intake form - telehealth therapist reno nv

INTAKEFORMThetherapyandcounselingworkwedoisuniquetoyou,justasitistoeachoneofourclients.Beforewegetstartedweneedtocollectsomegeneralinformationfromyou.

GENERALINFORMATION

FirstName LastName Gender

DateofBirth(mm/dd/yyyy) SocialSecurityNumber

Address

City State ZipCode

MainPhone OtherPhone

Email

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.


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.



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.



intake form - telehealth therapist reno nv

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