Intake Form

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Identifying Information - Step 1 of 7

PERSONAL INFORMATION

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Name *

Date *

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Birthdate *

SSN *

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Gender *

Male
Female
Other

Marital Status *

Single
Married
Divorced
Widowed
Seperated

Address *

Address Line 1

City

State

Zip Code

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Cell Phone *

Email *

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Employer *

How do you Prefer to Receive Calls? *

Home
Work
Cell

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Emergency Contact *

Relationship *

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Cell Phone *

Work *

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INSURANCE INFORMATION

PLEASE NOTE: WE REQUIRE A FRONT AND BACK PHOTOCOPY OF YOUR INSURANCE CARD, INSURANCES WE TAKE ARE AETNA, CIGNA AND MEDICARE.

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Name of Insurance *

Insurers Name *

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Date of Birth *

SSN *

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ID / Policy # *

Group # *

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Additional Insurance *

PLEASE MAKE SURE YOU PROVIDE US WITH A COPY OF YOUR INSURANCE CARD FOR OUR FILE. IF YOUR INSURANCE REQUIRES PRE AUTHORIZATION, IT IS YOUR RESPONSIBILITY TO OBTAIN THIS FROM YOUR INSURANCE COMPANY. I AUTHORIZE THE RELEASE OF ANY MEDICAL OR OTHER INFORMATION NECESSARY TO PROCESS MY INSURANCE CLAIM AND AUTHORIZE PAYMENT DIRECTLY TO THE DOCTOR FOR ANY SERVICES THAT I RECEIVE. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR PROMPT PAYMENT OF ALL DEDUCTIBLES AND COPAYMENTS.

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Signature *

Date *

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RELEVANT PHYSICIANS & PROVIDERS

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Referring Physician/ Provider:

Other physicians you now see:

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Most recent Psychiatrist, if any:

Which physicians/providers may we share information with?

Checkboxes *

I agree that my Psychiatrist may share information with any of the physicians/providers I have consented to above.

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SIGNATURE *

DATE *

Checkboxes *

I consent and agree to the conditions mentioned below. *

PLEASE NOTE:

● PAYMENT IS EXPECTED AT THE TIME OF YOUR APPOINTMENT UNLESS OTHER ARRANGEMENTS ARE MADE WITH OUR OFFICE.

● SELF PAY IS $300 FOR THE FIRST VISIT AND $160 FOR EACH APPOINTMENT THERE AFTER.

● RETURN PHONE CALL MESSAGES/PHONE APPOINTMENTS MAY BE CHARGED A FEE NOT BILLABLE TO ANY INSURANCE COMPANY

● YOU WILL BE CHARGED FOR MISSED APPOINTMENTS UNLESS 24HRS NOTICE IS GIVEN.

● NO SHOW FEE: $100.00

● REFILL CHARGE (IF NOT DURING APPOINTMENT):

● $35.00 PER NON-CONTROLLED PRESCRIPTION.

● $135.00 PER CONTROLLED PRESCRIPTION (ONLY AT PROVIDERS DISCRETION)

● URINE DRUG SCREEN: $35.00

● FUTURE APPOINTMENTS WILL NOT BE SCHEDULED UNTIL ANY BALANCES ARE TAKEN CARE OF.

● CONTROLLED SUBSTANCES WILL BE PRESCRIBED IN PERSON ONLY.

● IF YOU CANCEL YOUR APPOINTMENT AND ARE NOT SEEN WITHIN 30 DAYS, YOU WILL BE DISCHARGED FROM THE PRACTICE.

● AUTHORITIES WILL BE CONTACTED IF ANY MEMBERS OF STAFF.

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SIGNATURE *

DATE *

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PATIENT INTAKE FORM

1. Are you scheduling this appointment to obtain any type of disability/court paperwork to be completed by the doctor? *

Specify Further *

2. Please list all medications you currently take, both prescription drugs and over the counter medications. *

3. Do you suffer any medical illnesses? Are you recovering from any injury or physical trauma? *

4. Are you allergic to any medications? *

5. What symptoms have prompted you to seek psychiatric/psychological help? How long have they lasted? *

6. What event or events in your personal or professional life has caused you the most distress over the last year? *

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PATIENT INTAKE FORM Continued

7. Have you ever been treated by a psychiatrist or counselor? *

Has the treatment included inpatient psychiatric hospitalization?

Have you had any drug or alcohol treatment?

8. Please describe your current use of alcohol or drugs. *

9. Please list the ages of your children. List any that are deceased and give their year of death. *

10. Please list the ages of your siblings. Include those deceased and their year of death. *

11. Have any of your blood relatives had mental illnesses, drug abuse, alcohol abuse or suicide? Please describe. *

Thank you for filling out this form completely. The information you have provided will help us serve your needs more effectively and efficiently. If you have any questions, please feel free to ask for our help.

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NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third-party payers.
• Conduct normal health care operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

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Patient Name *

Relationship to Patient *

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Signature *

Date *

FOR OFFICE USE ONLY
I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below.

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Date

Initials

Reason

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AUTHORIZATION FOR RELEASE OF INFORMATION

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Name *

Date *

This form authorizes my treatment provider to release the following information from my mental health, substance abuse, or medical records. *

Scheduling
Billing
Medication Management
Diagnosis
Assessment(s)
Treatment Recommendation
Verbal Communication
Discharge Summary
Other

If checked the option "other" above, please explain.

Special instructions or limitations

This information can be shared with the following: (Please include name, relationship, and contact number)

In authorizing this release of information, I understand it will be used solely for the purpose of:

Coordination of Care
Statement of Understanding. I understand that I have the right to revoke this authorization at any time by providing written documentation to therapist. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that authorizing the disclosure of this health information is voluntary and may contain information relating to behavioral or mental health services, and treatment for alcohol and drug abuse. Disclosure may include information obtained by therapist from other providers. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the recipient and the re-disclosure may not be protected by federal confidentiality rules. I have a right to limit the information disclosed.

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My signature below acknowledges that I have read this form, understand its content and request that the above information be released as specified. Unless I revoke this authorization, it shall be valid until:

Date

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Signature of Client/Guardian *

Date *

Signature of Witness *

Date *

Notice. “This information has been disclosed to you from records protected by Federal confidentiality rules (42 CRF, part 2). The federal rules prohibit you from making any further disclosures of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR, part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.”