LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL 60062

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1 PHONE: LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL Intake Form Date of Intake: Caller: DRLEIGHWEISZ.COM Referral Source: May I thank referral person? Y N Name of Client: Date of Birth: Gender: M F Age: Social Security #: Address: (street) (city) (state) (zip) Home phone May I leave a message? Y N Cell/Work: May I leave a message? Y N May I you? Y N (I understand that transmission cannot be guaranteed to be secure as information can be intercepted, lost, arrive late or incomplete.) Marital Status: Occupation/School & Year: Guarantor Name: Date of Birth: Gender: M F Address: (street) (city) (state) (zip) Home Phone: Cell/Work: Marital Status: SS #: Occupation/School & Year: Additional Family Members DOB Gender M F Phone/ Occupation/School & Year Relationship to Client

2 Clinical Information: Have you ever had previous counseling or psychotherapy? Yes No If yes, by whom, when and for what? Have you ever been hospitalized for a psychiatric reason? Yes No Have you ever made a suicide attempt/gesture? Yes No Do you (or child) have any current thoughts of hurting or killing self? Yes No Please list any current or chronic health problems: Please list any current medications (prescribed & OTC): In the space below, please describe your reason(s) for seeking services:

3 LEIGH WEISZ, PSY.D. LICENSED CLINICAL PSYCHOLOGIST 900 SKOKIE BLVD SUITE 115 NORTHBROOK, IL PHONE: DRLEIGHWEISZ.COM SERVICE AGREEMENT/CONSENT FOR TREATMENT FEES & PAYMENT The fee for an initial evaluation is $175. The fee for an individual therapy session and/or a family session(both last minutes) is $150. For services lasting less than 10 minutes within a week period, I will not charge for my time. When services last longer than 10 minutes, I will charge for this service by prorating my hourly fee of $150. Billable services lasting longer than 10 minutes include, but are not limited to: report writing, telephone consultations, attendance at meetings with other professionals you have authorized, preparation of treatment records or treatment summaries, and the time spent performing other services you may request of me. Payment is expected at the beginning of each session, unless another arrangement is agreed upon in advance. For psychological testing, I charge a flat fee based on the hours required to administer and score tests, interpret the results, write a report, and provide feedback. In some cases, I will recommend observing a child in a school setting or be asked to attend a meeting with school professionals to review the test results. I charge my hourly rate for the time spent at the school as well as the time it takes for me to drive to and from the school. I am often asked to collaborate with other providers including psychiatrists, psychotherapists, occupational therapists, tutors, teachers, or other school professionals. I will do so only with your consent. I will charge my hourly rate for these conversations/collaborations. For psychological testing, I ask that a portion of the total bill be paid up front after the initial consultation and that the rest of the payment be made prior to my release of the report. Fees are subject to increase at my discretion as long as I provide written notice to all affected parties 30 days in advance of the fee increase. If your account has not been paid for more than 30 days and arrangements for payment has not been agreed upon, services may be terminated. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I will release regarding a client s treatment is his/her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT I do not accept insurance but will provide you with the information necessary to submit claims to your insurance provider on your own. However, you not your insurance company--- are ultimately responsible for full payment of services rendered. For that reason, it is highly recommended that you find out exactly what mental health services your insurance policy covers and that you keep track of pre-certifications, pre-authorizations, pre-notifications, deductibles, co-pays, co-insurance, and total sessions allowed.

4 Please be aware that therapy involving children and adolescents generally requires a number of services over and above the face-to-face session time spent with a client. These services include, but are not limited to: communication/collaboration via telephone or in-person with relevant people in the child s life (e.g., parent(s), teachers, school social worker, psychiatrist, occupational therapist, etc.); school observations and staffings; and progress reports and treatment summaries requested by schools or the court system. These services require my professional time and will be billed in accordance with the fee structure discussed in the aforementioned paragraph (i.e., a charge for services that take longer than 10 minutes). I will do my best to inform you in advance about the need for these services and will answer any questions you have. CANCELLATION POLICY Any cancellations must be made at least 24 hours in advance of the scheduled session. If you do not call to cancel and/or fail to show, you will be charged the full fee for that appointment. Extenuating circumstances are considered when appropriate. CONTACTING ME You may leave me a confidential voic at Though I am often not immediately available by telephone, I check my voic regularly on weekdays. You may leave a message on my confidential voic . I make every effort to return phone calls within 24 hours. In the event of an emergency, call 911 or proceed to your nearest emergency room for immediate care. CONFIDENTIALITY/PRIVACY All information concerning clients is held confidential and is released only through procedures consistent with the law and professional ethics. The rules of confidentiality provide that clients whose mental or emotional condition is an issue in a court of law may lose their right to confidentiality, and the court may successfully order records released and/or staff to testify. The law also requires that if knowledge is gained that a person may harm his/herself or any other person, the requirement to help or warn may take precedence over the obligations of confidentiality (and may include notifying the potential victim, contacting the police, or seeking hospitalization for the client). The law specifically obligates the therapist to report to the appropriate state agency any reasonable suspicion of child or elder abuse. These situations have rarely occurred in my practice. If they arise, I will make every effort to discuss the issue fully with you before taking action. I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel it is important to our work together. In certain testing situations, I request permission from parents to videotape and/or have a colleague observe a session for the purpose of collaboration. In those situations I will ask permission to share identifying information with a colleague.

5 PROFESSIONAL RECORDS The laws and standards of my profession require that I keep a treatment record for each client. This record contains protected health information about you and/or your child. You may examine and/or receive a copy of your/your child s record (if child is under 12), if you request it in writing. Because these are professional records, they can be misinterpreted by untrained readers. For this reason I recommend that you review them in my presence or have them forwarded to another mental health professional so you can discuss the contents. MINORS Clients under 12 years of age and their parents should be aware that the law allows parents to examine their child s treatment records. Parents of children between 12 and 18 years old cannot examine their child s treatment records unless the child consents and unless I find there are no compelling reasons for denying the access. If the child consents, I will provide parents with general information about their child s progress and his/her attendance at scheduled sessions. All other communication will require the child s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case I will notify the parent of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objects he/she may have. Client Consents to Terms of Agreement: We, the undersigned, understand this Service Agreement and apply for services with Dr. Leigh N Weisz in accordance with this agreement. A signature is required from the parent(s) or guardian(s) who have legal responsibility for medical decisions for children in treatment. Printed Name Signature Date Printed Name Signature Date Printed Name Signature Date Leigh N. Weisz, PsyD Signature Date Licensed Clinical Psychologist

6 Leigh Neiman Weisz, Psy.D. Licensed Clinical Psychologist NOTICE OF PRIVACY PRACTICES This Notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. I am required to give you this Notice about the use and disclosure of your health information, my legal responsibilities, and your rights concerning your health information and to abide by the terms of this notice. You may request a copy of this Notice at any time. 1. USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION We use and disclose the minimum necessary health information about you for treatment, payment, and health care operations. a. For Treatment. It may be beneficial at times to your treatment to provide your health information to another health care provider. In these situations, you must sign an authorization for release of information. b. For Payment. I may use and disclose your health information to obtain payment for services I provide to you as delineated in the Service Agreement. c. For Health Care Operations. I may use and disclose your health information as part of my practice s internal health care operations. Examples include reviewing records to assure quality or informing you of services, educational activities, and programs that I feel might be of interest to you. 2. INFORMATION DISCLOSED WITHOUT YOUR CONSENT Under Illinois and federal law, information about you may be disclosed without your consent in the following circumstances. a. Emergencies. Sufficient information may be shared to address and immediate emergency you are facing. b. Judicial and Administrative Proceedings. I may disclose your personal health information in the course of a judicial or administrative proceeding in response to a valid court order or other lawful process, including if you were to make a claim for Workers Compensation. c. Public Health Activities. If I felt you were an immediate danger to yourself or others, I may disclose health information about you to the authorities, as well as alert any other person who may be in danger. d. Child/Elder Abuse. I may disclose health information about you related to the suspicion of child and/or elder abuse or neglect. e. Criminal Activity of Danger to Others. I may disclose health information if a crime is committed on my premises or if I believe there is someone who is in immediate danger. f. National Security, Intelligence Activities, and Protective Services to the President and Others. I may release health information about you to authorized federal officials as authorized by law in order to protect the President or other national or international figures, or in cases of national security. g. Health Oversight Activities. I may disclose health information to a health oversight agency for activities authorized by law, such as audits or inspections by the government to monitor the health care system and assure compliance with civil rights laws. h. Business Associates. I may disclose the minimum necessary health information to business associates that perform functions on my behalf or provide me with services if the information is necessary for such functions or services (e.g., financial audit firm coming in contact with client billing records). All of my business associates sign agreements to protect the privacy of your information. i. Scheduling Appointments. I may contact you via telephone to schedule or remind you of appointments.

7 3. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION a. Right to Inspect and Copy. You have the right to look at or get copies of your health information, with limited exceptions. Your request must be in writing. If you request a copy of the information, a reasonable charge may be made for the costs incurred. b. Right to Amend. You have the right to request that I amend your health information. Your request must be in writing, and it must explain why the information should be amended. I have the right to deny your request under certain circumstances. c. Right to an Accounting of Disclosures. You have the right to receive a list of instances in which I have disclosed your information for a purpose other than treatment, payment, or health care operations. You might submit your request in writing. d. Right to Request Restrictions. You have the right to request a restriction or limitation on the health information I use or disclose about you. For example, you could ask that I not share information with an insurance company, in which case you would be responsible to pay in full for the services provided. I am not required to agree to your request, but I will consider the request very seriously. If I agree, I will abide by our agreement unless the information is needed in an emergency or by law. e. Right to Request Confidential Communications. You have the right to request that I communicate with you about health matters in a certain way or at a certain location. For example, you may ask that I contact you only by mail or at work. You must make this request in writing, and it must specify the alternative means or location that you would like me to use to provide you with information about your health care. I will make every attempt to accommodate reasonable requests. f. Right to Obtain a Paper Copy of this Notice. You have the right to receive a paper copy of this notice and any amended notice upon request. Any other uses and disclosures not set out in the information above will be made only with your written authorization. You may revoke a written authorization for release of information at any time. The revocation must be in writing and will become effective when it has been received by me, and will only be for disclosures not already completed. I reserve the right to change my privacy practices provided such changes are permitted by applicable law. Before the effective date of a material change, however, I will change this Notice and make a new Notice available to you. QUESTIONS AND COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with me or with the U.S. Department of Health & Human Services. I will not retaliate in any way if you choose to file a complaint.

8 Leigh Neiman Weisz, Psy.D. Licensed Clinical Psychologist Acknowledgment of Receipt: Notice of Privacy Practices By signing this form, you acknowledge that you have received the Notice of Privacy Practices of Dr. Leigh Neiman Weisz. This notice provides information about how I may use and disclose your protected health information. I encourage you to read it in full. The Notice of Privacy Practices is subject to change. You may obtain a copy of the current notice by contacting Dr. Weisz at I acknowledge that I have received the Notice of Privacy Practices. Signature Printed Name Date (client, parent/guardian) If no signature is obtained above, describe the good faith efforts made to obtain the individual s acknowledgment, and the reasons why the acknowledgment was not obtained: Signature Printed Name Date (therapist)

9 Consent Form I,, grant consent for my mental health care provider,, to correspond with me via for the purpose of scheduling appointments, or conveying general information about my treatment or the treatment of my child. I understand that is not a secure form of communication and that confidentiality of any ed information cannot be ensured. Please be advised that is not to be used in order to communicate urgent matters or emergencies. This is not a consent to release information to any specific person other than the patient (or the patient s parent when the patient is under age 12) Please indicate your address: Signature of Patient (or parent of Patient under age 12) Witness Signature of Parent for Child between 12 and 18 years of age if parent intends to Date Date

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