strive new participant packet

STRIVE New Participant Packet (rev. 10-13-2012) | Confidential

Welcome to STRIVE Motivational Group Counseling. Our mission is to educate, empower, and teach weight-loss

patients information and tools needed for long term success. Our primary goal is to build long term relationships with

patients by educating, encouraging, supporting, and leading patients through the journey of permanent lifestyle change.

Nancy Lum, RD, LDN has been practicing since 2001 and has been involved in multiple medical disciplines with a

concentration in GI and Bariatric Nutrition since 2002. She created the Bariatric nutrition program at Sinai Hospital in

Baltimore, MD in 2003 and is currently seeing weight loss and bariatric surgery patients for Dr. Kuldeep Singh, Dr. Isam

Hamdallah, and Andrew Averbach located at St Agnes Hospital in Baltimore, MD along with various medical practitioner

referrals and word-of-mouth.

Dawn A. O‘Meally, LCSW-C, P.A. has been practicing since 1988 and has worked as a Mental Health Clinician in a variety

of settings including Sheppard Pratt Hospital, Frederick Memorial Hospital and Carroll Hospital Center doing ER psych

evaluations, and since 1996, has been doing private practice as well. Dawn received training in 2005 on the Psychiatric

Evaluation of Bariatric Patients. Since that time she has been conducting mental health evaluations for various Bariatric

Surgeons at Sinai Hospital and St. Agnes Hospital. Dawn assists with facilitating Bariatric Support Group Meetings for St.

Agnes and Sinai Hospital as well. Dawn has a special passion for working with Bariatric patient’s pre and post-surgery.

Dawn loves running groups and facilitates various psycho educational and therapy groups in her private practice.

Our clients expect to be treated with the utmost care and concern for their well-being. They are provided with a

detailed and thorough education with access to long term follow up care. We look forward to assisting and advising you

throughout your weight loss journey. The nutritional and lifestyle changes you will be making are of the utmost

importance to your success with meeting your goals. We look forward to sharing our expertise and knowledge with you.

Sincerely,

Nancy Lum

Nancy Lum, RD, LDN

Dawn O’Meally

Dawn O’Meally, LCSW-C, P.A.

P: 443-490-1240

F: 443-490-1240

Website: www.StriveMD.com

Facebook: https://www.facebook.com/StriveMD

STRIVE Motivational Series

Nancy Lum, RD, LDN & Dawn O’Meally, LCSW-C, P.A.

http://www.strivemd.com/

https://www.facebook.com/StriveMD


Personal Goals & Intake Form for STRIVE

FIRST NAME, MIDDLE INITIAL

LAST NAME DOB ____/____/____ MM DD YYYY

AGE

MARITAL STATUS:

M S D W DP Other

Current Weight #

Height ‘ “

Are you in therapy now?

YES NO

Who referred you to us? ______________________________________________

Have you had bariatric surgery? YES NO If YES, which type (circle one): Gastric Bypass Gastric Band Gastric Sleeve OTHER: ________________________________________ Have you had more than one bariatric surgery (revision)? YES NO Who was your surgeon? (check on, or provide name):

Dr. Andrew Averbach Dr. Kuldeep Singh Dr. Isam Hamdallah

OTHER:__________________________________________________________________________________________

OCCUPATION

How did you hear about us? (for marketing purposes only)

□ Support Group Meeting

□ Nancy Lum, RD, LDN

□ Dawn O'Meally, LCSW-C, P.A.

□ Brochure/ Postcard

□ Email

□ Facebook, Twitter or LinkedIn

□ Gym/ Health Club

□ Dr. Averbach

□ Dr. Singh

□ Dr. Hamdallah

□ Another Healthcare Professional

□ Friend/Co-worker

□ Other: ______________________________________________________


MEDICAL HISTORY

COMORBIDITIES DIGESTIVE/ GI RELATED DISORDERS OTHER CONDITIONS CORONARY ARTERY DISEASE

BARRETT’S ESOPHAGUS ANEMIA/ IRON DEFICIENCY

DIABETES TYPE I CELIAC DISEASE ANXIETY

DIABETESE TYPE II CHRONIC CONSTIPATION ARTHRITIS

HIGH BLOOD PRESSURE (aka Hypertension or HTN)

CROHN’S DISEASE BIPOLAR

HIGH CHOLESTEROL DIVERTICULITIS DEPRESSION

SLEEP APNEA DIVERTICULOSIS GRAVES DISEASE

IRRITABLE BOWEL (IBS/ IBD) HASHIMOTO’S DISEASE

REFLUX DISEASE (GERD) HYPERTHYROIDISM

ULCERATIVE COLITIS HYPOTHYROIDISM

LACTOSE INTOLERANT

OCD

OSTEOPENIA

OSTEOPOROSIS

STROKE

VITAMIN D DEFICIENCY

OTHER MEDICAL CONDITIONS (PLEASE LIST):

Vitamins you are currently on (Brand, Dosage, Number per day)


Personal Goals for STRIVE:

If you had a magic wand and could solve all of your problems, what would be on your wish list? How would your life

change? Please list at least three personal goals you would like to accomplish through your participation in the STRIVE

program.

1. ___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

2. ___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

3. ___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________


PARTICIPANT AGREEMENT

For: STRIVE TO SUCCEED MEETINGS

I _________________________ (print your name), agree to participate in Strive group meetings. I understand that I will be required to attend all sessions in the series. I understand that during each session I will participate in group exercises that are designed to help me develop more positive thinking patterns and healthier thinking.

I understand that once I have made the commitment to participate in the program, the morale of the group will depend in part on my consistent attendance and involvement. I understand that if I drop out prematurely or attend inconsistently, this will be disruptive and may hurt the morale of the other group members.

Please check the box below that best describes how you feel about attending consistently:

I definitely plan to attend all sessions in this series.

I anticipate that I may not be able to attend all the sessions.

I understand that I will be asked to do daily self-help assignments between sessions. These assignments will consist of activities such as reading and doing self-help assignments. I understand that my learning and growth will depend on the amount of time I spend doing self-help assignments between sessions. I understand that my failure to do this homework may diminish any learning and growth that I might experience during this program.

Please check the box below that best describes how you feel about the homework assignments:

I am definitely willing and able to do the self-help assignments.

I am not sure that I will be able to do the homework assignments consistently.

I am not willing to do the homework assignments consistently.

If I miss a session due to illness or some other factor beyond my control, I agree to give the group facilitators notification

at least 24 hours in advance, I understand I am still responsible for paying for materials for missed sessions.

I have read this form and I have had the chance to ask questions about the purpose of the STRIVE meetings as well as the nature of my participation. I agree to participate along the lines described here.

_________________________________ ________________________________

Sign your name Group Facilitators

_________________________________ ________________________________

Today’s date Today’s date


Financial Policy – STRIVE Series

Thank you for your interest in the STRIVE to Succeed Series. We are committed to your weight loss journey being successful. The following is a

statement of our Financial Policy, which we require that you read and sign prior to your first meeting. Please understand this financial policy is

enforced to keep costs at a reasonable level, thus preventing fee increases. This also allows us to concentrate on what we do best: helping you with

your weight loss journey!!

Payment Methods Accepted: Initial

○ We accept cash, checks, money order, MasterCard, VISA, HSA, FSA cards with the VISA logo, and American Express.

○ Payment is expected, in full, at the time of service, we do NOT accept post-dated payments. We reserve the right to refuse service if

payment is not made at the time of service.

Insurance: Initial

○ Nancy Lum does not participate with insurance companies. You will be provided with a nutrition medically coded receipt for weight loss

upon completion of the series or once you have paid in full, whichever comes first. This nutrition coded receipt can be submitted to your

insurer to seek reimbursement; we cannot guarantee you will be reimbursed. If you are unable to be reimbursed for our services please

save the receipt for your tax and/or flex spending purposes.

○ You may be eligible for reimbursement from your insurance company IF you see therapist Dawn O’Meally for an individual assessment,

no less than two weeks prior to the first class. See below for instructions on how to utilize your mental health benefits from your

insurance company.

INSURANCE:

○ If you have insurance coverage and plan to use your mental health benefits, for the costs of group therapy, you will need to be individually

assessed by Dawn O'Meally LCSW-C, P.A. Insurance companies will not offer reimbursement without a proper diagnostic code(s). In order

for Dawn O’Meally to bill your insurance, you must be individually assessed to obtain a diagnosis code for her to bill under. It is your

responsibility to find out what coverage, you have for group therapy. Please visit Dawn's website www.bariatricpsychservices.com to see

a list of insurance companies accepted. Call 443-590-0030 to schedule your individual assessment appointment and for more

information regarding possible insurance reimbursement. You will be told what your co-payment, per class session, will be based on

your insurance coverage by Dawn’s office.

○ If you choose to utilize your insurance coverage through Dawn the co-payment for Nancy Lum will be $25 per class. Nancy’s co-payment is

to be paid at the beginning of each class, or can be paid in full for all sessions at the beginning of the first session. A nutrition receipt,

coded for weight-loss, will be provided to you at the end of the series for the total cost incurred. You may then attempt to submit to

insurance for reimbursement of her services; we cannot guarantee reimbursement.

Missed Meetings and Cancellations:

Initial

○ Because this is a 7-part series there are no “make-up” days if a meeting is missed. We are creating a small group series and when people

miss it disturbs cohesiveness of group. See Patient Agreement for details.

○ There is a $50 commitment fee whether you come to the meeting or not.

○ There is no reimbursement for missing meetings.

○ Cancellation: Should you decide to cancel your participation in this series please do so no later than 1 week prior to its start date. We

can only have up to 15 participants in any one group, we will only be running one group at a time, per series, so there may be people

waiting to get into the series you are cancelling. Please call 443-490-1240 to cancel your enrollment.


Returned Checks: Initial

○ If a check is returned unpaid, there will be a $50.00 Insufficient Funds Fee (NSF) charge and personal checks will no longer be accepted as

a method of payment.

Late Payment Fees, as a result of returned checks and/or meetings that remain unpaid for: Initial

○ A late payment billing charge of $50.00 will be applied to any account which has a balance ≥ 30 days past due. Each additional month your balance is outstanding will be assessed $25.00. Late fees will not exceed 100% of your original balance or $150.00, whichever is greater.

○ Accounts >60 days past due will be sent for legal action/ collections, you will be responsible for additional fees associated with this process. (ex. Court costs, legal fees, etc.)

Services: Initial

○ If you have enrolled in one of our series previously and dropped out, or neglected to complete all the meetings included, within 12 months from your initial date of service, you will be required to re-enroll in the program and pay the current fee for services.

I, the undersigned, assume financial responsibility as stated above and responsibility for all charges and fees if my account becomes past due. I have read, understand, and agree to this Financial Policy. I also understand future meetings may be denied if my account becomes past due until my balance to this office has been paid in full. Fees are subject to change without notice.

X ________________________________________________________________________ ___________________________

Signature of Patient Date

strive new participant packet

Documents