Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328
|
|
- Dulcie Gray
- 7 years ago
- Views:
Transcription
1 Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA An important part of the helping relationship is understanding the expectations of the relationship. Please read the following information and sign to acknowledge that you have read and understand the consent. Please keep one copy for yourself. Thank you. Fees: Our office sessions are scheduled for 50 minutes and are billed at $ Specific advice and education regarding your child s needs are provided in a collaborative approach. These meetings are not considered a therapy session. Sliding scale is available as needed. Telephone Calls: Brief phone calls and initial consultation for service calls are not charged. If our conversation is longer than 15 minutes and is clinical in nature, the phone call will be charged as follows: minutes $35.00 and 30 minutes or longer will be $ Emergencies: I can be reached for clinical emergencies at (404) , and I will return your phone call within 24 hours. If you have an emergency and cannot wait 24 hours for a return call, please call 911. Cancellations: I understand that sometimes it is not possible to make a scheduled appointment. Please do all you can to give me at least 24 hours notice if you need to cancel an appointment. If not, a fee may be charged of $ Payment: It is expected that you pay for your services at the time of the visit. In addition to checks and cash, all major credit cards are accepted: Visa, MasterCard, Discover, and American Express. Insurance: I do not file insurance claims. However, my services may be covered by insurance. Since coverage varies widely from policy to policy, I cannot guarantee that my services will be reimbursed by your policy. I request that you please file directly for reimbursement with your insurance carrier. I can provide you with the bill for services which you will attach to your insurance claim. Billing: It is my pleasure to work with you. However, if you have an outstanding balance at the end of the month, you will receive a monthly statement of your account, which is payable upon receipt. Should your account become delinquent, the total amount due will accumulate at a rate of 1.5% per month until paid in full. Should your account have to be collected through an attorney, you will be responsible for all reasonable attorneys fees and the cost of all collections. Thank you very much for the opportunity to work with you. Karen Kallis, M.Ed., LAPC, NCC Signature Date / / 1
2 Consent for Counseling Please read this information carefully and discuss any questions you may have with me. Please keep one copy for yourself and sign one to acknowledge you have read and understand this consent. Thank you. Confidentiality: Our communication will be held in confidence and will not be revealed to outside agencies without your written consent. Divulgence of communications will not be permitted without your consent unless specifically required by law (for example: child abuse, elder abuse, imminent threat of danger to yourself or others, court order, etc.). Information released to insurance companies for reimbursement purpose is released only on authorization from you. However, if you waive confidentiality for your insurance company, they may request that your entire record for counseling be released. Please be sure that you are clear about what information your insurance company is requesting before you waive confidentiality. May I communicate with your referring professional for feedback? Yes No Referring professional Phone ( ) - Are there any other professionals or agencies that you wish for me to contact? Yes No Please list them below with contact information: Phone ( ) - Phone ( ) - Phone ( ) - Factors in Therapy: It is my pleasure to work with you. However, the success of therapy is affected by many things: severity of the problem, match between therapist and patient, motivation of the patient, and many other factors may also affect the length of the therapy. Please feel free to discuss your feelings with me about your progress and the course of therapy. Typically, the decision to terminate therapy is made by mutual consent of the therapist and patient. In the event that you decide to discontinue counseling without notifying me, it is my policy to assume that the counseling relationship terminated 30 days from your last visit. Thank you for the opportunity to work together. I acknowledge that I have read the business policy and consent for counseling. Please print your name clearly Signature Date / / Social Security Number - - 2
3 Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA Adult Information Form Client s name: Today s Date: Age: Date of Birth: Marital Status: Address: Name of Employer (if applicable): Occupation (if applicable): Education level: Home Phone: Ok to leave Voice Mail: Yes or No Cell Phone: Ok to leave Voice Mail: Yes or No Work Phone: Ok to leave Voice Mail: Yes or No Ok to contact via Yes or No Please indicate any restrictions to contact information: Referred by: May I have your permission to thank the person that referred you? Yes No Person to notify in case of emergency and relationship to client: Contact information for emergency contact: We will only contact this person if we believe it is an emergency. Please provide your signature to indicate that we may do so: Client Signature: Date: 3
4 Please describe the problems you are having that prompted you to seek therapy: What are your goals for therapy? Do you have any history of significant medical problems or illnesses? Yes No If yes, please describe below: Have you had any medical or psychiatric hospitalizations? Yes No If yes, please describe below: Have you ever talked with a psychiatrist, psychologist, or other mental health professional? Yes No If yes, When? With Whom? For how long? Was it helpful? Have you been given a diagnosis with respect to psychological or developmental concerns? Yes No If yes, please describe below: 4
5 Please check all that apply Problems Now Past Comments Anxiety Depression Mood Changes Anger or Temper Panic Fears Irritability Concentration Loss of Memory Excessive Worry History of Child Abuse History of Sexual Abuse History of Physical Abuse Feeling Manic Domestic Violence Thoughts of Hurting Someone Else Drug Problems Alcohol Problems Thoughts of Hurting Self Hurting Self Attempted Suicide Nightmares Hyperactivity Finances Legal Problems Sexual Concerns 5
6 Problems Now Past Comments Trusting Others Communicating with Others Often Make Careless Mistakes Parents People in General Marriage/Partnership Friend(s) Co-Worker(s) Employer Speak Without Thinking Fidget Frequently Distracted by Noises Waiting Your Turn Completing Tasks Sweating Heart Palpitations Muscle Tension Pain in joints Allergies Frequent Vomiting Sleeping Too Little Eating Problems Getting to Sleep Paying Attention Severe Weight Gain Nausea Abdominal Distress 6
7 Problems Now Past Comments Fainting Dizziness Diarrhea Shortness of Breath Chest Pain Lump in the Throat Headaches Caffeine Sleeping Too Much Waking Too Early Easily Severe Weight Loss Blackouts Head Injury Chills or Hot Flashes 7
James A. Purvis, Ph.D. Psychotherapy Services Agreement
James A. Purvis, Ph.D. Psychotherapy Services Agreement PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist
More informationEllyn L. Turer, PsyD, PLLC 1320 19 th Street, NW Suite 202 Washington, DC 20036 Tel: 202-293-6463, ellyn-turer@hushmail.com
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
More informationADULT INTAKE QUESTIONNAIRE. Today s Date: Home phone: Ok to leave message? Yes No. Work phone: Ok to leave message? Yes No
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Ok to leave message? Yes No Work phone: Ok to leave message? Yes No Cell phone: Ok to leave message? Yes No Email:
More informationSanta Fe Sage Counseling Center
Couple/Family Client Intake Date: Names: Partner/Parent/Child (circle one) Partner/Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Insurance ID #:
More informationMichael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION
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
More informationGrapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900
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
More informationIntake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #:
Intake Form PATIENT INFORMATION Patient Last Name: First Name: Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Gender: Employer:
More informationArrive 15 minutes before your scheduled appointment time.
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
More informationCLIENT QUESTIONNAIRE
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:
More informationSuzanne Burger, Psy.D. 24 Patterson Road Pound Ridge, NY 10576 (914) 764-5582 Fax (914) 234-2398
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
More informationDate of Current Marriage/Separation: Highest Level of Education:
ADULT INTAKE FORM Name: Date: Social Security: Home Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: May we call you and leave messages at home? Yes No May we call you and leave messages
More informationDeclaration of Practices and Procedures
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
More informationNEW PATIENT INFORMATION CONSENT AND AGREEMENT
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
More informationOUTPATIENT SERVICES CONTRACT
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
More informationClient Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no
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
More informationThe Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM
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
More informationAssociates for Life Enhancement, Inc. 505 New Road ~ PO Box 83 ~ Northfield, NJ 08225 Phone (609) 569-1144 ~ Fax (609) 569-1510 ~ 1-800-356-2909
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:
More informationNew Perspective Counseling Services Child/Teen Intake Form
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.
More informationOK to leave Messages?
Jami Howell, Psy.D., LLC Licensed Clinical Psychologist 1215 SW 18 th Avenue, Portland OR 97205 p (503) 504-5222 f (503) 224-2134 jami@doctorjamihowell.com Client Information Name: Preferred Name: Date
More informationIRVING & ASSOCIATES IN BEHAVIORAL HEALTH, P.C. 5151 Mochel Drive, Suite 307 Downers Grove, IL 60515
: / / 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
More informationMegan Ogle, PsyD Clinical Psychologist 1215 SW 18 th Avenue, Portland, OR 97205 971.313.4518 dr.meganogle@gmail.com
Megan Ogle, PsyD Clinical Psychologist 1215 SW 18 th Avenue, Portland, OR 97205 971.313.4518 dr.meganogle@gmail.com Client Information Date: Name: Preferred First Name: Date of Birth: / / SSN: - - Address:
More informationINITIAL INTAKE FOR MEGAN POLLOCK THERAPY (PLEASE COMPLETE PAGES 1 5 AND RETURN TO THERAPIST)
INITIAL INTAKE FOR MEGAN POLLOCK THERAPY (PLEASE COMPLETE PAGES 1 5 AND RETURN TO THERAPIST) Last Name: Dr. Mr. Mrs. Ms. First Name: Middle Initial: Date of Birth: Home Address: City: Zip Code: Social
More informationMindful Health Advantage, LLC
8015 West Alameda Ave., Ste 230, Lakewood, CO 80226 - - - CLIENT ADDRESS, CONTACT & FUNDING INFORMATION - - { CLIENT INFORMATION } Last Name First Name M.I. Date of Birth Ethnicity How did you hear about
More informationKathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677
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:
More informationJames H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc.
James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc. 89 Moraga Way, Suite B Tel: 925-285-2429 Orinda, CA 94563 Fax: 925-429-9259 Name
More informationName: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
More informationADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code
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
More informationThe Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680
The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680 Dear Client: It is a pleasure to have you in our practice. We appreciate the opportunity
More informationWarner Family Counseling
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
More informationClient Information (Please Print) Therapist name: Date: Social Security# Work Phone (Please circle your preferred number?)
Client Information (Please Print) Therapist name: Date: Name Last First Initial Street Unit # City/State/Zip Employer Email (Please provide email address. Will only be used for clinic purposes.) Social
More informationRACHEL LACY, PSY.D., PC 1805 Herrington Road, Building 2 Lawrenceville, GA 30043. PSYCHOTHERAPIST- PATIENT AGREEMENT (Revision 01/12)
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
More informationAGREEMENT AND INFORMATION
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.
More informationPATIENT INFORMATION Please complete for self or minor child responsible party information below. Street Apt. City State Zip
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.
More informationHANSEN-COHEN ASSOCIATES IN PSYCHOLOGY
HΨC HANSEN-COHEN ASSOCIATES IN PSYCHOLOGY 5237 SUMMERLIN COMMONS BLVD, SUITE 116 FORT MYERS, FLORIDA 33907 PHONE: 239.274.PSYC (7792) FAX: 239.247.5344 Informed Consent for Financial Responsibility & Psychological
More informationWithdrawal Symptoms: How Long Do They Last?
Withdrawal Symptoms: How Long Do They Last? Posted by First Step Medical Detox on November 24, 2015 When considering stopping drugs or alcohol, many addicts and alcoholics are concerned about the withdrawal
More informationTRI-CITIES CENTER FOR CHRISTIAN COUNSELING 1111 N. Eastman Road Kingsport, TN 37664 Phone: 423-246-5111 Fax: 423-246-5288 www.tricitiescounseling.
TRI-CITIES CENTER FOR CHRISTIAN COUNSELING 1111 N. Eastman Road Kingsport, TN 37664 Phone: 423-246-5111 Fax: 423-246-5288 www.tricitiescounseling.org EDWARD H. MARTIN, M.A., LPC.. MARLA S. FREEMAN, M.A.
More informationDale C. Godby, Ph.D., ABPP, CGP 6330 LBJ Suite 150 Dallas, Texas 75240 972-233-0648
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.
More informationSPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial)
Katherine E. Walker, PhD, LPC, NCC, BCIA-C Licensed Professional Counselor 8300 Health Park, Suite 201 Raleigh, NC 27615 Mobile: 919-760-3068 Fax: 919-676-9946 Email: walker@carolinaperformance.net Couples
More informationWake Forest Mind and Health, PLLC 501 North Main Street Wake Forest, NC 27587
Wake Forest Mind and Health, PLLC 501 rth Main Street Wake Forest, NC 27587 Katherine E. Walker, PhD, LPC, NCC, BCIA-C Jennifer Endries, MEd, LPC Licensed Professional Counselor Licensed Professional Counselor
More informationPATIENT INTAKE / HISTORY FORM PATIENT INFORMATION
Mona Mikael, Psy.D., PSY 25089 Neuro- Rehabilitation Psychologist Neuro- Rehab Psychological Consultation & Treatment 630 S. Raymond Ave., #340 Pasadena, CA 91105 626-710- 7838 Web: www.neurorehabtlc.com
More informationJane Beresford, Psy.D. Licensed Psychologist PSY 16618 (310) 551-8535 Info@DrBeresford.com 15300 Ventura Boulevard, Suite 301
Patient Information (PLEASE PRINT) Patient Name: _ Today s Date: Patient s SSN: - - DOB: / / Age: Sex: Marital Status (circle): Single Married Separated Divorced Other: Home Address: Email: OK to leave
More informationCounseling Intake Form (Each person attending therapy should complete a form)
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
More informationFAIRBANKS PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST If you wish, you can save time and simplify the registration process by completing the registration paperwork before you arrive. This checklist will help make sure you
More informationAmy Davis, M A, L P C
Date: Referred by: May they be contacted to acknowledge your arrival? Yes No Client Information Name: Home Phone: Address: Cell Phone: City: State: Zip: Email: Date of Birth: / / School Name: Grade: School
More informationMendel Psychological Associates
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
More informationMarian R. Zimmerman, Ph.D.
Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date
More informationMelanie Bierenbaum, Psy.D. Licensed Psychologist 3040 E. Cactus Rd, Suite A Phoenix, AZ 85032 Office: 602-769-2773
Service Agreement and Treatment Consent Welcome and thank you for choosing to work with Dr. Bierenbaum. This document contains important information about professional services, the psychologist-patient
More informationHealth Insurance Portability and Accountability Act (HIPAA)
Atlanta Center for Positive Change 333 Sandy Springs Circle NE Suites 109 & 127 Atlanta, GA 30328 Anne Lewis Moore, PsyD (404) 277-7992 Karen Kallis, M.Ed., LAPC, NCC (404) 423-1087 Ephrat L. Lipton, LCSW,
More informationAlison J. Bomba, Psy.D.
Alison J. Bomba, Psy.D. Licensed Psychologist OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please
More informationMichael S. McLane, Psy.D. Licensed Psychologist. Informed Consent to Treatment / Evaluation of a Minor Child. who was born on and who resides at
Michael S. McLane, Psy.D. Licensed Psychologist 12830 Hillcrest Road Suite D233 Dallas, TX 75230 Ph: (972) 620-1225 Fax: (972) 620-4393 Informed Consent to Treatment / Evaluation of a Minor Child I am
More informationPATIENT / PSYCHOTHERAPIST SERVICE AGREEMENT INFORMED CONSENT. Welcome!
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
More informationBetsy Mencher, Ph.D. Licensed Clinical Psychologist 1350 Connecticut Avenue, NW Suite 602 Washington, DC 20036
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)
More informationWELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance.
Lorie Jenddryka, MS, LCPC, CH 800 E. Northwest Highway, Suite 500 Palatine, IL 60074 (847) 794-8836 WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work
More informationNEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
More informationPARTNERS IN PEDIATRIC CARE. Intake and History for Mental Health Referral
PARTNERS IN PEDIATRIC CARE Intake and History for Mental Health Referral This form is designed to give you an opportunity to provide us with background information that will help us help you. Please read
More informationDeclaration of Practices and Procedures
Peggy S. Arcement, MS, MA, LDN, LPC, NCC Licensed Professional Counselor Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722
More informationIntake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:
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
More informationBehavioral Health Consulting Services, LLC
www.bhcsct.org infohealth@bhcsct.org 46 West Avon Road 322 Main St. 530 Middlebury Road Suite 202 Suite 1-G Suite 103 B Avon, CT 06001 Willimantic, CT 06226 Middlebury, CT 06762 Office phone- 1-860-673-0145
More information1455 West Fair, Marquette, MI 49855 Phone - 906.226.0574 // Fax - 1.888.347.1135 // info@mqtrehab.com
To our valued patients, In order to speed up the registration process and begin your treatment as soon as possible, please complete the forms listed below and bring the proper documentation to your first
More informationRIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
More informationPSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT
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 info@thebethesdagroup.com PSYCHOTHERAPIST-PATIENT
More informationNichol A. Moses, Psy.D., NCSP
PATIENT INFORMATION SHEET It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to
More informationPATIENT INFORMATION FORM
737 Pearl Street, Suite 108 Phone: 858.456.2114 Fax: 858.456.2103 www.abilityrehabsd.com PATIENT INFORMATION FORM Please print and complete ALL items. If an item doesn t apply, put N/A Patient Name: Age:
More informationHeather Carroll, PsyD, PLLC 2121 South Oneida St. Suite 240 - Denver, CO 80224 www.carrolltherapyconnections.com phone: 303-756-1355
Heather Carroll, PsyD, PLLC 2121 South Oneida St. Suite 240 - Denver, CO 80224 www.carrolltherapyconnections.com phone: 303-756-1355 CLIENT INFORMATION AND CONSENT Welcome to my practice. This document
More informationNORTHERN EDGE PHYSICAL THERAPY
REGISTRATION PAPERWORK CHECKLIST In order to make registration simple and quick, please use this checklist to make sure you have provided all necessary information and signatures. The process, including
More informationPATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone
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
More informationWray De Anda, Psy.D., PSY 25484 Licensed Clinical Psychologist 1940 W. Orangewood Ave, Suite-110 Orange, CA 92868 (714) 623-0997
Wray De Anda, Psy.D., PSY 25484 Licensed Clinical Psychologist 1940 W. Orangewood Ave, Suite-110 Orange, CA 92868 (714) 623-0997 Informed Consent & Agreement for Psychotherapy Services Effective July 7,
More informationTIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452
TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452 Dorothy B. Brown, Ph.D. Anne Davidge, Ph.D. Dennis J. Rog, Ed.D. Licensed
More informationMosaic Arlington Counseling Center 817 W. Park Row Arlington, Texas 76013 Phone: (817) 929-3408 NEW CLIENT INFORMATION
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
More information5421 Riverbluff Parkway North Charleston, SC 29420 (843) 300-0440 counseling@riverbluff.org
Minor Child 5-12 years Client Information Packet Please take a moment to complete all of the following information. This information will assist us in getting to know you and what prompted you to seek
More informationOFFICE POLICIES AND SERVICE AGREEMENT
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
More informationPATIENT INFORMATION I. IDENTIFYING INFORMATION DATE: Name: Date of Birth: Age: Street: City: State: Zip: Email: Phones: Home Work Cell
PATIENT INFORMATION I. IDENTIFYING INFORMATION DATE: Name: Date of Birth: Age: Street: City: State: Zip: Email: Phones: Home Work Cell Occupation / Grade in school: Place of Employment / School: Can we
More informationAndrew Elman LPC ATR PROFESSIONAL DISCLOSURE STATEMENT
Personal counseling is conducted in various ways, depending on the counselor. As my client, you have the right to know my qualifications, methods, and mutual expectations of our professional relationship.
More informationDeclaration of Practices and Procedures
Kyndal C. Jacoby, MSW, 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
More information11120 New Hampshire Ave., Suite 411 Silver Spring MD 20904 Office (301)754-0505 Fax (301)754-0509
PATIENT REGISTRATION FORM (PLEASE PRINT) PATIENT S LAST FIRST MIDDLE DATE OF BIRTH / / AGE: SEX: M F SOCIAL SECURITY # STREET ADDRESS APT # CITY STATE ZIP HOME CELL EMAIL MARITAL STATUS: SINGLE / MARRIED
More informationIntegrative Psycho-Therapy and Assessment Services, P.L.L.C. PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT
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
More informationAddiction Treatment Strategies
Patient Registration Legal Name First Middle Last Birth Date Address Street City State Zip Phone(s) Home Cell Work Is it ok to contact your cell? Yes No SSN Email (Used for appointment reminder) Known
More informationAdult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
More information8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078
Southern Connecticut Christian Counseling Center, Inc. dba R E N E W C O U N S E L I N G A S S O C I A T E S Christian therapists committed to serving you, your family, and your community 8 Wakeman Rd
More informationName: Date of Birth: Age: Address: Telephone: What is the best number to reach you? Can we leave a message at this number? Yes No
Athlete Intake Form Erin Haugen, Ph.D., LP, CC-AASP Licensed Clinical Psychologist and Sport Psychologist Assessment & Therapy Associates of Grand Forks, PLLC 725 Hamline St., Grand Forks, ND 58203 Phone:
More informationCopayment Is Due At Time Of Visit. Self-pay (payment due at time of service)
REGISTRATION FORM Please present your insurance card and photo ID at time of check-in. Settlement of patient financial responsibility is expected at time of service. Copayment Is Due At Time Of Visit.
More informationRenee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187
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
More informationKiran Mishra, Ph.D. Licensed Clinical Psychologist. Sugar Land, TX 77478 (832) 876-3232 TEXAS NOTICE FORM
Kiran Mishra, Ph.D. Licensed Clinical Psychologist 1111 Highway 6, Suite 235 Sugar Land, TX 77478 (832) 876-3232 TEXAS NOTICE FORM Notice of Psychologists Policies and Practices to Protect the Privacy
More informationMarci Danielson, M.S., LMFT COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES
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
More informationPATIENT DEMOGRAPHIC INFORMATION FORM
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
More informationPsychological Services Contract
Azmaira Maker, Ph.D. Licensed Clinical Psychologist (PSY 21570) 12625 High Bluff Drive, Suite 104 San Diego, CA 92130 Tel: (858) 531-1122 Fax: (866) 861-7731 www.drmaker.net Thank you for inquiring about
More informationLeonard M. Bohanon, PhD Psychologist
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
More informationAGAPE. Therapist Client Services Agreement
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
More informationSouthwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
More informationPERSONAL INJURY QUESTIONNAIRE
PERSONAL INJURY QUESTIONNAIRE NAME: PHONE: ( ) ADDRESS: CITY/STATE/ZIP: AGE: BIRTHDATE: SEX: SS # EMPLOYER'S NAME/ADDRESS: YOUR INSURANCE CO: POLICY #: AGENT'S NAME & PHONE: NAME ON POLICY (IF OTHER THAN
More informationAccident / Injury Report
Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. Auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked?
More informationAnn Dunnewold, Ph.D., 2012
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
More informationJ. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax
J. Gary Dolinsky, Ph.D. 161 South Main Street, Suite 309 Licensed Psychologist Provider Middleton, MA 01949 (978) 750 1990 phone (978) 739 4042 fax jgdol@aol.com www.jgarydolinskyphd.com Psychologist-Patient
More informationAdult Intake Information
Focus for Living, PLLC 308 East Renfro, Suite 202 Burleson, Texas 76028 817 295 8708 Office Use Only ID# Intake Date: Therapist: Hourly Fee: Previous Client: Y/ N Previous Date of FFL Service: PW Signed
More informationDeborah Issokson, Psy.D.
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
More informationTIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401
TIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 Minor Consent for Treatment and Service Agreement Welcome to Tidelands Counseling!
More informationChildren s Community Health Plan INTENSIVE IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE SERVICES ASSESSMENT AND RECOVERY / TREATMENT PLAN ATTACHMENT
Children s Community Health Plan INTENSIVE IN-HOME MENTAL HEALTH / SUBSTANCE ABUSE SERVICES ASSESSMENT AND RECOVERY / TREATMENT PLAN ATTACHMENT Please fax with CCHP prior authorization form to 608-252-0853
More informationPatient Registration Please Print Patient Name Last First Middle
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
More informationClient Information Bariatric Surgery Support Group
Client Information Bariatric Surgery Support Group (Please Print) Therapist: Rhonda Scarlata, LCSW Name first middle last Date Age Date of Birth Sex: Male Female Home Address street city state zip Cell
More informationSouthern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889
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
More information