1 Therapy Client Medication Management Client Targeted Service Rehabilitation Psychological Evaluation & WAIS Testing Client Name: DOB: Age 7711 W. Riverside Drive, Garden City, ID Ph: (208) Fax: (208) CLIENT INTAKE MEDICAID ONLY CLIENT IDENTIFICATION Staff Use Only Copy to Director Primary Diagnosis: Client is a Child Teen Couple Adult Family Client is: Married Single Who referred you to us? Client s Name: Sex: M F Birth Date: Parent/Guardian (if client is a child): Relationship: Emergency Conact:: Number: Client s Social Security #: Employer: Client s Home Phone: Cell: Work: Okay to call? Yes No MESSAGING Riverside REHAB staff to leave a message on any answering machine or voice mail connected to the phone number(s) I am supplying as contact information. Yes No (please initial your choice) Client s Address: City State ZIP MEDICAID #: HEALTHY CONNECTIONS DOCTOR: FAMILY INFORMATION Who is currently living in your household? Name Relationship Age Occupation REASONS FOR SEEKING SERVICES CIRCLE ANY OF THE FOLLOWING AREAS OF DIFFICULTY THAT APPLY TO YOU/YOUR CHILD. THEN NUMBER THEM FROM 1 BEING THE MOST IMPORTANT, 2 BEING THE NEXT IMPORTANT, AND SO FORTH: (Example: 1 stress 2 family 3 fears ) anger depression sleep sexual problems divorce/separation legal matters career choices drug/alcohol loneliness family abuse suicidal thoughts pain fears work appetite stress grief/loss change in life finances Riverside REHAB, Inc. Thank you for seeking services here at Riverside Rehab!
2 7735 W. Riverside Drive, Garden City, Idaho F: CLIENT DIAGNOSTIC QUESTIONNAIRE Date: Medicaid number (if applicable): Client: DOB: Is this client a child/teen? Yes No Child/teen s age: If client is a child/teen, this intake is being completed by: Relationship to child/teen: Parent; Grandparent; Other legal guardian, specify: I. LIFE EXPERIENCES Please check off what applies to you or your child. Abusive Relationship Emotional Abuse Witnessed Abuse Few Friends Miscarriage Crime Victim Poverty Death of a parent Death of Someone Close Poor Academic Progress Other Physical Abuse Sexual Abuse Family Problems Rape Abortion War Natural Disaster Death of a Child Unhappy Childhood Violent to Others Other II. MEDICAL HISTORY AND CURRENT PROVIDERS Please list any current or past physical illnesses. Please include hospitalizations and/or any major surgeries) List illnesses with the age of when each started and how long they lasted. Example: Diabetes, age 25 until the present time. Please list any MAJOR medical and/or psychiatric issues that run in your family of origin (Mother, Father, Grandparents, Siblings, or Children). List family member and what the issue is/was. Example: Mother: Hypertension, Depression III. MEDICATIONS CURRENT MEDICATIONS. Please list the CURRENT medications you are or your child is taking. Medication For what condition? Dosage Prescribed by Please elaborate on how well your current medications are working for you/your child.
3 PAST MEDICATIONS. Describe what medications you have or your child has taken in the past and any significant known side effects, if applicable. IV. SYMPTOM CHECKLIST Only indicate the symptoms you are or your child is experiencing for which you are seeking help. In the blanks in front of the symptoms that are occurring, put one of the following ratings to give us an idea of how often that problem is occurring. Example: 2 (for sometimes/monthly) Bed wetting. USE THESE RATINGS: 1 = RARELY (a few times a year at the most) 2 = SOMETIMES (monthly) 3 = FREQUENTLY (weekly) 4 = ALWAYS (daily) Feel sad / empty Irritable Less interest in life Fatigue Feelings of worthlessness Can t concentrate Feelings of hopelessness Difficulty making decisions Suicidal thoughts Homicidal thoughts Insomnia Cries a lot More talkative than usual Decreased need for sleep Thinks negative all the time Racing thoughts Easily distracted Increase in goal-directed activities Excessive risky behaviors Obsesses on things (cannot stop thinking about things) Recurrent thoughts / Images that cause anxiety/fear Repetitive behaviors that must be done to reduce anxiety Feel numb Feel in a daze Can t remember trauma Flashbacks of trauma Nightmares Hypervigilant Easily startled Restlessness; keyed up Muscle tension Excessive worry Excessive fears Feels others are out to get you Bullies others Destroys property Hits others Hurts others (people or animals) Starts fires Steals Lies Angry outbursts Self harm Defiant and oppositional Relationship problems Bed wetting Soiling Physical complaints (stomach, headaches) Sees things not there Hears things in head Loss of appetite Weight loss Sleep problems Throwing up on purpose to lose weight Taking laxatives to lose weight Hard to focus / concentrate Forgets things Cannot organize things Other Other Other PLEASE SIGN AND DATE THIS QUESTIONNAIRE Client or Guardian Date Please print your name here
4 Therapy Client Medication Management Client Client Name: DOB: Age 7735 W. Riverside Drive, Garden City, ID 83714, Ph: (208) Fax: (208) INFORMED CONSENT COMMITMENT AND OUTCOMES Welcome and thank you for coming to Riverside Rehab Counseling, Clinic, and Community Services. We appreciate your business. It is important to understand that the outcome of therapy is often largely determined by the commitment of the client. Psychotherapy can have benefits and risks and we cannot guarantee specific results. Since therapy often involves discussing unpleasant aspects of your life in order to make changes, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Also, therapy can and does lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. The first few sessions will involve an assessment of your needs. Then you and your therapist will discuss your goals and develop a plan for your treatment. We encourage you to collaborate actively in your treatment process and communicate openly about your needs and concerns throughout the treatment process. YOUR RIGHTS AND RESPONSIBILITIES AS A CLIENT You have the right to: A full explanation of services offered and to receive appropriate service. Change providers or refuse services, and receive appropriate referral to other agencies. Be treated with respect. Participate in the process of making decisions about your treatment. Confidentiality (unless reporting is required by law or regulations). Be served in an environment that promotes independence, self-sufficiency, and positive regard. We ask that you: Keep your appointments or cancel with 24-hour notice if you are unable to attend appointments. Assist in planning your treatment goals and follow through with agreed upon goals. Report any changes in circumstances, i.e., insurance coverage, financial, residential, marital, etc. Provide verification of information required. Treat our staff with respect. Bear responsibility for fees not covered by your insurance. YOUR PRIVACY RIGHTS Riverside Rehab Counseling, Clinic, and Community Service takes every precaution possible to ensure your privacy as required by HIPAA regulations. Our Notice of Privacy Policies pamphlet provided to you describes the types of uses and disclosures of your protected health information that might occur in your treatment, payment of your bills, or in the performance of this clinic. The Notice also describes your rights and duties with respect to your protected health information. Riverside Rehab Counseling, Clinic, and Community Service also has copies of our Notice of Privacy Practice Policies available in our reception waiting area for your review. Please initial here that you have received a copy of the Notice of Privacy Practice Policies pamphlet. Initial here.
5 CONFIDENTIALITY AND LIMITS TO CONFIDENTIALITY Everything discussed in therapy is confidential. No information may be revealed to another person without client permission, except as required by law. The exceptions to confidentiality are as follows: If information that a client gives a therapist (either verbally or via artwork) indicates a clear and imminent danger of injury to self or to others, the therapist is required by law to contact the appropriate authorities and/or family members. Also, the therapist is required to release confidential records if a client is involved in a legal matter and/or the therapist s records are subpoenaed by a court of law. CONFIDENTIALITY IN THE CASE OF MINORS While parents are legally, morally, and financially responsible for the upbringing of their minor children, virtually all the standards for protecting client rights and confidences that apply to adults are equally applicable to minors. Minors have the right to be informed before information is disclosed to others and the right to be involved in making therapeutic decisions and be informed of decisions as they are made. PARENT INVOLVEMENT Parental involvement is essential to successful treatment with younger children. Therefore, therapists generally inform children when they feel it is appropriate to share information with their parents. We will also provide parents with a verbal summary of their child s treatment periodically as is helpful and/or when therapy is complete. On the other hand, privacy in psychotherapy is often crucial to successful progress with teenagers. Teens, therefore, are involved in the decision to involve/inform parents if that is helpful. CHILDREN/ADOLESCENT SHARING OF SESSION CONTENT With children, we will encourage them to share with their parents what they are doing (i.e., the course of what happened in their sessions, what sand trays and/or artwork they did) to whatever extent they feel comfortable doing so. If enough time remains, we will give them the choice to share their work for that day. If time is limited, the therapist will indicate sharing sand trays/artwork is not possible for that day. With adolescents, the therapist will communicate that they are responsible for the course of their therapy and that it is up to them to determine how or when their session content, artwork, and/or sandtrays are shared with parents, if at all. POSSESSION OF ARTWORK/SAND TRAY PICTURES Artwork and sandtray pictures are generally kept in client files until therapy concludes. The same policies relative to confidentiality and the limits of confidentiality apply to art/sandtray expressions. Generally, upon termination of therapy, artwork and pictures of sandtrays are given to clients. NO COURT CAUSE Riverside Counseling therapists make it a policy to not appear in court as this generally compromises our therapeutic relationship with clients and can jeopardize our primary goal of providing supportive and healing therapy.
6 THERAPISTS Amy Korb Lena Biondolillo Amy Houser Debi Scholten Trina Elsasser Lynn Horton Joyce Hickerson Kimberly Ledwa Beth Guryan Ivy Williams Michelle Scoville-Dorman LICENSES LSW, NCC, LPC, CPRP, Licensed Social Worker, Nationally Certified Counselor, Licensed Professional Counselor, Certified Psychiatric Rehabilitation Practitioner LCPC, Licensed Clinical Professional Counselor LPC, Licensed Professional Counselor LCPC, LSW, Licensed Clinical Professional Counselor, Licensed Social Worker LPC, Licensed Professional Counselor LCSW, Licensed Clinical Social Worker APRN, CNS, Advanced Practice Registered Nurse, Clinical Nurse Specialist LPC, ACADC LPC, Licensed Professional Counselor LMSW, Licensed Master Social Worker LPC, Licensed Professional Counselor Intern (Master s Level) Intern (Master s Level) MEDICAL STAFF Edward Newcombe Julie Schrader Nicki Peters Stacey Wright MD PMHNP MSN, FNP, NP-C FNP-C CRISIS POLICY / AFTER HOURS CALLS FOR CLIENTS RECEIVING PSR AND CM SERVICES: Riverside Rehab Counseling, Clinic, and Community Services has a 24-hour crisis pager for clients who receive Psychosocial Rehabilitation (PSR) and Targeted Service Coordination (TSC) services paid for by Medicaid. PSR/TSC clients ONLY, call Please understand that this number is available for emergencies only and should not be used for routine requests. FOR ALL OTHER CLIENTS (PRIVATE INSURANCE OR MEDICAID): All other clients without PSR/TSC services whether you have Medicaid or private insurance coverage in the case of after hour emergencies, you are advised to call 911 or go to the nearest emergency room. NON EMERGENCY AFTER HOURS CALLS: You may leave a message on the answering machine at and your call will be reviewed as soon as possible the next day. REGARDING YOUR RECORDS You can request a copy of your records. We will ask you to sign a Release of Information and we do ask that you pay a $5 to $10 fee for staff time and copying charges. Please note that, per HIPAA regulations, we cannot release third party records to you (i.e., records sent to us by another agency only authorized for us to receive) or psychotherapy notes (which are the property of the Clinic).
7 CONSENT FOR TREATMENT This is to certify that I consent to treatment at Riverside Counseling, Clinic and Community Services. I know I have a choice of providers and I choose the therapist identified as my provider in this consent. I know that Riverside also has the right to refuse services to me as well. Treatment may include individual, family, or group psychotherapy, counseling, medication management, or testing. I understand that treatment may include consultation with other care providers, such as medical, educational, probation officers, or court personnel. If this is the case, I will separately authorize release(s) of information utilizing Release of Information forms that will be provided to me. I understand that therapists routinely staff cases and consult with other clinicians, doctors, and providers to ensure continuity of care, and that my protected information will be kept confidential in the course of such staffings. The Bureau of Occupational Licenses regulates the practice of licensed and unlicensed persons in the field of psychotherapy. Any questions, concerns, or complaints regarding the practice of Mental Health Counseling may be directed to the State Board by contacting the Bureau of Occupational Licenses, 1109 Main Street, Suite 220, Boise, ID OTHER IMPORTANT ITEMS I have also completed and received copies of the following agreements pertaining to my therapy. Initials, please: Initials, please: NO SHOW / CANCELLATION POLICY MEDICATION MANAGEMENT CONSENT, if applicable I also acknowledge that I have access to and/or can request a copy of Riverside Rehab Counseling, Clinic, and Community Services Client Handbook. Handbooks are available in the waiting room. I consent to treatment and the policies explained in this Informed Consent policy. Print Name of Adult Date Signature With the above signature, I consent to treatment for my son(s)/daughter(s). Print Name of Child/Minor Age Date Print Name of Child/Minor Age Date Print Name of Child/Minor Age Date \\Storagedrive\newstorage\Community Rehab\Forms\2008\FORM P Informed Consent.doc 3/14/2012 Riverside REHAB, Inc.
8 Therapy Client Medication Management Client Client Name: DOB: Age Specializing in Psychosocial Rehabilitation, Targeted Service Coordination, Psychotherapy, and Clinical Services since W. Riverside Drive, Garden City, ID 83714, Ph: (208) , Fax: (208) FORM Q MEDICATION MANAGEMENT INFORMED CONSENT COMMITMENT AND OUTCOMES Welcome and thank you for engaging medication management services at Riverside Rehab Counseling, Clinic, and Community Services. We appreciate your business. With regard to taking medications, it is important to be aware that the outcome of this form of treatment is dependent upon many factors, including most importantly your commitment to take your medications appropriately as directed and prescribed by your medical provider. In signing this consent, we cannot guarantee specific results with psychotropic medications. Treatment may involve altering medications and dosages to find the most effective regimen for you. All people do not respond to medications the same way. Also, medications may cause unwanted side effects, which you agree to acknowledge by signing this consent form. YOUR RIGHTS AND RESPONSIBILITIES AS A CLIENT You have the right to: A full explanation of your diagnosis, your medications, and their possible side effects. Participate in choosing the medications you are going to take. Participate in setting goals for your treatment. Be treated with respect. Confidentiality (unless reporting is required by law or regulations). Be served in an environment that promotes independence, self-sufficiency, and positive regard. We ask that you: Accurately and fully report your symptoms to your practitioner. Refrain from using any substance (for example: alcohol, drugs, etc.) that could interfere with the effectiveness of your medications and/or cause harm to yourself in combination with prescribed medications. Utilize your medications responsibly. Keep your appointments or cancel with 24-hour notice if you are unable to attend appointments. Report any changes in circumstances (i.e., insurance coverage, financial, residential, marital, etc.). Treat our staff with respect. Bear responsibility for fees not covered by your insurance. PARENTS AND MINORS Minors of any age need to be accompanied to medication management appointments and treatment planning appointments (as applicable for Medicaid clients) by their parents and/or foster parents. Parents can designate others, such as grandparents, to bring their children. Those who are designated agree to be responsible to convey information to parents regarding their child s treatment. PSR workers cannot intercede on behalf of parents for their minor clients (i.e., they cannot handle any prescriptions to pharmacies or deliver medications of any kind or be the sole adult to accompany minors to medical management appointments on an ongoing basis).
9 OUR POLICY ON PRESCRIPTIONS AND REFILL REQUESTS Generally, we require that you attend your medication management appointments as is medically necessary and appropriate to review your medications on a consistent basis. We strictly adhere to rules governing the follow-up of patients on medications for your protection. The State of Idaho requires a medical checkup prior to the reissuance of a prescription at a maximum of every six months. Certain medication may require laboratory tests and more frequent medical checkups. We do not refill prescriptions via phone or fax requests by pharmacies for: 1. Clients who are not attending their appointments consistently. 2. Clients who are new and not yet established and stable on their medications. Generally, it takes three (3) months to become an established client. 3. Clients who owe outstanding fees for no show appointments and/or co-payments. For clients in good standing who may need medication refills, you should contact your pharmacy. Your pharmacy, in turn, will contact us. Please do not call us directly for refills. Please allow seven (7) days for your refill request to be processed. Note: Clients on Lamictal must not allow more than three days lapse in their medication schedule in order to avoid beginning a new titration, so please plan accordingly if you take this medication. If you are experiencing a crisis, we advise you to go to the nearest emergency room. Also, please note, we don t mail prescriptions of any kind. FEES FOR SERVICES NOT COVERED BY INSURANCE Records Charge: If you should request copies of your records from Riverside, there will be a $5 to $10 maximum charge for staff time and copying. Late Cancellation/No Show Charge: Per our Late Cancellation/No Show policy, there is a $50 fee for missed appointments and or late cancellations without 24-hour notice. CONSENT TO TREATMENT This Consent to Treatment addresses medical management policies specifically. Initial here to acknowledge that you have also reviewed and signed our general clinic Informed Consent, as well. I consent to treatment and the policies explained in this policy. Print Name of Adult Date Signature With the above signature, I consent to treatment for my son/daughter. Print Name of Child/Minor Age Date Print Name of Child/Minor Age Date \\Storagedrive\newstorage\Community Rehab\Forms\2008\FORM Q Medication Management Informed Consent.doc 3/14/2012 Riverside REHAB, Inc.
10 CLINIC NO SHOW / MISSED APPOINTMENT POLICY Because consistent participation is essential in providing quality mental health services, Riverside REHAB/Community REHAB has adopted the following No-Show / Missed Appointment Policy: All services of Riverside REHAB/Community REHAB are provided through scheduled appointments. Clients of Riverside REHAB/Community REHAB are expected to be active in their programs. This includes keeping all scheduled appointments. For the purposes of this policy, a missed appointment is defined as a previously scheduled appointment that was not attended or was cancelled with less that a 24-hour notice when no emergency was present. Please call to cancel or reschedule appointments with 24-hour notice. Please report emergencies to this number as well. IF YOU MISS YOUR APPOINTMENTS WITHOUT 24-HOUR NOTICE: 1. You agree by signing this policy to pay a $25 no-show fee for each missed therapy appointment and/or $50 for each missed medical management physician appointment. 2. You agree that if you miss three (3) total appointments within a six (6) month period with a therapist and/or with the doctor or a nurse practitioner, that you will no longer be eligible for services here at Riverside. 3. You agree that if you miss scheduled appointments without 24-hour notice that you will be contacted via phone or letter to notify you that you owe fees for those missed appointments. In most cases, payment plans can be arranged. 4. You agree that if you incur more than one fee at a time, future appointments will be suspended until you are able to pay the balance you owe in full. If You Become Ineligible for Services Due to Excessive Missed Appointments or Unpaid Fees: 1. We will notify you via letter that you are suspended from services and supply you with a list of other mental health providers. 2. If you are suspended from physician s services, you will have thirty (30) calendar days to find a new physician. We will supply you with the names of other physicians. 3. If you are suspended from services and wish to re-apply, you may do so after a ninety (90) calendar day waiting period. Application must be made with the Clinical Services Director before appointments can be resumed. A decision will be determined at that time. Thank you for being a client of Riverside REHAB, Inc. By signing below, I understand and agree to the above. Client Signature Date THANK YOU VERY MUCH FOR COMPLYING WITH OUR 24-HOUR CANCELLATION NOTICE
11 7711 Riverside Drive, Garden City, ID Phone: Fax: AUTHORIZATION FOR RELEASE / EXCHANGE OF INFORMATION I,, hereby authorize Riverside Rehab to request Print Client Name and/or disclose information, in verbal or written form, regarding my services / treatment to. My date of birth is Name of Agency or Individual The records I am requesting relate to the following services: Mental Health Services Medication Management Mental Health Services Counseling Developmental Disabilities Services Vocational Services Substance Abuse/ Alcohol Abuse Services PSR Case Management Payee Services HIV/AIDS related Information Other: The specific records being requested or authorized for disclosure are: Comprehensive Diagnostic Assessment Most Recent Annual Update Assessment Most Recent Functional Assessment Most Recent Psychiatric Evaluation Current 5-Axis Diagnosis Current Prescribed Medications Medication Management Nurse s Notes Physician s Notes Discharge Summary Other: Current Medication Management Treatment and Most Recent Reviews Current Therapy Treatment Plan and Most Recent Reviews Current PSR Treatment Plan and Most Recent Reviews Initial Targeted Service Coordination Assessment Current Targeted Service Coordination Plan and Most Recent Reviews Other: My signature also authorizes Riverside to do the following: NOTE: PLEASE COMPLETE #3 1. Riverside REHAB employees (therapists, PSR workers, and staff) may share information pertinent to my care. I understand that staff routinely reviews client treatment for purposes of supervision to ensure compliance with insurance company requirements and best practice for client care. 2. Riverside REHAB may receive, use or release information and records to/from: my insurance carrier(s) including Idaho Department of Health and Welfare (Medicaid). 3. I authorize Riverside REHAB staff to leave messages on my answering machine or voice mail. Check one: NO or YES: you may leave messages for me at these numbers only: # # # REGARDING THIS RELEASE Expiration: Unless otherwise revoked, this authorization will automatically expire 30 days after termination of services with Riverside or according to the relevant state law. Revocation: I have the right to revoke this release authorization at any time in writing to the address above. Revocation will not apply to records and information that have already been released. Re-disclosure: I understand that there is a potential for unauthorized re-disclosure of the information and that the re-disclosed information may not be protected by federal confidentiality rules. Patient rights: I understand that refusal to sign this authorization will not compromise the treatment, payment, enrollment or eligibility for benefits or services that Riverside provides. NOTICE TO RECIPIENT: PROHIBITION OF RE-DISCLOSURE This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations (42CFR, Part 2) prohibit you from making any further disclosure of this information without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulation. A general authorization for the release of medical or other information is NOT sufficient for this purpose. Client Signature Date Witness / Staff Member Date
12 MEDICAID REQUIREMENTS STEP To ONE: start We services need to with get a Riverside Healthy Connections REHAB 3 steps! Referral from your Primary Care Provider assigned to you by Medicaid and documentation of a recent History and Physical/ Well Child Check that is current with in the last year. We may need you to sign Releases to get information from other providers if you are transferring services to our clinic. Once we have this documentation, we will schedule with you. STEP TWO: You are scheduled for your COMPREHENSIVE DIAGNOSTIC ASSESSMENT with your therapist or nurse. Unless, we have receive a Current Assessment from your prior agency. This assessment is mandatory, annually to meet Medicaid compliance and qualifies you for services. STEP THREE: Within 30 days of your first visit you must complete an ANNUAL appointment with our SUPERVISING PHYSICIAN for him to sign off on your/ your child s treatment. PLEASE NOTE: If you do not meet with the Doctor you cannot continue services and if your appointment is missed without a 24 hour notice there is a $50.00 No Show fee. If you also qualified for Psychosocial Rehabilitation and/or Case Management STEP FOUR: You or your child s COMPREHENSIVE DIAGNOSTIC ASSESSMENT services will be forwarded to your assigned social worker and he or she will contact you to begin services. To continue services throughout the year see Yearly Requirements
13 Riverside REHAB Yearly Requirements 1. You must have a TREATMENT PLAN established for Therapy, Medication Management, Psychosocial Rehabilitation, and/or Case Management services and continually work towards completing your goals. 2. Every 120 days, all treatment plans need to have a 120 Day Review to evaluate your progress. 3. On your yearly anniversary of beginning each service, you will need to participate in a YEARLY REASSESSMENT. 4. Every year you must get a NEW History and Physical/ Well Child Check from your primary care provider. This is mandatory from Medicaid and services will be discontinued if it is not completed before your anniversary date. 5. If you become INELIGIBLE for MEDICAID at any time, your services will be suspended until your ELIGIBLITY is restored. We value you as a client at Riverside REHAB and would like to answer any questions you may have.
Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT Thank you for choosing Family Life Resource Center (FLRC) as your mental health provider. This document contains important
LOGAN MCILWAIN, LCSW Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: (225) 387-2287 Fax: (225) 383-2722 Declaration of Practices and Procedures I am pleased
Warner Family Counseling General Policies Insurance: I will file claims on your behalf, provided that I am an in-network contracted provider with your individual plan. Prior to our first meeting contact
PATIENT INTAKE FORM PATIENT INFORMATION Name Soc. Sec. # Last Name First Name Initial Address City State Zip Home Phone Work/Mobile Phone Sex M F Age Birth date Single Married Widowed Separated Divorced
PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip
Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave
Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 F(808) 748-0778 OUTPATIENT SERVICES CONTRACT This document
Child/Teen Intake Form Welcome to New Perspective Counseling Services. We look forward to providing you with excellent and efficient counseling services. Please take a few minutes to fill out this form.
1 Ann Dunnewold, Ph.D. 8140 Walnut Hill Lane, Suite 100 Dallas, TX 75231 (214) 343-1353 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important
Michael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION PLEASE PRINT CLEARLY DATE NAME ADDRESS DX (OFFICE USE ONLY) CITY STATE ZIP OCCUPATION HOME PHONE EMAIL WORK PHONE CELLULAR
Consent to Treatment (Long Version) Sabrina Walters Counseling, LLC 3000 NW Stucki PL, Suite 230 Hillsboro, OR 97124 503-869-8108 COUNSELOR-CLIENT SERVICE AGREEMENT Welcome to my practice. This document
Parents Names (If Client is a Minor) Client Information Sheet Client s Last Name First M.I.. Social Security No. Date of Birth: Age Sex M / F Home Phone No.( ) Education Level: Marital Status: Home Address:
Molly Casebere, M.S., LPC, NCC Licensed Professional Counselor, North Carolina (License # 8518) Nationally Certified Counselor (Certification # 239857) PROFESSIONAL DISCLOSURE STATEMENT Information and
RACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043 1 PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12) Welcome to my practice. This agreement contains important information
Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328 An important part of the helping relationship is understanding the expectations of the relationship.
Patient Registration Please Print Patient Name Last First Middle Address City Zip Home Phone Work Ext Cell Birthdate - - Social Security # - - Gender Marital Status Employer Referred by_emergency Contact
Nancy Thomas, M.A., LPC-Intern Supervised by Jennifer Perla, LPC-S The Vale Counseling and Therapeutic Center 2862 N. Belt Line Road, Sunnyvale, TX 75182 www.nancythomascounseling.com Office: (972) 698-8478
PSYCHOLOGIST- PATIENT SERVICES AGREEMENT This document is an agreement between therapist: and client:. Welcome to our practice. This document (the Agreement) contains important information about professional
ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from
Revised 7/1/08 AGAPE Therapist Client Services Agreement AGAPE is a faith-based organization guided by Christian values. As part of its overall mission, AGAPE offers professional counseling and psychological
Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Welcome! Please take a minute to complete the following information. Your name: Phone Number: Address:
Integrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional
Dale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648 Problems in love and work, as well as troubling symptoms like depression and anxiety, often lead people to seek therapy.
The Bethesda Group Psychological Services, LLC Old Georgetown Office Park 7988 Old Georgetown Road, 8A Bethesda, Maryland 20814 Phone 301.718.4544 Fax 301.718.4545 email@example.com PSYCHOTHERAPIST-PATIENT
Date CLIENT INFORMATION Client Name Address City State Zip Code Primary Contact Ph # Cell Home Work Secondary Ph # Cell Home Work Email Address Do you text? Yes No Birth date Social Security Number Occupation
Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name
2203 Timberloch Pl., Suite 100 PERSONAL DATA RECORD Client Name: Date of Birth Address: City/State/Zip: Home Phone: Cell Phone: SSN: Work Phone: Other Phone: TXDL: Employer/School: Referred to Our Office
The more information we know about you and your family, the better medical care we can provide you. None of this information will be released to any person except with your written consent. LAST NAME FIRST
Technical Assistance Document 5 Information Sharing with Family Members of Adult Behavioral Health Recipients Developed by the Arizona Department of Health Services Division of Behavioral Health Services
Leland E. McHatton, MFT Marriage Family Therapist 1430 East Avenue, Suite 4C 530.566.1212 Chico, California 95926 CLIENT QUESTIONNAIRE Client s Name: Spouse s or Parent s Name: Date of Birth: Date of Birth:
NEW PATIENT INFORMATION CONSENT AND AGREEMENT PSYCHOLOGICAL SERVICES. Psychological services vary depending on the reason for referral. In all cases, the initial appointment is set up with the parents/guardians
Deborah Issokson, Psy.D. Licensed Psychologist HEALTHCARE PRIVACY AND SECURITY POLICIES PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important
Child Personal Information Child s Name: Date: Age: DOB: / / Gender: M F Race: Address: Apt: City: State: Zip Code: Father s Name: Date of Birth: / / Age Father s Occupation: Phone Number: Mother s Name:
PSYCHOTHERAPIST-CLIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary
Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document
Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist
PRE-SCREENING CHECKLIST Please provide the following information and mail, email or fax to: Positive Synergy Corp. 45 Spring Hill Ave. Northbridge, MA 01534 Email: firstname.lastname@example.org Fax: (508)-401-2696
: / / Client Name: _ SSN: / / of Birth: Age: Sex: Male Female Address: City/State/Zip: Home Phone Number Is it okay to leave a message here? Y/N Work Number Is it okay to leave a message here? Y/N Cell
Betsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036 PSYCHOLOGIST-CLIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement)
The Healthy Mind PSYCHIATRIC SERVICES 900 Straits Tpk Suite D Middlebury, CT 06762 New Patient Registration: Patient s First Name Last Name Patient s Telephone: Home Cell Email: Patient s Date of Birth:
INTAKE SERVICES HIGHER LEVEL OF CARE REFERRAL DEPARTMENT OF SERVICES FOR CHILDREN, YOUTH & THEIR FAMILIES DIVISION OF PREVENTION & BEHAVIORAL HEALTH SERVICES 1825 Faulkland Road Wilmington, DE 19805 (302)
AGREEMENT AND INFORMATION We would like to welcome you to our office. Please review this Agreement and Information sheet to assist you in understanding our office policies. Our therapists are private practitioners.
: Patient Relationship to Guarantor: of Birth: Sex: M F Social Security Number: Home Address: City: State: Zip Code: Home Telephone:( ) Referred By: Pharmacy of Choice: Pharmacy Address: Pharmacy Phone
Life Tide Counseling, PC Individual, Marriage and Family Counseling OUTPATIENT SERVICES CONTRACT Therapist: ( Therapist ) Client: ( Client ) Welcome to Life Tide Counseling, PC ( Life Tide Counseling ).
Suzanne Burger, Psy.D. 24 Patterson Road Pound Ridge, NY 10576 (914) 764-5582 Fax (914) 234-2398 Thank you for filling out this form. All information will be kept in strict confidence. Name Date Address
Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 CONSENT FOR EVALUATION AND TREATMENT Welcome to my practice. This document
Aaron J. Dodini, Ph.D. Licensed Clinical Psychologist Licensed Marriage & Family Therapist PSYCHOTHERAPY CONTRACT Welcome to my practice. This document contains important information about my professional
Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Patient Name (please print): Welcome to the therapy services
Jeremy Frank, PhD CADC Licensed Psychologist and Certified Alcohol and Drug Counselor Presidential City Madison Building 2 Bala Plaza, Suite Plaza 13 (Pl-13) Bala Cynwyd, Pennsylvania 19004 215-356-8061
Helen G. Jenne, Psy.D.,FAACP Board Certified, Clinical Psychology PSYCHOLOGIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document (the Agreement) contains important information about my professional
Information for Clients Welcome to Sterman Counseling and Assessment. We appreciate the opportunity to be of assistance to you. This packet answers some questions about therapy services. It is important
PATIENT INFORMATION DATE: Patient s Name Last First Middle Initial Patient s Address City State Zip Patient s Birth Date / / Male Female Age SS# Single Married Other May we call/leave message for appt.
1 Welcome to. This document contains important information about my professional services and business policies. Attached is also a summary of information about the Health Insurance Portability and Accountability
Counseling Intake Form (Each person attending therapy should complete a form) Name Male Female Mailing Address Date of Birth Home Phone Work Email How would you like to be contacted? Home Work Email Okay
PROFESSIONAL SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions
: Chris Groff, JD, MA, Licensed Pastor Certified Sex Addiction Therapist Candidate 550 Bailey, Suite 235 Fort Worth, Texas 76107 Client Intake Information Client Name: Street Address: City: State: ZIP:
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete
OFFICE POLICIES AND PROCEDURES Thank you for choosing Cardiology Consultants of Atlanta for your cardiovascular care. We realize that you have a choice in medical providers and are pleased that you have
COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES The mission of the counselors at Synchronicity Counseling is to offer a holistic, nonjudgmental approach to therapy with an understanding that all human
JANET PURCELL, PH.D. 1818 N.E. IRVING STREET PORTLAND, OR 97232 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT This document contains important information about my professional and business policies. It also
THRIVE Center for ADHD and Comprehensive Mental Health Informed Consent and Clinical Policies Welcome to THRIVE. This document contains important information about our professional services and business
APPLICATION FOR CHILD AND YOUTH MENTAL HEALTH SUPPLEMENTARY SERVICES PROGRAM REQUESTED: Respite Services Supportive Intensive Home and Community-Based Case Management Case Management Services Waiver Referrals
The Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM Personal Information Date: Name: Phone #: Cell #: May we leave a message on these numbers?: Best time to reach me
Thomas Cicciarelli, Psy.D. PSY17298 350 Parnassus Avenue, Suite 601. San Francisco, CA 94117. 415-767-5199 OFFICE POLICIES AND SERVICE AGREEMENT Introduction Welcome to my practice. This document contains
Patient Information Form Trinity Wellness Center Last Name, First Name, MI* Date of Birth* / / Social Security # -- -- Sex* : Female / Male Student Status (circle one): Full-time / Part-time / not a student
1540 Sunday Drive Suite 200Raleigh, NC 27607 Office: 919-859-9040FAX: 919-859-9030 Name: Date Examined: Responsible Person: _ Birth Date: Address: Age: Sex: M F Marital Status: S M D W SSN: Home Phone:
If you did not complete these forms in advance and bring them with your initial appointment today, then please complete them, and sign them now. Our office does not receive email from patients. We do use
Notice of Privacy Policies Form ***This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE READ IT CAREFULLY!*** The tells
NEW CLIENT INFORMATION (Please Print) / / Client Name M/ F of Birth Address City/State Zip Home ( ) Work ( ) Cell ( ) Email Address: (Circle One) Minor Single Married Divorced Separated Widow Living Together
OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions
LAKELAND FAMILY MEDICINE Dennis J. Charette, M.D. 155 McDonald Drive SW Shirley E. Charette, MS, PA-C Carri A. Meiler, MS, PA-C Phone: 330-308-8999 Fax: 330-308-8016 www.lakelandfamilymedicine.com PATIENT
Keweenaw Holistic Family Medicine Patient Registration Form How did you first learn of our Clinic? Circle one: Attended Lecture Internet KHFM website Newspaper Sign in window Yellow Pages Physician Friend
TIDELANDS COUNSELING STACY GUISSE, PSY.D., MFT LICENSE #48134 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 Adult Consent for Treatment and Service Agreement Welcome to Tidelands Counseling! Tidelands
Name: Address: E-mail: Phone numbers: Lisa Dungate, Psy.D., M.A. Mental Health Counseling PATIENT INFORMATION Please complete for self or minor child responsible party information below DOB: Street Apt.
Dear Parent, Glen Davis PhD Maine Child Psychology 2 Elm Street, Waterville, ME 04901 Telephone: (207) 221-2631 Fax: (207) 221-3368 MaineChildPsych.com Thank you for your interest in psychological services