be responsible for any costs for
              denied or uncovered services rendered after the expiration of my initial or subsequent
              authorization if a new authorization has not been obtained.   
         iii) Be aware of the possible limitations or termination of financial coverage for services should
              I change health insurance plans, the need to obtain a new authorization for service and the
              need to provide new policy information within 48 hours of my next visit or to pay in full for it.

Click on link to review:
3.  I understand that my insurance coverage will reimburse only for "medically necessary" services and that any "non-covered" services will be billed to me and not my insurance company.  Forensic and legal services, whether requested or subpoenaed, are billed at a different fee schedule ($200-$500 per hour), are not covered by health insurance and are my financial responsibility.  I have reviewed and understand the information provided regarding services not covered by insurance and understand that I will be billed directly for any of those services.

4.  Forensic and legal services, whether requested or supoenaed,  are billed at a different fee schedule ($200-$500 per hour), are not covered by health insurance and are my financial responsiblity.

5.  Medication refills phoned into pharmacies may incur a $35 service charge and that a face to face visit with my prescriber (if applicable) is required no less often than every 2-3 months to remain in regular care and receive medication management services from The Counseling Center.

6.  I will be charged in full ($90-$250) for appointments missed or not canceled 24 hours in advance or on Fridays for Monday appointments.  Insurance does not pay for these charges.

7.  I understand that any account balances left unpaid beyond 60 days will be referred to a collection agency or small claims court and an additional 35% of your balance will be due to cover associated collection fees.  Specific information, your name, address, phone number and balance due will be released to the collection agency, and my signature below authorizes such release.

Do you have any additional insurance? *

Review and Consent of Counseling Center Policies and Privacy Statement

Click on link to review:
I have read The Counseling Center's Information and Policy Statement and understand and acknowledge:

1.  The legal limits of confidentiality (also reviewed in HIPAA privacy practice notification)

2.  That certain clinical information (i.e., a diagnosis and possibly a plan for my counseling or medication appointments) will be submitted to my insurance and/or their managed care company (if applicable) to obtain reimbursement and I understand that they may review my medical record when requested.
3.  That I have been notified of our after hours emergency call coverage systems and the fees for using this service.

4.  I understand that calls to our psychiatrists and Nurse Practitioners during office hours are most often returned by our administrative staff.  Time needed to speak directly with your provider typically requires an appointment to be scheduled unless in case of emergency.

5.  That for Psychologist and Therapy services, I understand that the mental health bill of rights is posted in the waiting room and is available for review and I will be given a copy of my provider's license on his or her professional autobiography at my first appointment.
Click on link to review:
Click on link to review:
6.  That I have reviewed The Notice of Privacy Practices summarizing the uses and disclosure of  my   protected health information, my rights, how I may exercise these rights and The Counseling Center's legal duties regarding my private health information.  I also understand that affiliated businesses or agencies may be utilized for billing and other administrative services and that limited clinical information may be shared with them confidentially under HIPAA business associates agreements and privacy guidelines.

7.  That I give my consent to The Counseling Center and its professional staff to deliver psychological and/or psychiatric services to me (or my children) and that I understand that information regarding my care may be released to my PCP and other providers involved in my or my children's care unless I specifically request or decline such release by informing my provider.

For Suboxone Patients Only:

~~ Please Note:  Only complete this form if you have spoken to our Intake Department and have already scheduled your first appointment. If you have not, please complete the Request Appointment Form for an Adult or Child/Teen ~~