Justin Kukowski Center for Spiritual and Physical …€¦ · Web viewI agree to have the intern...

Cashman Center Client Registration and Treatment Contract Client Information

Client Name: __________________________________________________ Gender: __________ Date of Birth: ________________

Address: _________________________________________ City: _____________________ State: __________ Zip:_____________

Phone: __________________________Type: Cell/Home/Work Alt Phone: __________________________ Type: Cell/Home/Work

Marital Status: __________ Employer:_____________________________________________________________________________

Emergency Contact: _______________________________ Relationship: ______________ Phone Number: ____________________

Insurance

Insurance Company: _______________________________________________ Phone:______________________________________

ID# __________________________ Policy#_________________________________________ Group#________________________

Co-pay amount per visit Individual therapy: _________________ Effective Date:__________________________________________

Policy Holder Information

Insured Person:________________________________________________________________________________________________

Date of Birth: ________________ Relation to Client: ___________________ Employer:_____________________________________

Secondary Insurance

Insurance Company: _______________________________________________ Phone:______________________________________

ID# __________________________ Policy#_________________________________________ Group#________________________

I assign all benefits from insurance or other third-party coverage to the provider of service. I understand that by signing this form, I acknowledge that if my insurance carrier or HMO/PPO does not cover certain services, I will pay for them in full. I authorize the release of any medical information necessary to process any claim for services provided by provider or its independent contractors. A photocopy of this authorization may be honored.

____________________________________________________________________________________________Client Signature Date

Cashman Center Client Registration and Treatment Contract of 9Print Client Name______________________________________Date Of Birth _______________________________________

For Clinician Use: (submit with copies of insurance card & photo id)

Intake/Service Date__________ Dx Code ________ CPT Code ___________ Total Time __________

Health Data

How did you hear about Cashman Center? ______________________________________________________________________

If referred, who referred you here? _____________________________________________________________________________

Please briefly describe your presenting problem: __________________________________________________________________

____________________________________________________________________________________________________________

Current Physician: ___________________________________________________________________________________________

Physician’s Clinic: ___________________________________________________________________________________________

Address: ___________________________________________________________________________________________________

Phone Number: ___________________________________ Fax: _____________________________________________________

Date of most recent physical: __________________________________________________________________________________

Please list your current medications and dosages: _________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Please list any vitamins, herbs, or supplements that you currently use: _______________________________________________

____________________________________________________________________________________________________________

Please list any allergies or drug sensitivities: _____________________________________________________________________

____________________________________________________________________________________________________________

Are you currently or have you in the past been diagnosed and/or treated for? (Please check all that apply)

__stroke __seizures __migraines __liver damage __thyroid problems __anemia __chronic fatigue __diabetes __chronic pain __urinary tract infection __asthma __hepatitis __tuberculosis __eating disorder __persistent flu-like symptoms __cancer __hypertension __menopause __perimenopause __poly-cystic ovarian syndrome __cardiac problems __communicable diseases __Other: ____________________________________________________________________________________________________


CAGE Assessment

The CAGE and CAGE-AID QuestionsThe original CAGE questions appear in plain type. The CAGE questions “Adapted to Include Drugs” (CAGE-AID) are the original CAGE questions modified by the italicized and bold text.

The CAGE or CAGE-AID should be preceded by these two questions:

1. Do you drink alcohol?2. Have you ever experimented with drugs?

If the patient has experimented with drugs, ask the CAGE-AID questions. If the patient only drinks alcohol, ask the CAGE questions.

CAGE and CAGE-AID Questions1. In the last three months, have you felt you should cut down or stop drinking or using drugs?

Yes No2. In the last three months, has anyone annoyed you or gotten on your nerves by telling you to

cut down or stop drinking or using drugs?Yes No

3. In the last three months, have you felt guilty or bad about how much you drink or use drugs?Yes No

4. In the last three months, have you been waking up wanting to have an alcoholic drink or use drugs?Yes No

Each affirmative response earns one point. One point indicates a possible problem. Two points indicate a probable problem.


PHQ-9 Assessment

Over the last 2 weeks, how often have you been bothered by any of the following problems? Please check your answers.

Not at all Several days

More than half the

days

Nearly every day

1.Little interest or pleasure in doing things2.Feeling down, depressed, or hopeless3.Trouble falling or staying asleep, or sleeping too much4.Feeling tired or having little energy5.Poor appetite or overeating6.Feeling bad about yourself…or that you are a failure or have let yourself or your family down7.Trouble concentrating on things, such as reading the newspaper or watching television8. Moving or speaking so slowly that other people could have noticed. Or the opposite…being so fidgety or restless that you have been moving around a lot more than usual9.Thoughts that you would be better off dead, or hurting yourselfAdd ColumnsTOTAL:

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?


Provider Contract/Release of InformationDear Client,Cashman Center has a strong commitment to your holistic health. For that reason, it is important to have a close working relationship with your physician, psychiatrist, and/or other health care provider. We are asking for permission to communicate with your health care providers. You can be best served if we are aware of mental health and substance abuse concerns, which often affect health and well-being. Please complete the attached release to enable us to communicate with your other caregivers. If you have more than one provider, we will provide you with additional forms. You will need to complete a separate release of information for each provider you wish us to communicate with during the course of your care at Cashman Center. We will be happy to answer any of your questions or respond to your concerns regarding this matter.

If you do not wish to communicate with your other health care providers please read and sign the bottom of this page.Thank you.

Please check all that apply:

___Yes, please communicate information about my care with my primary care physician. I have completed the release of information (that follows this page) with the contact information.

___Yes, please communicate with providers other than my primary care physician. I have completed a release of information with the contact information.

___No, I do not want Cashman Center to communicate with my primary care physician.___No, I do not want Cashman Center to communicate with other providers.

I understand that I may sign a release of information at any time for a specific provider and Cashman Center will initiate communication with that provider.

Signature of Client________________________________________Date_________________________

Signature of Parent/Guardian________________________________Date ________________________


I understand that my psychologist or therapist generally may not condition psychological services upon my signing an authorization unless the psychological services are provided to me for the purpose of creating health information for a third party.

I understand that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.

______________________________ _________________ ________________________Signature of Patient Date Witness

________________________________________________________________________If the authorization is signed by a personal representative of the patient, a description of such representative's authority to act for the patient must be provided.

Cashman Center – Phone: 952-224-8990 Fax 952-224-89912100 County Road 42 W, Burnsville, MN 55337

562 Bavaria Lane, Chaska, MN 55318Consent for Release of InformationThis authorizes Cashman Center to use and disclose the specific health informationdescribed below concerning:Client: ________________________________________________ Date of Birth: ___________________

This will authorize Cashman Center to release to/obtain from: Name: _____________________________________________________________________________________Address: ________________________________City: _____________________State: ________ Zip: ________Phone: ________________________________________________Fax:_________________________________Information from the medical record maintained from (please list dates such as “all”, or 1/11 to 2/12):The information to be disclosed is (please check all info that you are willing to have exchanged):

History and intake information Social/ Psychological/ Medical reports

Consultation notes/progress reportsChemical dependency abuse or diagnosis, history and treatment (protected by Federal and State regulations 42 CFR Part 2 and ORS 430.399(5), 179.505)

Treatment plan, goals, and results Medications used in treatmentCourt or probation records Other (specify)

The purpose of the information release is (please check all that apply): Diagnosis and evaluation To facilitate treatmentTreatment planning Other (specify)

If we are requesting the Authorization from you for our use and disclosure or to allow another health care professional or entity to disclose information: (1) You have the right to inspect a copy of the protected information to be used or disclosed; (2) You may refuse to sign this authorization; and (3) We must provide you with a copy of the signed authorization at your request. You may revoke this consent at any time and that upon fulfillment of the above stated purposes(s) or within one year, this consent will automatically expire without express revocation.

By signing this authorization, you may be directing us to disclose your health information to a person or organization that does not have the same obligations to protect privacy required of health care practitioners under state and federal law. The disclosure of the information specified above may carry with it the potential for unauthorized disclosure of your protected health information and loss of protection under state and federal law. You may request that we require the recipient of your protected health information to sign a Confidentiality Agreement in which the recipient agrees to limit its use and disclosure of your information as specified by the confidentiality agreement. If the intended recipient refuses to sign the confidentiality agreement you request, we will not release the information.

I have reviewed the Authorization and I understand it. I understand that the information used or disclosed under this Authorization may be subject to redisclosure by the recipient and may no longer be protected under federal privacy law.

Signature of Client________________________________________ Date_____________________

Signature of Parent/ Guardian/Witness_______________________ Date ____________________


Practicum Intern Authorization Form

Client Name_______________________________________________ Date of Birth______________

This form when completed and signed by you, authorizes me (_________________________________) to release protected information from your clinical record to the intern(_______________________________). I agree to have the intern sit in and participate in my therapy and/or do psychological testing and assessment. The intern understands and agrees to keep all information confidential. I understand that the purpose of the intern’s participation is for training purposes.

This authorization shall remain in effect until _________________ .

You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization.

___Yes, I am interested in having a practicum intern to participate in my therapy and/or assessment sessions.

___No, I do not want to have a practicum intern participate in my therapy and/or assessment sessions.


Client Receipt of Information

Email address ___________________________________________________________________________I authorized Cashman Center to periodically contact me on my email with information about Cashman Center. No personal information will be transferred on these emails; this is for educational and informational purposes only. Yes, I agree __________ (Initials of client) No, I do not authorize use of my email _______ (Initials of client)

I have read, understood, and agree to abide by the policies give to me in the Client Registration and

Treatment Contract handbook. This includes:

Client registration

Crisis Coverage

Notice of Health Information and Privacy Practices

Responsibilities of Cashman Center

Bill of Rights

Client Responsibilities

_________________________________________________ ________________________________________Client Signature Date

Parent Signature Date


Justin Kukowski Center for Spiritual and Physical …€¦ · Web viewI agree to have the intern...

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