INTAKE FORM - Healing Mindshealingminds.com/.../2017/04/Adult-Intake-Forms.pdf · INTAKE FORM The...
Transcript of INTAKE FORM - Healing Mindshealingminds.com/.../2017/04/Adult-Intake-Forms.pdf · INTAKE FORM The...
INTAKEFORMThetherapyandcounselingworkwedoisuniquetoyou,justasitistoeachoneofourclients.Beforewegetstartedweneedtocollectsomegeneralinformationfromyou.
GENERALINFORMATION
FirstName LastName Gender
DateofBirth(mm/dd/yyyy) SocialSecurityNumber
Address
City State ZipCode
MainPhone OtherPhone
EMERGENCYCONTACT
FirstName LastName
Phone Relationship
Doyouauthorizethispersontodiscusscareortreatmentwiththeofficeinthecaseofanemergency?
☐ YES ☐ NO
INSURANCEINFORMATION
PRIMARYINSURANCE PolicyHolder
PolicyHolderD.O.B.(mm/dd/yyyy) Relationship
PolicyHolderAddress
City State ZipCode
PolicyNumber GroupNumber
SECONDARYINSURANCE PolicyHolder
PolicyHolderD.O.B.(mm/dd/yyyy) Relationship
PolicyHolderAddress
City State ZipCode
Policy Number Group Number
MENTALHEALTHHISTORY/STATUSWhatproblemsareyouseekinghelpfor?
PastMentalHealthTreatment
Haveyoueverbeenhospitalizedforpsychiatricreasons? ☐ YES ☐ NO
Ifyes,whenandwhere?
Haveyoueverhadoutpatienttreatmentbyapsychiatrist? ☐ YES ☐ NO
Ifyes,whenandbywhom?
Haveyoueverreceivedcounselingorpsychotherapyinthepast? ☐ YES ☐ NO
Ifyes,whenandbywhom?
PleaseListanypsychiatricmedicationyouhavetakenoraretaking:
Medication Date SideEffects/Benefits
PleaseCheckallthatapply:
☐ Depressedmood ☐ Excessivetalking ☐ Unreasonablefear
☐ Lostorgainedweight ☐ Racingthoughts ☐ Fearofsocialsituations
☐ Notenoughsleep ☐ Easilydistracted ☐ Repetitivethoughts/behavior
☐ Toomuchsleep ☐ Overworkingyourself ☐ Upsettingmemories
☐ Sluggish ☐ Impulsivebehavior ☐ Recentloss/grief
☐ Agitated ☐ See/hearthingsthatarenotreal ☐ Work/schoolproblems
☐ Nevertired ☐ Suspectthingsmaynotbereal ☐ Violentthoughts/behaviors
☐ Cannotconcentrate ☐ Tense/unabletorelax ☐ Selfharm
☐ Afraidtoleavehome ☐ Excessiveworry ☐ Angeroutburst
☐ Inflatedselfesteem ☐ Panicattacks ☐ Careless,high-riskbehavior
☐ Feelguiltyorworthless ☐ Thoughtsofdeathorsuicide ☐ Financialproblems
GENERALMEDICALHISTORY
PrimaryCarePhysician:Pleaselistanymedicalproblemsyoumayhavebelow:
Pleaselistanyseriousmedicalproceduresyouhavehadinthepast:
Areyouonanymedicationsforanygeneralmedicalproblemsyoumayhave? ☐ YES☐ NO
Ifyes,whichones?
Doyouhaveanyallergiestomedications?☐ YES☐ NO
Ifyes,whichones?
Alcohol,Drug,andTobaccoUse
Describeyouruseofalcohol:
Describeyouruseofrecreationaldrugs:
Describeyouruseoftobacco:
FamilyMedicalHistoryListanyhistoryofillness(mentalorother)andsubstanceabuseamongbloodrelatives:
Mother’sside Father’sside
SOCIALHISTORY
Birthplace: Wheredidyougrowup?
Didyourparentsgetdivorcedasachild?☐ YES☐ NO
Ifso,howoldwereyouwhentheyseparated?
Father’soccupationgrowingup:
Mother’soccupationgrowingup:
Howmanysiblingsdoyouhave?
Didyouhaveanyearlydevelopmentproblemsasachild?
Areyou/wereyouavictimofanyformofphysical/sexual/emotionalabuse?
HighestLevelofEducation:Pleaselistthelastthreejobsyouhavehadbelow:
Currentemployment:
Areyoucurrentlyinaromanticrelationship?☐ YES☐ NO Duration:_________
Describeyourrelationship:
Spouseorpartner’scurrentoccupation:
Doyouhaveanychildren?☐ YES☐ NO Howmany?_________
Whatareyourchildren’snamesandages?
Whatactivitiesdoyouenjoydoing?
Haveyoueverbeenconvictedofanycrimes,servedtime,orbeenonprobation?☐ YES☐ NO
Details:Pleaselistanyadditionalnotesthatyouthinkwouldbehelpfulfortreatmentbelow:
CONSENTTOTREATMENT
FirstName LastName
Youareabouttotakeaveryimportantstepinyourmentalwellnessplan,andyouareseeingamentalhealthprofessional.Asyourmentalhealthprovider,wewillbeenteringintoaprotectedrelationship.Treatmentmightinvolveamultidimensionalfamilyapproach.Duetothisconsentisneededforallthoseattendingsessions.
Wearetreatingyouandwewilldoourbesttoaccuratelydiagnoseyouanddesignacomprehensivetreatmentplanthatwillenableyoutocontinuewithanormalemotionaldevelopment.Thismayincluderecommendationsoftherapy,ormedications.Thisisallpartoftheserviceofamentalhealthprofessional.Wewillalsoworkwithyourprimarycarephysiciantoassurecoordinationofcare._________(Initial)
Youareourclientandhaveconfidentiallyrights.Confidentialitydoesnotapplyundercertainsituation:Weareobligatedbylawtoreportanysuspicionofchildabuse.Thisincludesphysicalorsexualabuse.Also,wehaveadutytoprotectifwesuspectanyoneisindangerofkillingthemselvesorhasmadethreatstohurtsomeoneelse.Exceptintheseraresituations,yourchildhastherighttokeepparticulartopicsconfidentialfromevenhis/herguardian.Pleaserespectthisconfidentiality.Again,ifthereisanyconcernofharm,suicideorotherdangerousbehavior,wewillinformyou.
IfIrequireorthinkitisinyourbestinteresttocommunicatewithanoutsidesource,Iwillrequestareleaseofinformation.Toassuregoodtherapeuticcare,frequentappointmentsarerequired.Unlessarrangedotherwise,clientsthathavenotbeenseenin3monthswillbeconsideredinactive.Anewevaluationwillberequiredforanyinactiveclienttobeseen._________(Initial)
I,_______________________________(client),doherebyseekandconsenttotakepartinthetreatmentprovidedbyHealingMinds,LLC.IfIamattendinggroupservicesIalsounderstandandconsentthatconfidentialitystillappliesandthatHealingMinds,LLCisnotliableforgroupmembersbreakingconfidentiality.Iunderstandthatdevelopingatreatmentplanwiththisproviderandregularlyreviewingourworktowardthetreatmentgoalsareinmybestinterest.Iagreetoplayanactiveroleinthisprocess.Iunderstandthatnopromiseshavebeenmadetomeastotheresultsoftreatmentorofanyproceduresprovidedbythismentalhealthprofessional._________(Initial)
IamawarethatImaystoptreatmentwiththismentalhealthprofessionalatanytime.IunderstandthatImayloseotherservicesormayhavetodealwithotherproblemsifIstoptreatment.(Forexample,ifmytreatmenthasbeencourt-ordered,Iwillhavetoanswertothecourt.)_________(Initial)
IamawarethatifIattempttocontactmyproviderthroughphone,email,text,oranyotherformofcommunicationovertheInternet,myinformationmaynotbecompletelysecure.Intheeventthatmyinformationisintercepted,HealingMindsisnotresponsibleforthebreachofpatientprivacy.Belowaretheapprovedcontactmeanstoleavemessagesonorrespondtoifcontacted:
Phone Email
_________(Initial)
ClientName(pleaseprint)
ClientSignature Date
LIFETIMEINSURANCEAUTHORIZATIONANDRELEASEOFINFORMATION
FirstName LastName
ReleaseofInformation:I,thesubscribernamedbelow,authorizeHealingMinds,LLCandanyphysiciansworkingunderHealingMinds,LLCexaminingortreatingmetoreleaseanyandallinformationpertainingtomytreatmenttoanythirdpartypayer(suchasmyinsurancecompanyoragovernmentagency)asneededtodetermineaclaimforpaymentforsuchtreatmentandordiagnosis.
PhysicianInsuranceAssignment:I,thebelownamedsubscriber,herbyauthorizepaymentdirectlytoHealingMinds,LLCformytreatmentatthisofficethatisotherwisepayabletomefortheirservicesasdescribed.
Medicare/Medicaid–Client’scertificationauthorizationtoreleaseinformationandpaymentrequest,IcertifythattheinformationgivenbymeinapplyingforpaymentunderTitleXVIII/XIXoftheSocialSecurityActiscorrect.IauthorizeanyholderofmedicalorotherinformationaboutmetobereleasedtoSocialSecurityAdministration/DivisionofFamilyServicesoritsintermediariesorcarriesanyinformationneededforthisofarelatedMedicare/Medicaidclaim.Iherbycertifyallinsurancepertainingtotreatmentshallbeassignedtothephysiciantreatingme.
IPERMITACOPYOFTHESEAUTHORIZATIONSANDASSIGNMENTSTOBEUSEDINPLACEOFTHEORIGINALWHICHISONFILEATTHEPHYSICIAN’SOFFICE.Thisassignmentwillremainineffectuntilrevokedbymewriting.
Pleaserememberthatinsuranceisconsideredamethodofreimbursingtheclientforfeespaidtothedoctorandisnotasubstituteforpayment.Somecompaniespayfixedallowancesforcertainproceduresandotherspayapercentageofthecharge.Iunderstandit’smyresponsibilitytopayanydeductibleamountco-insurance,oranyotherbalancenotpaidforbymyinsuranceorthirdpayerwithinareasonableperiodoftimenottoexceed90days.
ClientName(pleaseprint)
Client/GuardianSignature Date
InsuranceCompany
HIPPANOTICE/PRIVACYPRACTICES
FirstName LastName
Thisnoticedescribeshowmedicalinformationaboutyoumaybeusedanddisclosedandhowyoucangetaccesstothisinformation.Pleasereviewitcarefully.
HealingMinds,LLC6490S.McCarranBlvdA-6,RenoNV,89509,775448-9760
Weunderstandtheimportanceofprivacyandarecommittedtomaintainingtheconfidentialityofyourinformation.Wemakearecordofthemedicalcareweprovideandmayreceivesuchrecordsfromothers.Weusetheserecordstoprovideorenableotherhealthcareproviderstoprovidequalitymedicalcare,toobtainpaymentforservicesprovidedtoyouasallowedbyyourhealthplanandtoenableustomeetourprofessionalandlegalobligationstooperatethismedicalpracticeproperly.Wearerequiredbylawtomaintaintheprivacyofprotectedhealthinformation,toprovideindividualswithnoticeofourlegaldutiesandprivacypracticeswithrespecttoprotectedhealthinformation,andtonotifyaffectedindividualsfollowingabreachofunsecuredprotectedhealthinformation.Thisnoticedescribeshowwemayuseanddiscloseyourmedicalinformation.Italsodescribesyourrightsandourlegalobligationswithrespecttoyourmedicalinformation.Ifyouhaveanyquestionsaboutthisnoticepleasecontactouroffice.
Seefrontofficefor“HIPPADetail”forms.
ClientName(pleaseprint)
Client/GuardianSignature Date
AUTHORIZATIONFORRELEASEOFINFORMATIONFirstName LastName
DateofBirth(mm/dd/yyyy)
WerespectyourpersonalinformationandwantyoutoknowyourrightsasaclientofHealingMinds.Pleasereadtheinformationbelow.
PATIENTRIGHTS
• Youmayendthisauthorization(permissiontouseordiscloseinformation)anytimebycontactingouroffice.
• Ifyoumakearequesttoendthisauthorization,itwillnotincludeinformationthatmayhavealreadybeenusedordisclosedbasedonyourpreviouspermission.
• Youwillnotberequiredtosignthisformasaconditionoftreatment,payment,enrollment,oreligibilityforbenefits.
• Youhavearighttoacopyofthissignedauthorization.
• Ifyouchoosenottoagreewiththisrequest,yourbenefitsorserviceswillnotbeaffected.
PATIENTAUTHORIZATION
Iherebyauthorizethename(s)orentitieswrittenbelowtoreleaseverballyorinwritinginformationregardinganymedical,legal/courtrecords,educationalrecords,mentalhealthand/oralcohol/drugabusediagnosisortreatmentrecommendedorrenderedtotheaboveidentifiedpatient.Iauthorizetheseagenciestoshareinformationbymail,phone,inperson,faxand/oremailcontact.IunderstandthattheserecordsareprotectedbyFederalandstatelawsgoverningtheconfidentialityofmentalhealthandsubstanceabuserecords,andcannotbedisclosedwithoutmyconsentunlessotherwiseprovidedintheregulations.IalsounderstandthatImayrevokethisconsentatanytimeandmustdosoinwriting.Arequesttorevokethisauthorizationwillnotaffectanyactionstakenbeforetheproviderreceivestherequest.
☐ IherebyauthorizeHealingMinds,LLCtoRELEASEmyprotectedhealthinformation(PHI)to:
☐ IherebyauthorizeHealingMinds,LLCtoOBTAINmyprotectedhealthinformation(PHI)from:
DISCLOSURESCOPEFORPHIRELEASE:Disclosuremayincludethefollowingverbalorwritteninformation:(checkallthatapply)
☐ Facesheet ☐ History&physical
☐ Laboratory/diagnostictestingresults ☐ Schoolinformation
☐ Dischargesummary ☐ Medicationrecords
☐ Behavioralhealth/psychologicalconsult ☐ Psychosocialassessment/Familyhistory
☐ ERrecordreport ☐ Psychiatricevaluation
☐ Substanceabusetreatmentrecords ☐ HIV/AIDSlabresults&treatmenthistory
☐ Progress&CaseNotes ☐ Summaryoftreatmentrecords&contactdated
☐ Psychologicalevaluation/testingresults ☐ Tense/unabletorelax
☐ Afraidtoleavehome ☐ Excessiveworry
☐ Inflatedselfesteem ☐ Panicattacks
☐ Feelguiltyorworthless ☐ Thoughtsofdeathorsuicide
☐ Other:
☐ Informationnecessarytoidentify,diagnose,prognosis,ortreatmentformentalhealth,substanceabuse(alcohol/druguse),andanyotherrelevantinformationforthepurposeoftreatment.
AllinformationIherebyauthorizetobeobtainedfromtheaboveidentifiedsourcewillbeheldstrictlyconfidentialandcannotbereleasedbyHealingMinds,LLCwithoutmywrittenconsent.Iunderstandthatthisauthorizationwillremainineffectfor:
☐Theperiodnecessarytocompletealltransactionsonaccountsrelatedtoservicesprovidedtome.
☐One(1)year
☐Other:
Iunderstandthatunlessotherwiselimitedbystateorfederalregulationandexcepttotheextentthatactionhasbeentakenwhichwasbasedonmyconsent,Imaywithdrawthisconsentatanytime.Ifclientisaminorchild,IverifythatIamthelegalguardian/custodianofthischild.SignatureofClient/LegalGuardianorLegallyAuthorizedRepresentative Date Witness Date
APPOINTMENTCANCELLATIONAGREEMENT
FirstName LastName
Eachmeetingisanotheropportunitytohelpyouconfidentlytakechargeandstartlivingthelifethat’simportanttoyou.Weunderstandthingscomeupandyoumayneedtomissyourappointment.Ifyouneedtorescheduleorcancelanyappointments,theofficeofHealingMindsrequires24businesshoursnotification(MondaythroughFriday8:00amto5:00pm).Pleaseunderstandthatwesetasidethistimeforyou,andifyouareunabletomakeit,wewillhavemissedanopportunitytomeetwithanothervaluableclient.Thispolicyisinplacetogivetheofficeenoughtimetoscheduleanotherclientinthattimeslot.Ifyoufailtocancelwithinthe48hourspriortoyourappointmenta$60feewillbechargedtothecardbeloworthecreditcardonfile.IfyouareaMedicaidorAmerigrouppatientyouarenotsubjecttothe$60fee,howeverafter1violationofthisagreement,servicesatthisofficewillbeterminated.
Whilewedocalltoremindyouofyourappointment,itisyourresponsibilitytocalltheofficeat775-448-9760,extension1,tocancel.
Iauthorizethefollowingcardtobeusedforco-paysandfee’sincurredduringthetimeIamapatientwithHealingMindsLLC.
CardNumber
Expires CVV
PrintedName
Signature Date
IunderstandthattheofficeofHealingMindsLLCwillattempttobillmyinsurance,howeverifmyinsurancedoesnotpay,forwhateverreason,Iamresponsibleforanyremainingbalance.Thismayincludedeductibles,copays,oroutofpocketexpenses.
Mysignatureacknowledges:
• InthecaseofaPsychiatricEmergencyIwillcall911orgotothenearesthospital• 7daysnotificationispreferredforanyprescriptionrenewals.• Iwilladheretotheguidelinesabovetothebestofmyability.
ClientName(pleaseprint)
Client/GuardianSignature Date