Jodi L. Ceballos, Psy.D. Clinical Psychologist

Transcription

1 Hello, my name is Dr. Jodi Ceballos and I am a Licensed who recently relocated to Del Rio. I offer psychological and psycho-educational testing services, as well as individual, couples, and family therapy to children, adolescents, and adults. This package will contain several pieces of information that will help you have the best possible experience as a new patient. For your convenience, I have enclosed forms for you to complete and bring to your first visit. These include: a patient information form, a consent form, a release of information form, and a notice of privacy practices. If you would prefer, these forms are also available for download at my website which can be printed and completed (). There are a few other pieces of information that will also help with your experience here. Any previous evaluations that have been completed, IEPs, 504 Plans, or other relevant health information will allow me to more easily develop a treatment plan. I will also need to make a copy of your insurance card and identification. This is a fraud prevention precaution that the health insurance companies require for your protection. As a courtesy to other patients who are trying to schedule appointments, I ask that you provide 24 hours notice if you need to cancel or change your time. Failure to show up for a scheduled appointment which has not been canceled within 24 hours will result in a $75 fee. Please try to arrive about 15 minutes early for your first appointment to allow for check-in and to ensure that all of your paperwork is in order prior to your session. I will do my best to obtain as much detailed information about your insurance plan and any associated fees such as co-pays or deductibles prior to your appointment. You may also check with your insurance carrier to find out this information. Thank you and I look forward to working with you. Sincerely, Jodi Ceballos, Psy.D. Jodi Ceballos, Psy.D.

2 Therapy & Evaluation Services Therapy An intake appointment is the first step in setting up a therapy relationship. I will meet with you to discuss in more detail the current concerns. We can then discuss my suggestions about the best treatment approach and the best match for your particular needs. Therapy options include: Individual Therapy For children, adolescents, and adults Family Therapy Couples Therapy Psychological Evaluations Psychological evaluations are a crucial component to treatment planning. I often recommend an evaluation, especially if this is your first time coming in to our office. Evaluations help to determine appropriate diagnoses, develop appropriate treatment plans, coordinate care with other professionals, and provide insight as to what may be underlying a particular problem. Psychological evaluations assess whether the symptoms that someone is experiencing might be explained by a psychological diagnosis. An evaluation may also describe or explain the general psychological adjustment problems being presented by an individual, in an effort to understand the individual's behavior. Psychological tests are designed to examine a variety of cognitive abilities, including general level of cognitive functioning, memory, visual-perceptual-motor skills, speed of information processing, attention, language, and executive functions, which are necessary for goal-directed behavior. Educational evaluations are used to assess for academic difficulties or giftedness. In addition, the comprehensive version can be administered to assist with diagnosis of learning disabilities, to help design learning interventions, or to make educational program placement decisions. A comprehensive psychological or educational evaluation may take several hours, or even several days, depending on the problems being assessed, and the reason for the assessment. Each evaluation is tailored to the specific needs of the person and the questions that are being asked. I offer numerous types of evaluations including: Psychological Evaluations Educational Evaluations Diagnostic Screenings Bariatric Screenings If a previous evaluation has been conducted, please bring a copy of that evaluation to your first appointment. It is helpful to see what previous evaluators may have found in the past. Jodi Ceballos, Psy.D.

3 Patient Information Adult *Patient s name: Date of appointment: *Gender: F M Date of birth: Age: SSN: *Form completed by (if someone other than client): *Address: *City: State: Zip: *Phone (home): (work): (cell): *Occupation: FT PT *Where employed: *Emergency contact: Phone: *Spouse / Significant Other (if applicable) Name: DOB: Age: Address if different than above: Occupation: FT PT Where employed: Work phone: *Others Who Live in the Household Names Relationship Age Gender Insurance Information: *Primary Medical Insurance: Insurance # *Subscriber Name DOB SSN Secondary Medical Insurance Insurance # Subscriber Name DOB SSN Referred by: Family Doctor: *Current Medications and reason: *Health or medical issues: Jodi Ceballos, Psy.D.

4 *Primary concern(s) that brings you in: Jodi Ceballos, Psy.D.

5 Office Policies and Procedures This guide is intended to provide you with answers to questions about fees, appointments, insurance and how to contact me. Please read this guide carefully. If you have questions or concerns, please feel free to discuss them with me at any time. Services Offered: I offer a variety of services, which include, but are not limited to individual, family, couples, and group psychotherapy. I also offer psychological and psycho-educational evaluations and consultations. Appointments: Appointments are times that are reserved for you. It is important that if circumstances arise which require you to change an appointment, I ask that you provide me with at least 24 hours notice. This will allow me to offer your time to another patient. I charge a fee of $75 for appointments not cancelled with at least 24 hours notice. Fees for missed appointments are not billable to your insurance company. Time is valuable and if you continue to miss appointments without providing 24 hours notice, you and I will discuss your commitment to treatment and possible termination of services. Cost for Services: Co-payments and fees not covered by insurance are due at the time of service. I accept cash, check, and money order. A service charge may be added for any outstanding balances unpaid after 30 days from the date of service. The cost of therapy services is $120 for initial appointments and $80 for appointments thereafter. The cost of testing services is dependent on the complexity of the evaluation that is conducted. Health Insurance: Many health insurance policies cover the services that I offer. Nevertheless, reimbursement varies considerably from company to company and from policy to policy. Also, most policies have co-payments and some have annual deductibles, or other limits. It is up to you as the policyholder to read your policy carefully and be aware of what is or is not covered. I recommend that you call your insurance company directly to ask about your benefits. I will make my best effort to obtain reimbursement information for you. If your services are covered, I will bill your insurance company directly. If you do not have insurance, payment is expected on the day services are rendered. Confidentiality: Psychological services are best provided in an environment of trust. Because trust is so important, all services are confidential. Nevertheless, I am required by law to make exceptions in circumstances such as suspicion of child or elder abuse/neglect, immediate danger to yourself or another person. Please review the Notice of Privacy Policy for further information, and ask any questions you may have in our initial session. Emergencies: If you have a medical emergency, please call 911. My office is generally open Monday through Friday and my business phone number is (830) If you need immediate assistance and/or if you have a life-threatening emergency, please dial 911 and/or go to your nearest emergency room. Other Services: There are times when I am asked to complete paperwork or deliver services that are outside the realm of the medical record or coordination of care. Some examples include letter for Jodi Ceballos, Psy.D.

6 attorney, disability questionnaires, and school consultations/observations. These services are not covered by insurance and are charged at an hourly rate of $100. Electronic Communications: With the ease of electronic communication, many of my patients have been asking to correspond or schedule appointments electronically. I cannot guarantee that electronic communications will remain private, therefore if you choose to send me a communication (e.g. - , electronic appointment request, etc.), please be aware that third party vendors may have access to this information. Patient s Signature/ Parent/ Guardian Witness Date ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF JODI CEBALLOS, PSY.D. S OFFICE & PRIVACY POLICICES I hereby acknowledge that I have received, read, and understood the Office & Privacy Policies of Jodi Ceballos, Psy.D. Signature of Patient or Guardian Print Name of Patient or Guardian Date I hereby acknowledge that I have received, read, and understood the HIPAA regulations that were provided to me. Signature of Patient or Parent/Guardian Print Name of Patient or Parent/Guardian Date Jodi Ceballos, Psy.D.

7 Authorization to Disclose Confidential Healthcare Information Patient Name: Date of Birth: Address: I,, hereby authorize Jodi Ceballos, Psy.D. to release/disclose/obtain my confidential health information to the following specified individual: Name of Doctor or School: Address: Phone: Do Not Release Information The information to be used or disclosed is: Progress notes Psychological evaluation other (specify): The purpose(s) of the use or disclosure are: coordination of care at my request other (specify): Specific understandings: By signing this authorization form, you authorize the use or disclosure of your protected health information as described above. This information may be further disclosed if the recipient(s) described on this form is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations. You have a right to refuse to sign this authorization. Your healthcare, the payment for your healthcare, and your healthcare benefits will not be affected if you do not sign this form. You have a right to see and copy the information described on this authorization form in accordance with the policies of the Medical Practice. You also have a right to receive a copy of this form after you have signed it. If you sign this authorization, you will have the right to revoke it at any time, except to the extent that the Medical Practice has already taken action based upon your authorization. To revoke this authorization, please write to Privacy officer at the Medical Practice. Unless otherwise revoked, this Authorization will expire on the following date, event, or condition:. If I fail to specify an expiration date, event, or condition, this Authorization will remain valid for not more than twelve (12) months from the date this Authorization was signed. By: Date: Patient Parent Legal Guardian Jodi Ceballos, Psy.D.