TREATMENT FORMS

Our forms are ready for downloading. Download, print them out and bring them with you to your first appointment to speed the enrollment process.

CornerstoneVision Counseling & Psychological Services is dedicated to helping families find hope again.

Below you will find the forms most commonly used in our office. If you are a new client you should have received an email detailing which forms you need to download. Please download all forms listed, complete them and bring them with you to your first appointment. If they are not completed prior to your appointment, we will have some available for you to complete in the office. However, please note this will limit the amount of time you would spend with your therapist as these forms will take you about 30 minutes to complete and must be done prior to your appointment starting.

Some of these forms may also be used in other situations, such as when you would like us to send your records to another doctor’s office. If you are unsure which forms you need, please call our office and we can try to assist you in getting the right ones selected. If you have printed the form but need some guidance in how to complete it, please feel free to call our office so we may walk you through it. This will likely prevent incomplete forms from slowing down the process.


 

CornerstoneVision Forms

Client Intake/Consent to Treatment Form

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.

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.  

 

CORPORATE

Cornerstone Vision Counseling & Psychological Services
10315 Dawson's Creek Blvd. Building #12 – Suite E
Fort Wayne, IN
46825
Telephone: 260-387-6340
FAX: 260-387-6984
Toll Free: 1-866-676-7285

OUR COMMUNITY

For those clients who do not have mental health insurance benefits, CornerstoneVision offers an adjusted fee scale application based on the number of people in the household and family income. You will need to provide two pay stubs or a copy of last year’s income tax return when you arrive. For your convenience you may pay by check, cash, or credit card.

Crisis
Emergency Response
Workshops

INSURANCE INFO

We are a provider for most Insurance companies. Please contact our office to get the most updated information that your insurance company covers in your plan along with which of our therapists are accepting your insurance. We are a provider for: Aetna, Anthem, Anthem Medicare Advantage, Ambetter, Encore/Encircle, Humana, LifeSynch Lutheran Preferred, Magellan, Medicare, PHP, Sagamore, Signature Care, Supermed Plus, Three Rivers Preferred, Tri-Care/Champus, United Behavioral Health/United Health Care, Value Options

CHURCH ASSISTANCE

It is our desire to provide care through a partnership with the community. Speak with your pastor about the possibility of the church assisting with the cost of counseling. Have the pastor contact CornerstoneVision to make financial arrangements. Please be assured we will still be able to maintain complete confidentiality between you and your therapist.

CVC partners with Churches to develop fee assistance options.