CornerstoneVision Forms Details

Client Intake Form – this form needs to be completed by anyone who wishes to receive treatment.

Psychosocial/Medical History Form – this form needs to be completed by anyone who wishes to receive treatment.

Custody Addendum – anytime a minor is scheduled, this form must be signed by a biological or adoptive parent.  Foster Parents can sign this with court records that prove their authority to seek medical treatment in non-emergency cases.

Medicaid PCP Notification – if the client has Medicaid insurance, this form must be completed in full (including fax number) to comply with Medicaid guidelines.

Church Agreement – if a church chooses to assist with a client’s counseling fees, at a reduced rate, and the client is not using insurance, then this form needs to be completed by the church and sent back to our office.

Church Agreement using insurance –if a church chooses to assist with a client’s counseling fees and the client is using insurance, the rate cannot be reduced. This form is different from the standard church agreement form. Please ask your church to contact the CornerstoneVision Counseling office if more explanation is needed as to how this works. This form then needs to be completed by the church and sent back to our office.

Reduced Fee Application – if a client does not have insurance, (s) he may qualify for reduced fee. A call to the Cornerstone Vision Counseling office
is needed to determine qualification, based on household income after taxes (not after deductions). This application form must be completed and presented to the office at the first appointment along with two current paystubs for any adult in the home, or last year’s tax return
(no W-2’s please).

Release – a “Consent for Release of Information” form must be completed and signed for any person(s) with whom the client wants to allow any staff of CornerstoneVision Counseling to be in contact about anything, including appointments and billing. Without this form on file, no one other than the client
can make or cancel appointments. For minors, unless this form is on file, only biological parents can communicate with the staff.

Records Request – if a clients wants anything from his/her records sent to another doctor, attorney, etc, this Records Request Form must be completed and returned to the office. A Release for the same doctor, attorney, etc., needs to be completed as well.