Same as above. Address on File with Insurance Company: Phones (home): (cell): (work): Address: Referral Source: Name: Phone:

Transcription

1 Mental Health Intake Information Please complete all information on this form and bring it to the first visit. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Thank you! Patient Information: Name: Age: DOB: Date: Ethnicity: Social Security Number: Address: Insurance Type: Insurance Group Number (If applicable): Phone Number on back of Card: Current Address: Insurance Policy Number: City/State: Zip Code: Phones (home): (cell): (work): Place/type of Employment: Is the client currently seeing any other counselors or mental health therapists: Yes No If yes, please list name of counselor and date of last appointment: Payment: Type of Payment: Private Pay Insurance: Copay amount: Cash, Check and most Major Credit Cards are accepted for Payments Person responsible for payment (If different from Patient): Same as above Name: Age: DOB: SS#: Insurance Type: Address on File with Insurance Company: Insurance Policy Number: Same as above City/State: Zip Code: Phones (home): (cell): (work): Address: Referral Source: Name: Phone: (if available): Emergency Contact (in the case of an emergency, please provide the name and contact information of a person Regan Hager LMHC may notify) Name: Phone: Relation to Client: *Patient is responsible for payment (co-payment) upon receipt of services. 1

2 Patient s Spouse s name: N/A Current Address: Same as client, or Phone: Patient s Mother s Name: N/A Client is not a minor Current Address: Same as client, or Phone: Patient s Father s Name: N/A Client is not a minor Current Address: Same as client, or Phone: If Patient is a minor, Please List Current Caregivers Same as above N/A Client is not a minor Name: Relationship: Phone: Address: Patient is currently: Married Partnered Divorced Single Widowed Does the Patient have any Children? Yes No If yes, please list: Name Date of Birth/Age: Does the Patient have any Siblings? Yes No If yes, please list: Name Date of Birth/Age: Patient s Primary Care Physician Name and Phone Number: Date of last Apt: Any other Healthcare Provider(s) : Yes No If yes, Name and Type of Physician: Date of last Apt: Presenting Problem What are the problem(s) for which you are seeking help? What are your treatment goals? Current Symptoms Checklist: (check all that apply) Depressed mood Racing thoughts Excessive worry Unable to enjoy activities Impulsivity Anxiety attacks Sleep pattern disturbance Increase risky behavior Avoidance Loss of interest Increased libido Decrease need for sleep Hallucinations Decreased libido Suspiciousness Concentration/forgetfulness Change in appetite Excessive energy Excessive guilt Increased irritability Fatigue Crying spells 2

3 What is the main reason you are seeking services? Are there any recent changes in your life? Yes No If yes, How have these changes affected you? What are some of your strengths? What are some of your limitations? Have you ever attempted suicide? Yes No If yes, When: How: Do you currently have or have you recently had thoughts of harming yourself? Yes No If yes, describe: Have you ever attempted to harm yourself? Yes No If yes, When: How: Do you currently have or have you recently had thoughts of harming another person Yes No If yes, describe: Patient Health History: Does the patient have any current or chronic health issues? Yes No If yes, please list: Is the patient currently taking any medication? Yes No If yes, please list: Type: Start Date: Dosage: Reason for Medication Current over-the-counter medications or supplements: Family Medical History (Current or past): Patient Unknown Mother Unknown Father Unknown High blood pressure Yes No Yes No Yes No Diabetes Yes No Yes No Yes No Lung problems (asthma) Yes No Yes No Yes No Heart problems Yes No Yes No Yes No Miscarriages Yes No Yes No Learning problems Yes No Yes No Yes No Mental illness Yes No Yes No Yes No Drinking problems Yes No Yes No Yes No Domestic violence(victim) Yes No Yes No Yes No Past Psychiatric History: Previous Counseling Yes No If yes, Please describe when, by whom, and nature of treatment. Reason Dates Treated By Whom Psychiatric Hospitalization Yes No If yes, describe for what reason, when and where. Reason Date Hospitalized Where 3

4 Past Psychiatric Medications (Check all that apply): If you have ever taken any of the following medications, please indicate the dates, dosage, and how helpful they were (if you can't remember, just write in what you do remember). Antidepressants Date: Dosage: Response to Medication Prozac (fluoxetine) Zoloft (sertraline) Luvox (fluvoxamine) Paxil (paroxetine) Celexa (citalopram) Lexapro (escitalopram) Effexor (venlafaxine) Cymbalta (duloxetine) Wellbutrin (bupropion) Remeron (mirtazapine) Serzone (nefazodone) Anafranil (clomipramine) Pamelor (nortrptyline) Tofranil (imipramine) Elavil (amitriptyline) Other Mood Stabilizers Date: Dosage: Response to Medication Tegretol (carbamazepine) Lithium Depakote (valproate) Lamictal (lamotrigine) Tegretol (carbamazepine) Topamax (topiramate) Other Antipsychotics/Mood Stabilizers Date: Dosage: Response to Medication Seroquel (quetiapine) Zyprexa (olanzepine) Geodon (ziprasidone) Abilify (aripiprazole) Clozaril (clozapine) Haldol (haloperidol) Prolixin (fluphenazine) Risperdal (risperidone) Other Sedative/Hypnotics Date: Dosage: Response to Medication Ambien (zolpidem) Sonata (zaleplon) Rozerem (ramelteon) Restoril (temazepam) Desyrel (trazodone) ADHD medications Date: Dosage: Response to Medication Adderall (amphetamine) Concerta (methylphenidate) Ritalin (methylphenidate) Strattera (atomoxetine) Other Antianxiety medications Date: Dosage: Response to Medication Xanax (alprazolam) Ativan (lorazepam) Klonopin (clonazepam) Valium (diazepam) Tranxene (clorazepate) Buspar (buspirone) Other 4

5 Family Psychiatric History: Has anyone in your family been diagnosed or treated for any of the following: (Check all that apply) Bipolar disorder Schizophrenia Depression Anxiety Post-traumatic stress Alcohol abuse Anger Suicide Violence Other substance abuse If yes, who had each problem? Substance Use: Have you ever been treated for alcohol or drug use or abuse? Yes No If yes, for which substances? If yes, where were you treated and when? Do you think you may have a problem with alcohol or drug use? Yes No Have you used any street drugs in the past 3 months? Yes No If yes, which ones? Tobacco History: How you ever smoked cigarettes? Yes No Currently? Yes No How many packs per day on average? How many years? In the past? Yes No How many years did you smoke? When did you quit? Pipe, cigars, or chewing tobacco: Currently? Yes No In the past? Yes No What kind? How often per day on average? How many years? Educational History: Highest Grade Completed? Where? Did you attend college? Where? Major? What is your highest educational level or degree attained? Occupational History: Are you currently: Working Student Unemployed Disabled Retired How long in present position? What is/was your occupation? Where do you work? Have you ever served in the military? If so, what branch and when? Honorable discharge ( ) Yes ( ) No Other type discharge Relationship History and Current Family: Are you currently: Married Partnered Divorced Single Widowed Legal History: Have you ever been arrested? Do you have any pending legal problems? Spiritual Life: Do you belong to a particular religion or spiritual group? Yes No If yes, what is the level of your involvement? Do you find your involvement helpful during difficult times, or does the involvement make things more difficult or stressful for you? more helpful stressful Is there anything else that you would like us to know? 5

6 CONSENT TO TREATMENT Today's Date: Patient Name: Date of Birth: I, the Patient (or legal guardian of the minor patient), hereby voluntarily consent to outpatient mental health services from Regan Hager LMHC which encompasses assessments and subsequent therapeutic treatments, if indicated. I understand and agree that all charges incurred on behalf of my care here are my responsibility. I understand that if I have insurance, it will be billed as a courtesy and payments/credits from my insurance company will be made accordingly. I authorize any holder of medical or other information about me to be released to Electronic Data Systems, Federal, Department of Public Health or other carriers any information needed for any related claim. I permit a copy of this authorization to be used in place of the original to request payment of medical benefits. I, the undersigned, authorize payment of medical benefits to Regan Hager LMHC for any services furnished to me by the mental health therapist. I authorize any holder of medical information about me to release to the Health Care Financing Administration, Social Security Administration and its agents any information needed to determent these benefits or benefits payable for related services. I understand that this consent form will be valid and remain in effect as long as I receive services from Regan Hager LMHC. HIPPA/Notice of Privacy Practices: By signing below, I understand that the information contained within this document pertains to certain rights to how my protected health information is utilized in the treatment, payment and healthcare operations at this facility. I understand that, if I am more than 15 minutes late for a scheduled session, I may not be able to be seen by my clinician on that day. Please check any method of communication that is not acceptable for us to contact you: Phone Text Message Physical Mail Reason for visit: stress/anxiety depression anger issues divorce/relational problems communication difficulties traumatic event behavioral problems ADHD school/job related stressors other This form has been explained to me and I fully understand this Consent To Treatment and agree to its contents. Signature of Patient or Person Authorized to consent for patient: X Date: Signature of Witness (Name and Credentials) who explained the contents of this "Consent to Treatment" form: Date: I have seen and been offered a copy of HIPPA s Patient s Bill of Rights and Privacy Policies I have seen and been offered a copy of Regan Hager LMHC s Client s Bill of Rights 6

7 AUTHORIZATION FOR RELEASE OF INFORMATION Client: SSN: DOB: Authorized Consultant: Regan Hager LMHC I certify that I am the patient or person authorized to consent for patient. I hereby authorize representatives from the following agencies/programs to engage in verbal, written, or electronic communication on behalf of myself (or client if minor) with the specific provider named above. I am aware that the information exchanged will be used for professional purposes in the development of a treatment plan and that the information will be considered strictly confidential. Therefore, I release all agencies/professionals involved from any legal liability that may arise from this transfer of information. Any information obtained is for the sole use of this agency and shall not be re-released. Please check one box per form. Lakeview Center, Inc. DCF Children s Home Society Escambia County Schools Lutheran Services Santa Rosa County Schools Families First Network (FFN) Okaloosa County Schools Avalon Center, Inc. DJJ Bridgeway Center, Inc. Guardian Ad Litem Program COPE Center, Inc Children s Medical Services Private Physician: Private Hospital: Other: Private Agency: TYPE OF INFORMATION TO BE EXCHANGED Check all that apply School Records/Testing Speech/Language Evaluations Health and Medical Records Psychological Evaluations Psychiatric Evaluations Psychosocial History/Reports DCF Records and Reports Mental Health Records Other: Attendance/Progress Summary The above includes, but is not limited to, available verbal and written information regarding: past and present functioning in school, community, and residence; review and results of previous interventions; past and present living environment and the impact of this on the client s current functioning and capacity to benefit from intervention. This information will be discussed and reviewed by members of the client s specific Multi- Disciplinary staffing as part of the Mental Health therapeutic process. This authorization will remain in effect for one (1) year from the date of my signature. I understand that I may withdraw this authorization at any time by written notification to the assigned Mental Health consultant. Mental Health Counselor, Regan Hager LMHC: Date: Signature of Patient or Person Authorized to consent for patient: X Date: 7

8 Cancellation Policy/No Show Policy My goal is to provide quality individualized Behavioral Health care in a timely manner. "No-shows", and late cancellations inconvenience those individuals who need access to Behavioral Health care in a timely manner. I would like to outline my office s policy regarding missed appointments. This policy enables me to better utilize available appointments for my patients in need of timely care. 1. Cancellation for Scheduled Appointment I understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and I am unable to schedule you for a visit, due to a seemingly full appointment book. In order to be respectful of the needs of other patients, please be courteous and contact Regan Hager LMHC promptly if you are unable to show up for an appointment. If it is necessary to cancel your scheduled appointment, I require that you call at least 24 hours in advance in order to give another person the possibility to have access to timely care. Late cancelation: there will be a $35.00 fee will be billed to your account How to Cancel Your Appointment To cancel appointments, please call or text If you reach the voic you may leave a detailed message on the voice mail. You may also your need to cancel your appointment to If you would like to reschedule your appointment, please leave your phone number. I will return your call and give you the next available appointment time. 2. No- Show for Scheduled Appointment A "no-show" is someone who misses an appointment without cancelling it in an adequate manner. A failure to be present at the time of a scheduled appointment will be recorded in your record as a "no-show". No-show/No-Call missed appointment: $60.00 fee will be billed to your account Grievance Policy As a client of Regan Hager LMHC I want to ensure that you are satisfied with the mental health services that you are receiving. If you are not satisfied, you have the right to file a grievance. A grievance is an expression of dissatisfaction about the services that you are receiving. If you decide to file a grievance, you can do so without fear of punitive action by your mental health counselor. Examples of types of grievances include the following areas: a. Access-to-Care: This category addresses the provider s capacity to arrange a timely first visit. b. Clinical Care: This category relates to any aspect about the assigned consultant and the quality of services that are provided by the therapist (e.g. their manner, competency, the treatment, etc.). c. Claims: category applies to issues related to claims or the payment of claims. If you decide to file a grievance you must do the following: a. You must file a grievance within one year after the date of the occurrence that initiated the grievance. b. You may file the grievance either orally or in writing however an oral request must be followed with a written request but the time frame for resolution begins the date of the oral filing. You will receive written notification acknowledging receipt of the grievance. c. If your grievance is with your clinician, talk to the clinician first. d. If you are still not satisfied, contact your insurance provider. My signature acknowledges that grievance policy and the Cancelation/No Show policy has been reviewed with me. Date Patient/Caregiver Printed Name Patient/Caregiver Signature Regan Hager LMHC Intake Packet Revised May 2015

9 Limits of Confidentiality Contents of all therapy sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client s legal guardian. Noted exceptions are as follows: Duty to Warn and Protect When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client. Abuse of Children and Vulnerable Adults If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities. Prenatal Exposure to Controll ed Substances Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. Minors/Guardianship Parents or legal guardians of non-emancipated minor clients have the right to access the clients records. Insurance Providers (when applicable) Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes, and summaries. I agree to the above limits of confidentiality and understand their meanings and ramifications. Signature of Patient or Parent / Guardian if client is a minor Date Regan Hager LMHC Intake Packet Revised May 2015

10 Regan Hager, LMHC 4300 Bayou Blvd. Suite 21 Pensacola, FL Financial Policy We make every effort to keep our costs down. All co-pays, co-insurance, deductibles and payments for non-covered services are to be paid at the time the services are rendered. For patients with insurance policies for which our office does not participate, or patients who are self-pay, we require payment upon receipt of service. Due to an increased number of patients cancellations/no shows for scheduled appointments, we have been forced to institute a cancellation policy. When appointments are cancelled without adequate notice, we are unable to schedule another patient in that appointment time slot. Any cancellations without one business day notice will risk a charge of $ You will receive a phone call, text, or regarding your missed/cancelled session and your card will be charged immediately. Exceptions will be made for emergencies and will be taken into consideration session by session. Thank you for your understanding and attention to this policy. Credit Card Information Name on card: Card number: Exp. Date Security code: Zip code of billing address: By signing here you are authorizing Regan Hager, LMHC to charge your card for the missed session. Patient Signature: Date: Regan Hager LMHC Intake Packet Revised May 2015