Wholeistic Mental and Physical Health, LLC 2601 Wyoming Blvd. NE Suite 208 Albuquerque, NM 87112 Phone: 505.503.0272 Fax: 505.608.7258 albuquerquementalhealth.org [email protected]
Client Information/Intake Form
Today’s date:
Note: If you have been a client here before, please fill in only the information that has changed.
GENERAL HISTORY
A. Identification: Your name: Gender: Date of birth: Age: Home Street Address: Apt.: City: State: NM Zip: Phone Number: e-mail: Social Security Number (for insurance verification purposes only): Calls or e-mail will be discreet, but please indicate any restrictions:
B. Health Insurance and Funding Information Primary: Insurance Company: Client Member # Group # Co-Pay (under “specialist”) Primary Holder’s Name (if different from yours) Primary’s Date of Birth: Secondary: (if any) Insurance Company: Client Member # Group # Co-Pay (under “specialist”) Primary Holder’s Name: Primary’s Date of Birth: C. Emergency information If some kind of emergency arises and we cannot reach you directly, or we need to reach someone close to you, whom should we contact? Any restrictions on this contact? Name: Phone: Relationship: Restrictions: By submitting this form, you grant Wholeistic Mental and Physical Health, LLC and hired biller to contact your and your insurance concerning scheduling of services. ______Signature Print Date
D Referral: How did you hear of this agency? Who gave you our name to call, or why did you choose us?
How did this person explain how we might be of help to you? (if applicable)
E. Religious and Ethnicity Identification (Only if Applicable) Wholeistic Mental and Physical Health, LLC 2601 Wyoming Blvd NE Suite 208 Abq. NM 87112 Phone: 505.503.0272 Fax: 505.608.7258 [email protected]
Current Religious Affiliation:
Past Religious Affiliation:
How important are spiritual concerns in your life (if any/applicable) Ethnicity/national origin or other way that you identify yourself
F. FAMILIAL AND SOCIAL HISTORY
A. Current Relational Status and Satisfaction of Current Relational Situation:
B. Past Relational Status and Satisfaction of Past Relational Situation: (only if applicable)
C. Children (if any) Please include name (first name only,) age and satisfaction of relationship:
D. Are there any current or past relational concerns you feel are of concern? If so, please explain:
E. Current employment (if any.) Please note if unemployed. Include the degree of employment satisfaction, as well as military history.
F. Highest level of education completed. Please note if currently a student, year and school attending
G. History of arrests/jail time (if any)
H. Parents (natural, step and/or other type) Please describe name, occupation, education, past or present substance use, relevant medical/mental health concerns, and satisfaction of relationship
I. Anything during childhood/adolescence you feel would be useful for therapist to know prior to beginning therapy?
G. PHYSICAL AND EMOTIONAL HEALTH HISTORY
A. Medical Information : From whom or where do you get your medical care?
Clinic/doctor’s name: Phone:
Address: (Please see page 8 for information regarding release of your medical records. Note that page 8 is an insurance page requirement and you have the right to refuse to disclose your medical records.)
B. Overall general health and any current or past health concerns:
C. Current Medications (if any) and your satisfaction with their effectiveness:
D. History of counseling/therapy including (if known) names, dates and effectiveness (if any): Wholeistic Mental and Physical Health, LLC 2601 Wyoming Blvd NE Suite 208 Abq. NM 87112 Phone: 505.503.0272 Fax: 505.608.7258 [email protected]
E. Recreational substances used regularly (both past and present,) noting any concerns (Please be advised this is for treatment planning only and will absolutely be kept confidential )
F. Do you currently have suicidal ideation? Yes No If yes, do you have a plan? Yes No
Notes:
G. Do you have concerns about your anger or do you have thoughts of harming someone? Yes No
Notes:
H. PERSONAL THOUGHTS ABOUT CURRENT LIFE STATE
A. In your words, what do you feel is the problem?
B. What have you done on your own to stop the problem?
C. What do you feel your strengths are? What are your hobbies/what do you like to do?
D. Anything else you feel would be helpful to know before beginning therapy? Wholeistic Mental and Physical Health, LLC 2601 Wyoming Blvd NE Suite 208 Abq. NM 87112 Phone: 505.503.0272 Fax: 505.608.7258 [email protected] Consent For Treatment
I, (print name) do hereby seek and consent to take part in the treatment at WMPH, LLC. I understand that developing a treatment plan with the therapist here, and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.
I understand that no promises have been made to me as to the results of treatment or of any procedures provided by WMPH, LLC. I further understand that my therapist is a part of a clinical consultation team and my case may be presented for the overall best clinical care. My full name or other identifying information will not be shared.
I am aware that I may stop my treatment at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.)
I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the therapist may stop my treatment.
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Cancellation Policy:
Because we hold a session time for you, and only you, a minimum of 24 hours notice is required if you must miss your therapy appointment or you will be charged half the full session fee of $100. This is a policy that will be enforced.
I know that I must call to cancel an appointment at least 24 hours (1 day) before the time of appointment. If I do not cancel within 24 hours, I understand that I will be charged a $50 cancellation fee, which is half of the standard hourly rate.
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Limits of Confidentiality: WMPH, LLC recognizes that confidentiality is essential to effective therapy, and in order for counseling and therapy to work in the best way possible, you must feel safe about sharing your personal information with your me. Under most circumstances, all information about you, in written or verbal form, obtained in the counseling process (including your identity as a client) will be kept ethically and legally confidential. Information will not be disclosed to any outside person(s) or agency without your written permission except in certain situations, which include, but are not limited to: If you are determined to be an imminent danger of harming yourself or someone else If you disclose abuse or neglect of children, the elderly or a disabled person(s.) Wholeistic Mental and Physical Health, LLC 2601 Wyoming Blvd NE Suite 208 Abq. NM 87112 Phone: 505.503.0272 Fax: 505.608.7258 [email protected] If you disclose sexual misconduct by a mental health professional Your mental health conditions becomes a part of a lawsuit or other legal subpoena If you authorized a release of information with your signature
Initial Here CONTACT CONFIDENTIALITY I understand that therapists at WMPH, LLC use a cell phone as their primary telephone line and an unsecured (gmail) email as their primary mode of email communication. I understand that these lines may not be completely secure and the information I convey thorough these methods may be accessed by unauthorized personal by neither of our knowledge.
Initial Here COURT FEES Unless otherwise discussed, my therapist will only take part in a court case if they have been subpoenaed by a judge. If/when this happens, the hourly rate of $100 applies to appear in court with a minimum of a 4 hour time commitment.
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My signature below shows that I understand and agree with all of these statements.
Printed name of client Date
______Signature of client Date
If client is under 14 years, parents name and signature must be included
______
I, the therapist, have discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this person’s behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent.
______Signature of therapist Date Wholeistic Mental and Physical Health, LLC 2601 Wyoming Blvd NE Suite 208 Abq. NM 87112 Phone: 505.503.0272 Fax: 505.608.7258 [email protected]
Notice of Privacy Practices (This is for you to keep)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
How we use and disclose your protected health information with your consentWe will use the information we collect about you mainly to provide you with treatment, to arrange payment for our services, and for some other business activities that are called, in the law, health care operations. After you have read this notice we will ask you to sign a consent form to let us use and share your information in these ways. If you do not consent and sign this form, we cannot treat you. If we want to use or send, share, or release your information for other purposes, we will discuss this with you and ask you to sign an authorization form to allow this.
Disclosing your health information without your consent
There are some times when the laws require us to use or share your information. For example:1. When there is a serious threat to your or another’s health and safety or to the public. We will only share information with persons who are able to help prevent or reduce the threat.2. When we are required to do so by lawsuits and other legal or court proceedings.3. If a law enforcement official requires us to do so.4. For workers’ compensation and similar benefit programs.There are some other rare situations. They are described in the longer version of our notice of privacy practices.
Your rights regarding your health information
1. You can ask us to communicate with you in a particular way or at a certain place that is more private for you. For example, you can ask us to call you at home, and not at work, to schedule or cancel an appointment. We will try our best to do as you ask.2. You can ask us to limit what we tell people involved in your care or the payment for your care, such as family members and friends.
3. You have the right to look at the health information we have about you, such as your medical and billing records. You can get a copy of these records, but we may charge you for it. Contact our privacy officer to arrange how to see your records. See below.4. If you believe that the information in your records is incorrect or missing something important, you can ask us to make additions to your records to correct the situation. You have to make this request in writing and send it to our privacy officer. You must also tell us the reasons you want to make the changes.
5. You have the right to a copy of this notice. If we change this notice, we will post the new version in our waiting area, and you can always get a copy of it from the privacy officer.6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with our privacy officer and with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way. Also, you may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. We will be happy to discuss these situations with you now or as they arise. If you have any questions regarding this notice or our health information privacy policies, please contact our privacy officer, who is and can be reached by phone at or by e-mail at Wholeistic Mental and Physical Health, LLC 2601 Wyoming Blvd NE Suite 208 Abq. NM 87112 Phone: 505.503.0272 Fax: 505.608.7258 [email protected] Anney Snyder, LISW 505.503.0272 [email protected]
Receipt and Acknowledgement of Notice of Privacy Practices Statement (HIPAA Information)
Client’s Name: Client’s DOB (mm/dd/yyyy): Client’s SSN:
I hereby acknowledge that I have received and or had the opportunity to review the Notice of Privacy Practices Statement, provided by Anney Snyder. I understand that if I have questions regarding the notice or my privacy rights I can contact my therapist. Client’s Signature: ______
Guardian Signature (if needed): ______
Date:
Therapist Signature: ______
Date:
Behavioral Health Release of Medical Information and Coordination of Care Form Communication between your behavioral health provider and your Primary Care Physician is important to provide streamlined and well coordinated quality care. No information will be released without your signature authorization. Release of medical information FROM: ______(Practitioner Name) TO: ______(Practitioner Name) Patient Name: ______Patient DOB: ______Member ID number/Social Security Number: ______Records to be released: _____ All Health Records _____ Heath Records related to drub/alcohol/substance abuse _____ Health Records related to emotional/mental/developmental disabilities/psychiatric conditions (excluding psychotherapy notes) _____Other: ______
o I authorize the above checked records to be released as indicated above
Patient’s Signature: ______Date: ______Wholeistic Mental and Physical Health, LLC 2601 Wyoming Blvd NE Suite 208 Abq. NM 87112 Phone: 505.503.0272 Fax: 505.608.7258 [email protected] o I do not authorize information about my physical/behavioral health treatment to be released
Patient’s Signature: ______Date: ______Cancellation/Expiration: I Understand that I may cancel this authorization at ay time by sending my health care providers my cancellation notice in writing. I understand that my health care providers may have already released records according to this authorization prior to receiving my notice of cancellation. Unless cancelled, this authorization expires 6 months after signature date. Health Care Coordination Information Treatment Start Date: ______DSM-IV Diagnosis ______Medication Managed by (if applicable:) ______Medication and Dosages: 1. ______2. ______2. ______4. ______Treatment Plan: ______If there is any additional information you feel I should know in order to provide the best possible care to this patient, especially any coexisting medical conditions, or if you would like to discuss treatment, please contact me. Practitioner’s Signature: ______Date: ______Telephone: ______Confidential Protected Health Information: Protected Health Information is personal and sensitive information related to a person’s health care. It is being delivered to you after appropriate authorization from the patient/member or under circumstances that do not require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without additional patient/member consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law.