CLIENT INFORMATION SHEET

Transcription

1 CLIENT INFORMATION SHEET NAME: PHONE: Daytime: OK to leave message? Y N Evening: OK to leave message? Y N Other: OK to leave message? Y N ADDRESS: CHART NO: Intake : Dx Code: Clinician: BIRTH DATE: SS#: GENDER ID: SEX: M F MARITAL STATUS: Single Married Separated Divorced Widowed Domestic Partnership EMPLOYMENT STATUS: Full-Time Part-Time Student Unemployed Retired Disabled/unable to work PLACE OF WORK: POSITION: ETHNICITY: YEARS OF EDUCATION: RESPONSIBLE PARTY: ADDRESS: HOME PHONE: WORK PHONE: REFERRED BY: COMMUNICATION PREFERENCES With whom may we share information about: 1. APPOINTMENT SCHEDULING: Spouse Child Parent Other Name: 2. BILLING OR INSURANCE ISSUES: Spouse Child Parent Other Name: 3. TREATMENT, CLINICAL, DIAGNOSTIC INFORMATION RELATED TO YOUR THERAPY: Spouse Child Parent Other Name: How would you prefer to receive appointment confirmations? Text Phone CONSENT FOR TREATMENT I, the undersigned, have voluntarily applied for and agree to participate in counseling, psychological, &/or psychiatric services. I hereby authorize to release treatment and psychological information to my primary medical physician and health insurance carrier if necessary. I understand that I am fully responsible for all fees relating to my treatment which are not covered by my insurance plan, and I further agree to pay my co-payment at the time of each visit. In the event that I miss an appointment or cancel an appointment with less than 24 hours notification, I understand that I am solely responsible for paying a $60 fee. Furthermore, if I fail to appear for three consecutive scheduled appointments, my case may be placed on inactive status. Client signature

2 950 Windy Rd, Suite 305 Apex, NC CONSENT & RELEASE FOR USE AND DISCLOSURE OF HEALTH INFORMATION SECTION A: Client giving Consent Name: Address: Telephone: of Birth: SS#: SECTION B: To the Client Please read the following statements carefully Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. This information may be disclosed via mail, fax, phone, direct communication, or electronic transmission. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting our office. Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to our Privacy Officer. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. Signature: I,, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. Signature of Client If this Consent is signed by a personal representative on behalf of the client, complete the following: Personal Representative s Name: Relationship to Client: REVOCATION OF CONSENT I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations (Please write explanation on the back of this form). I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.

3 NONE SOME A LOT NONE SOME A LOT CLIENT CLINICAL INFORMATION - ADULT page 1 Below is a list of concerns people sometimes have. Consider each one and decide how much each one has bothered you or has been a problem for you during the past month: Job related concerns Educational concerns Relationship concerns Health concerns Sexual concerns Behavioral concerns Financial concerns Spiritual concerns Identity concerns Parenting concerns Legal concerns Family concerns Difficulty sleeping Poor judgement Concentration problems Substance abuse Impulsive behavior Self-control problems Mood swings Lack of friends Self-esteem issues Grief, loss, or mourning Problems with trust Violent/aggressive behavior Problems making decisions Memory problems Confusion Headaches Stomach problems Chronic pain Anxiety, nervousness Preoccupation with thoughts Chronic worry Fear or phobia(s) Difficulty relaxing Panic attacks Perfectionistic personality Nightmares Intrusive thoughts Feeling depressed Feeling overwhelmed Irritability Lack of enjoyment Feeling lonely Feeling isolated/withdrawn Loss of energy Poor appetite Overeating Lack of sexual interest Suicidal thoughts Weight gain Weight loss Feeling hopeless Poor motivation Do YOU have a history of Is there a FAMILY history of Substance abuse? Yes No Mental illness? Yes No Abuse or trauma? Yes No Substance abuse? Yes No Criminal behavior? Yes No Domestic violence or abuse? Yes No Seizure? Yes No How often do you Psychiatric hospitalization? Yes No Smoke cigarettes (# packs/day) Suicide attempt? Yes No Drink alcohol (# drinks/week) Educational or learning problems? Yes No Smoke marijuana (# times/mo.) Threatening or harming others? Yes No Use other drugs (# times/mo.) Who is your primary care physician? Please list any medications (& dosages) you are taking: Please list any chronic or serious medical problems: Please list any prior mental health treatment received: Name of agency or counselor: s of service: Reason for treatment:

4 MEDICAL REVIEW OF SYSTEMS Please identify areas of concern, symptoms, previous or current diagnosis: General- Circle: Weight loss or gain Past Present Fatigue Past Present Fever or chills Past Present Weakness Past Present Trouble sleeping Past Present Skin- Rashes Past Present Lumps Past Present Dryness/Itching Past Present Color changes Past Present Hair and nail changes Past Present Head- Headache Past Present Head injury Past Present Ears- Decreased hearing Past Present Ringing in ears Past Present Earache Past Present Drainage Past Present Eyes- Vision Loss/Changes Past Present Glasses or contacts Past Present Redness/pain/dryness Past Present Blurry or double vision Past Present Flashing lights, aura, specks Past Present Glaucoma Past Present Cataracts Past Present Nose- Stuffiness Past Present Discharge Past Present Hay fever/allergies Past Present Nosebleeds Past Present Sinus pain Past Present Neck- Lumps Past Present Swollen glands Past Present Pain Past Present Stiffness Past Present Vascular- Calf pain with walking Past Present Leg cramping Past Present Hematologic- Ease of bruising Past Present Ease of bleeding Past Present Throat- Bleeding/non-healing sores Past Present Dentures Past Present Sore tongue Past Present Dry mouth Past Present Sore throat Past Present Hoarseness Past Present Thrush Past Present Breasts- Lumps Past Present Pain Past Present Discharge Past Present Self-exams Past Present Breast-feeding Past Present Respiratory- Circle: Cough Past Present Sputum Past Present Coughing up blood Past Present Shortness of breath Past Present Wheezing Past Present Painful breathing Past Present Cardiovascular- Chest pain or discomfort Past Present Tightness Past Present Palpitations Past Present Shortness of breath Past Present Difficulty breathing Past Present Swelling/Edema Past Present Sudden awakening from Past Present sleep w/ shortness of breath Past Present Gastrointestinal- Swallowing difficulties Past Present Heartburn Past Present Change in appetite Past Present Nausea/vomiting Past Present Change in bowel habits Past Present Rectal bleeding Past Present Constipation Past Present Diarrhea Past Present Yellow eyes or skin Past Present Urinary- Frequency Past Present Urgency Past Present Burning or pain Past Present Blood in urine Past Present Incontinence Past Present Change in urine strength Past Present Musculoskeletal- Muscle or joint pain Past Present Stiffness Past Present Back pain Past Present Redness of joints Past Present Swelling of joints Past Present Trauma Past Present Neurological- Dizziness Past Present Fainting Past Present Seizures Past Present Weakness Past Present Numbness Past Present Tingling Past Present Tremor Past Present Endocrine- Heat or cold intolerance Past Present Sweating Past Present Frequent urination Past Present Thirst Past Present Change in appetite Past Present Psychiatric- Nervousness Past Present Stress Past Present Depression Past Present Memory loss Past Present

5 EMERGENCY SITUATION DISCLOSURE & GUIDELINES Sara J. Hagen, MSN, PMHNP-BC Because Lifescapes Counseling Associates does not have crisis coverage for urgent situations after office hours, I need to inform my clients of the following: I am usually, but not always, in this office on Mondays, Tuesdays, Wednesdays, and Thursdays. I will keep you informed of any changes in my schedule. At any time, you can leave voice mail messages for me by calling However, due to frequent scheduled appointments, I am not often available to answer the phone. Please leave a message and I will make every attempt to return your call by the next business day. If you need to schedule or change an appointment or wish to leave me a non-urgent message, you can call our office at Please know that I may not be able to check my messages until the end of the day due to appointments. If you have an emergency during the weekend or after hours, or whenever I am not available, please pursue the following alternatives: 1) Contact Wake County Mental Health at They have weekend crisis coverage. If you live in another county, contact your county s mental health services. 2) Go to your nearest hospital emergency room and ask for the psychiatrist on staff. 3) Call Holly Hill Respond at They also have after hours and weekend crisis coverage. 4) Call our office at when it is safe and convenient for you to do so, and let our office staff or myself know of your circumstances so that we can be of assistance to you. If you feel that your particular difficulties will lead to a need for after-hours or emergency services on a regular basis, you should consider seeking professional mental health services from a provider who can offer crisis coverage. I am happy to assist you with referrals for more appropriate services. Thank you for understanding my particular situation. This system generally works smoothly, and your needs will be well met. It is very important, however, that we plan ahead and know what to do when extraordinary or urgent situations arise. MEDICATION REFILL PROCEDURES Prescription refills will be primarily be taken care of at appointments. However, if a refill is needed, call at least 2 days in advance of prescription ending. Leave me a voic with the following information: Patient name, date of birth, medication name and dose, pharmacy and pharmacy phone number. It may take as long as 48 hours to complete your refill request. If I am filling a prescription due to a missed appointment (no show), there will be a $25 dollar refill charge, only one month of the medication will be called in, and the missed appointment will need to be rescheduled. I have read and understand the above and agree to follow the suggested guidelines. Client Name Client or Parent/Guardian Signature Witness

6 950 Windy Rd, Suite 305 Apex, NC ATTENDANCE & CANCELLATION POLICY: When you make an appointment with a therapist at our practice, we reserve that time especially for you. We do not overbook our appointments because we feel that our clients deserve to be seen in a timely manner. Just as you deserve your therapist s full attention during your appointment, we greatly appreciate knowing in advance when a client is unable to keep their appointment. When appointments are cancelled with less than 24 hours notice, it is almost impossible to fill that time slot with another client. Also, please note that insurance companies do not pay benefits for missed and late-cancelled appointments. Therefore, missed appointments create a financial strain for our practice and make it difficult to serve the many clients on our waiting list. It is also important to note that consistency in attending counseling sessions is critical to effective counseling, and we want our clients to really benefit from our services. For these reasons, your account will be charged a $60 fee if you miss a scheduled appointment or cancel an appointment with less than 24 hours notice. Please let our office staff know if there is an extenuating circumstance preventing you from being able to keep your appointment (ie, illness, death in the family, etc ) as we certainly recognize that unexpected situations can arise. FINANCIAL POLICY FOR MINOR CHILDREN OF SEPARATED/DIVORCED PARENTS: It is our policy that the parent who consents to the treatment of a minor child is responsible for payment of services rendered. Neither, nor its contracted therapists will be involved with separation/divorce disputes. Divorced parents bear the responsibility for splitting the cost of therapy. The parent who brings a minor client to appointments is expected to pay the full copay due. By signing below, I acknowledge understanding that Lifescapes Counseling Associates charges a $60 fee for no-shows and appointments cancelled with less than 24 hours notice, and I acknowledge understanding of the client billing policy as it affects treatment of minor children with divorced/separated parents. Signature of Client Signature of Witness

7 950 Windy Rd, Suite 305 Apex, NC ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES You may refuse to sign this acknowledgement On this date, I, received a copy of the Notice of Privacy Practices to protect the privacy of my health information. I am aware that I may direct questions about our privacy practices to the Privacy Officer listed in the NPP. Signature of Client Signature of Witness FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign. Communications barriers prohibited obtaining acknowledgement. An emergency situation prevented us from obtaining acknowledgement. Other (Specify)

8 Bradley Commons 950 Windy Road, Suite CREDIT CARD AUTOMATIC PAYMENT AGREEMENT For your convenience, we offer our clients the option of arranging to pay all session fees and account balances with a credit card. With this arrangement, you do not have to spend additional time paying each time you come in. We accept Visa and Mastercard. TransFirst (TSYS), our credit card processing vendor, will store your information on a secure and encrypted site, which will enable us to run bank card transactions through our computer system. Our employees will not have access to your bank card information within this system once it is entered. This form will be stored in a locked, secure location. If you would like to take part in this voluntary payment arrangement, please complete the following information: NAME OF PERSON RECEIVING TREATMENT: FULL NAME PRINTED ON CARD: CREDIT CARD ACCOUNT NO.: EXPIRATION DATE: / / SECURITY Code: TYPE: Visa MC HSA HRA I authorize LCA to charge the above credit card (or HSA/HRA card) for all account balances Since payment amounts may vary, I understand that I will receive notification each time my credit card is charged. I will alert Lifescapes Counseling of any changes in my address. This authorization is valid until I provide you with a written cancellation AGREED (Signature): DATE: