Adult Intake Paperwork

Patient Name *

First

Middle

Last

Patient Phone Number *

Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere? *

Yes
No

Have you had previous psychotherapy? *

Yes
No

(If yes) Previous therapist’s name.

Are you currently taking prescribed psychiatric medication (antidepressants or others)? *

Yes
No

(If yes) Please list

(If yes) Prescribed by

HEALTH AND SOCIAL INFORMATION

Do you currently have a primary physician? *

Yes
No

(If yes) who is it?

Are you currently seeing more than one medical health specialist? *

Yes
No

(If yes) Please list

When was your last physical?

Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.

Are you currently on medication to manage a physical health concern? If yes, please list:

Are you having any problems with your sleep habits? *

Yes
No

(If yes) Check where applicable:

Others

How many times per week do you exercise? *

Approximately how long each time?

Are you having any difficulty with appetite or eating habits? *

Yes
No

(If yes) Check where applicable:

Eating less
Eating more
Bingeing
Restricting

Have you experienced significant weight change in the last 2 months? *

Yes
No

Do you regularly use alcohol? *

Yes
No

In a typical month, how often do you have 4 or more drinks in a 24 hour period?

How often do you engage recreational drug use? *

Daily
Weekly
Rarely
Never

Do you smoke cigarettes or use other tobacco products? *

Yes
No

Have you had suicidal thoughts recently? *

Frequently
Sometimes
Rarely
Never

Have you had them in the past? *

Frequently
Sometimes
Rarely
Never

Have you ever been arrested or had legal difficulties? *

Yes
No

(If yes) please describe:

Are you currently in a romantic relationship? *

Yes
No

(If yes) how long have you been in this relationship?

On a scale of 1-10 (10 being the highest quality), how would you rate your current relationship?

Selected Value: 0

In the last year, have you experienced any significant life changes or stressors? If yes, please explain:

Have you ever experienced any of the following?

Physical Abuse *

Yes
No

Emotional Abuse *

Yes
No

Sexual Abuse *

Yes
No

Extreme depressed mood *

Yes
No

Dramatic mood swings *

Yes
No

Rapid speech *

Yes
No

Extreme anxiety *

Yes
No

Panic attacks *

Yes
No

Phobias *

Yes
No

Sleep disturbances *

Yes
No

Hallucinations *

Yes
No

Unexplained losses of time *

Yes
No

Unexplained memory lapses *

Yes
No

Alcohol/substance abuse *

Yes
No

Eating disorder *

Yes
No

Body image problems *

Yes
No

Repetitive thoughts (e.g. obsessions) *

Yes
No

Repetitive behaviors (e.g. frequent checking, hand washing) *

Yes
No

Homicidal thoughts *

Yes
No

If yes please describe below:

Suicide Attempts: *

Yes
No

If yes please describe and list dates below:

Psychiatric hospitalizations: *

Yes
No

If yes please describe and list dates below:

Self-Injurious Behavior: *

Yes
No

If yes please describe type of self-injury and time-frame of most recent incident below:

Developmental Delays *

Yes
No

If yes please describe below:

OCCUPATIONAL INFORMATION

Are you currently employed? *

Yes
No

(If yes) Who is your currently employer/position?

If yes, are you happy with your current position?

Please list any work-related stressors, if any

EDUCATIONAL INFORMATION

Is the client currently attending school? *

Yes
No

Name of School

Grade

Major

Level of Education Completed: *

Does the client have an IEP or 504? *

Yes
No

RELIGIOUS/SPIRITUAL INFORMATION

Do you consider yourself to be religious? *

Yes
No

(If yes) What is your faith?

(If no) Do you consider yourself to be spiritual?

Yes
No

MARITAL INFORMATION

Marital Status: *

Single
Married
Divorced
Widowed

Date of Union://

Date of Separation (if applicable)://

FAMILY COMPOSITION

Family Member - Age - Date of Birth - Relationship *

Family Mental Health or Substance Abuse Concerns? *

Yes
No

If Yes- Family Member & Diagnosis/Difficulty

OTHER INFORMATION

Have there been any significant events in the household environment in the last year? (For example: births, deaths, divorces, adoptions, pregnancy, change in employment/occupation, job loss, remarriage, miscarriage)

What do you consider to be your strengths?

What do you like most about yourself?

What are effective coping strategies that you have learned?

What are your goals for therapy?

Consent For Communication

Patients/Clients frequently request that we communicate with them by phone, voicemail, email or text. Suffolk Family Therapy LCSW P.C. respects your right to confidential communications about your protected health information (PHI) as well as your right to direct how those communications occur. Since email and texting can be inherently insecure as a method of communication, we will only communicate with you by email or text with your written consent at the email address or phone number you provide to us below. Please be aware that if you have an email account through your employer, your employer may have access to your email. When you consent to communicating with us by email or text you are consenting to email and texting communications that may not be encrypted. As well voicemail or answering machine messages may be intercepted by others. Therefore, you are agreeing to accept the risk that your protected health information may be intercepted by persons not authorized to receive such information when you consent to communicating with us through phone, voicemail, email or text. Suffolk Family Therapy LCSW P.C. will not be responsible for any privacy or security breaches that may occur through voicemail, email or text communications that you have consented to. You may choose to limit the type of voicemail, email or text communication you have with us if you wish to limit your risk of exposing your protected health information to unauthorized persons. Please indicate below what types of correspondence you consent to receive by email or text.

I do not consent to any voicemail, email or texting communication.
I consent to receiving communication about the scheduling of appointments or other communications that do not reveal my protected health information only by the following means (check all that you consent to):

Email
Text
Voicemail

I consent to all communication, including but not limited to communication about my medical condition and advice from my health care providers by the following means (check all that you consent to):

Email
Text
Voicemail

Email address you are consenting to communicate through: *

Home number you are consenting to communicate through:

Cell Number(s) you are consenting to communicate through: *

Patient or Authorized Representative/Guardian Signature: *

No Show, Late Cancellation and Co-payment Policy

1. I understand that I will be charged a LATE CANCELLATION fee of the full session fee if I fail to give at least 24 hour notice prior to cancelling my appointment. 2. I understand that I will be charged a NO-SHOW fee of the full session fee if I fail to show for my appointment. 3. I understand that I am responsible for knowing my co-payment amount and deductible amount. 4. I understand that I will be charged a $15 service charge if I fail to make my payment and/or co-payment at the time of my appointment. 5. I understand that these charges are an out of pocket expense and that my insurance carrier will not cover these charges. 6. I understand that the therapy session will last 45 minutes. I understand that if I am late to the appointment, I will still have to end the session at the allotted time. By signing this, I am agreeing to the above stated terms and stipulations regarding the services I receive from this therapist.

Patient or Authorized Guardian Signature *

I authorize Suffolk Family Therapy LCSW P.C. to charge my credit/debit/health account card for professional services 24 hour before my appointment for copays or direct session fees. If I do not cancel before 24 hours, I recognize that Suffolk Family Therapy LCSW, P.C. will charge my card as a late cancel or no show if I do not show up for the appointment. I will be billed my full session fee for late cancel or no show fees. I verify that my credit card information, provided above, is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied. I also understand by signing and initialing this form that if no payment has been made by me, my balance will go to collections if another alternative payment is not made within thirty days.

Please initial here

Client Name *

First

Middle

Last

Name on Card if Different than Client

First

Middle

Last

Card Number: *

Expiration Date: *

CVC: *

Address: *

Patient or Authorized Guardian Signature: *

Health Insurance Claim Form

Patient Name *

First

Middle

Last

Patient Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient Date of Birth (MM/DD/YYYY): *

Patient Relationship to Insured *

Patient Marital Status:

Is Patient's Condition Related to:

Employment
Auto Accident
Other Accident

Emergency Contact Name *

First

Last

Emergency Contact Relationship to Patient *

Emergency Contact Phone Number(s) *

Primary Insurance Information:

**Please be advised that copayments/coinsurance payments and/or self-payments will be charged 24 hours before your appointment. Failure to remit payment will result in a service charge fee of $15.00.** *** A service charge of my full session fee with be applied for any scheduled appointment not cancelled within 24 hours (or rescheduled within the same business week), or for failure to attend a scheduled appointment.***

Please initial here.

Insurance Company Name *

Insurance ID Number *

Insurance Policy Group Number

Insurance Provider Phone Number *

Insured's Name *

First

Middle

Last

Person policy is under*

Insured's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Person policy is under*

Insured's Date of Birth (MM/DD/YYYY) *

Person policy is under*

SECONDARY Insurance Plan (If not applicable, skip)

Insurance Company Name

Insurance ID Number

Insurance Policy Group Number

Insurance Provider Phone Number

Insured's Name

First

Middle

Last

Person policy is under*

Insured's Address

Address Line 1

Address Line 2

City

State

Zip Code

Person policy is under*

Insured's Date of Birth (MM/DD/YYYY)

Person policy is under*

Patient or Authorized Guardian Signature *

Patient’s or Authorized Person’s Signature: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment claims related to medial services provided.

INFORMED CONSENT TO INDIVIDUAL PSYCHOTHERAPY

This form documents that I, *

give my consent to Suffolk Family Therapy LCSW P.C. (the “psychotherapist”) to provide psychotherapeutic treatment to me. While I expect benefits from treatment, I fully understand that no particular outcome can be guaranteed. I understand that I am free to discontinue treatment at any time but that it would be best to discuss with the psychotherapist any plans to end therapy before doing so. I have fully discussed with the psychotherapist what is involved in psychotherapy and I understand and agree to the policies about scheduling, fees and missed appointments. I understand that I am fully financially responsible for treatment, which, if I have health insurance, includes any portion of the psychotherapist’s fees that are not reimbursed by my insurance. I understand that the frequency of my sessions will be weekly that I am fully responsible for payment of all deductibles and co-payments if I have health insurance, that the frequency of billing will be weekly and that payment will be due at the session that immediately follows my receipt of bill, and that I will be responsible for payment in full for any cancellation (please note that insurers don’t pay for canceled sessions). Our discussion about therapy has included he psychotherapist’s evaluation and diagnostic formulation of my problems, the method of treatment, goals and length of treatment, and information about record keeping. I have been informed about and understand the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment. I understand that therapy can sometimes cause upsetting feelings to emerge, that I may feel worse temporarily before feeling better, and that I may experience distress caused by changes I may decide to make in my life as a result of therapy. I understand that the psychotherapist cannot provide emergency services. The psychotherapist has told me whom to call if an emergency arises and the psychotherapist is unavailable. In any cases. I understand that in any emergency, I may call 911 or go to the nearest hospital emergency room. I understand that information about psychotherapy is almost always kept confidential by the psychotherapist and not revealed to others unless I give my consent. There are few exceptions as follows: The psychotherapist is required by law to report suspected child abuse or neglect to the proper authorities. The psychotherapist is also mandated to report authorities patients who are at imminent risk of harming themselves or others for the purpose of those authorities checking to see whether such patients are owners of firearms, and if they are or apply to be, then limiting possibly removing their ability to possess them. If I tell the psychotherapist that I intend to harm another person, the psychotherapist must try to protect that person, including by telling the police or person or other health care providers. Similarly, if I threaten to harm myself, or my life or health is in any immediate danger, the psychotherapist will try to protect me, including by telling others such as my relatives or the police or other health care providers, who can assist in protecting or assisting me. If I am involved in certain court proceedings the psychotherapist may be required by law to reveal information about my treatment. These situations include child custody disputes, vases where therapy patient’s psychological condition is an issue, lawsuits or formal complaints against the psychotherapist, civil commitment hearings, and court-related treatment. If my health insurance or managed care plan will be reimbursing me or paying the psychotherapist directly, they will require that I waive confidentiality and that the psychotherapist give them information about my treatment. The psychotherapist may consult with other psychotherapists about my treatment, but in doing so will not reveal my name or other information that might identify me. Further, when the psychotherapist is away or unavailable, another psychotherapist might answer calls and so will need to have some information about my treatment. 6. If my account with the psychotherapist becomes overdue and I do not pay the amount due or work out a payment plan, the psychotherapist will reveal a limited amount of information about my treatment in taking legal measures to be paid. This information will include my name, social security number, address, dates and type of treatment and the amount due. In all of the situations described above I understand that the psychotherapist will try to discuss the situation with me, or notify me before any confidential information is revealed, and will reveal only the least amount of information that is necessary. If I am participating in a managed care plan, I have discussed with the psychotherapist the plan’s limits, if any, on the number of therapy sessions. I have discussed with the psychotherapist my options for continuation of treatment when my managed care benefits end. I understand that I have a right to ask the psychotherapist about the psychotherapist’s training and qualifications and about where to file complaints about the psychotherapist’s professional conduct. By signing below I am indicating that I have read and understood this form and that I give my consent to treatment. *

Please initial here

Signature: *

Date / Time *

Date

Time