Fontana, Stidham & Associates

The PRISM Center 6750 West Loop South, Suite 950 Bellaire, TX 77401 Office: (832) 778-6750 Fax: (832) 778-6752 Psychotherapy Consultation Adult Client Registration

Client Name: ______Date: ______

Home Address: ______Number Street City/State Zip Code Phone Number: Home: ______Work: ______Cell: ______

Date of Birth: ______Age: _____ Sex: _____ Marital Status: _____ Race: ______

Employer: ______Occupation: ______Email: ______

Whom may we thank for referring you to The PRISM Center? ______

Emergency Contact: Name: ______Relationship to client: ______

Phone Number: Home: ______Work: ______Cell: ______

What is the problem or issue for which you are seeking treatment or consultation?

______

Name of Primary Care Physician: ______Phone: ______

Date of Last Appointment: ______Date of Next Appointment ______

Are you presently under the care of a psychiatrist? ( ) No ( ) Yes If yes, please complete the following:

Name of Psychiatrist: ______Phone Number: ______

Date of last Appointment: ______Date of Next Appointment: ______

Date first began seeing this doctor: ______

Are you presently under the care of a psychotherapist? ( ) No ( ) Yes If yes, please complete the following:

Name of Psychotherapist: ______Phone Number: ______

Date of Last Appointment: ______Date of Next Appointment: ______

1 Date first began seeing this professional: ______

Current Medications

Name of Dosage How long have you Reason for Response: Helpful? Medication been taking this Medication Side effects? medication?

Please mark all of the following that apply to you today:

Behavioral Symptoms:

____Appetite disturbance ____Poor peer relationships ____Impulsivity ____Parent/child conflict ____Promiscuity ____Theft ____Sexual problems ____Gambling ____Social isolation ____Self injuring(cutting, burning) ____Excessive use of alcohol ____Marital conflict ____Acting out sexually ____Procrastinating ____Financial issues ____Compulsive behavior ____Illegal drug use ____Binge eating ____Abuse of prescribed meds ____Excessive absences from work ____Other______Difficulty maintaining a clean & orderly home

Emotional symptoms:

____Irritability/Easily agitated ____Anger/resentment ____Stressed ____Sadness/grief ____Shame/guilt ____Tearful ____Anxious/panicky ____Numb ____Detached ____Hopeless/Helpless ____Feelings of inferiority ____Afraid ____Depressed ____Emptiness ____Worthless ____Unmotivated ____Other______

Cognitive (Thought) symptoms:

____Poor concentration ____Difficulty making decisions ____Unattractive ____Confused ____Nightmares ____Unlovable ____Memory loss ____Overly sensitive ____Racing thoughts ____Obsessive thoughts ____Distracted ____Disorganized ____Paranoia ____Delusions/hallucinations ____Fear of going crazy

2 ____Worries about body image ____Fear of dying ____Other______

Physical symptoms:

Area of Physical Health No Past Current If a Current or Past Problem, Problem Problem Problem Describe Vision (eye sight, cataract, glaucoma) Hearing (hearing impairment, tinnitus) Circulatory (heart disease, migraine/headache, chest tightness, blood pressure, stroke) Nervous System (seizures, numbness, shaking, trembling, tingling, etc.) Muscles/Bones (breaks/sprains, muscle disease, etc.) Digestive (stomach, bowels, IBS, GERD/reflux, vomiting, nausea, weight gain/loss, etc.) Reproductive (STD, infertility, chills/hot flashes, pregnancy, prostate, peri-menopause, etc.) Respiratory (lungs, TB, emphysema, etc.) Hepatic (liver, hepatitis A, B, C) Lymphatic (swollen glands) Skin/Hair (rash, lesions, etc.) Immune (HIV, cancer, frequent colds, coughs, infections, CFS, Epstein Barr) Infectious (staph, MRSI, blood-borne) Urinary (kidneys, bladder, etc.)

Other significant past and current medical problems not described above: ______

______

Allergies: ______

Current Pain? ( ) No ( ) Yes If yes, describe severity and location: ______

Current Treatment of Pain? ( ) Yes ( ) No Referred to Physician on ______date

Current Sleep: ( ) No sleep disturbance ( ) Trouble falling asleep ( ) Trouble staying asleep ( ) Excessive sleep

Appetite: ( ) No appetite disturbance ( ) Loss of appetite ( ) Excessive appetite

Energy: ( ) Normal amount of energy ( ) Loss of energy ( ) Excessive energy

Suicidal Thoughts: Currently: ( ) No suicidal thoughts ( ) Suicidal thoughts

3 If yes, please describe: ______

Past: ( ) Never had suicidal thoughts ( ) Thoughts of suicide in past

( ) Attempted suicide in the past:

If yes, please explain (when? how?):______

Homicidal/Violence Thoughts: Currently: ( ) None ( ) Yes, I have violent or homicidal thoughts If yes, please describe: ______

Hallucinations: Check off current hallucinations, if any: ( ) Visual ( ) Auditory ( ) Touch ( ) Taste ( ) Smell

Check off past hallucinations, if any ( ) Visual ( ) Auditory ( ) Touch ( ) Taste ( ) Smell

Have you had the following abuse history, as victim or perpetrator:

Type of Abuse Yes No Please describe Emotional/Verbal Abuse

Sexual Abuse

Physical Abuse

Domestic Violence/ Battering Rape/Date Rape

Other violent crime

Substance Use:

Substance Yes No Describe pattern of use Date/Amount of last use Tobacco Alcohol

Marijuana Cocaine/Crack Stimulant Drugs (Ritalin, Adderal1, Speed, 4 Methamphetamine, Crank) Opiates (Vicodin, Oxycontin, Heroin) Hallucinogens (XTC, PCP, LSD, Mushrooms) Sedatives, Tranquilizers (Xanax, Valium, sleeping pills)

Please answer yes or no to each question regarding your drug and/or alcohol use:

Question Yes No Please describe/explain Have you ever felt you should cut down on your use of alcohol or drugs?

Have you ever been annoyed when people have commented on your alcohol or drug use?

Have you ever felt guilty or badly about your alcohol or drug use?

Have you ever had an “eye opener” first thing in the morning to steady your nerves, avoid withdrawal symptoms, or avoid the low feeling you get after using?

Please describe all past Outpatient Psychotherapy and/or Psychiatric Hospitalizations:

Provider of Service Dates of Service Reason(s) for Was it Treatment helpful?

Financially Responsible Party (If Different Than Client)

Name: ______Home Phone #: ______Work #: ______

Cell #:______Address: ______Number Street City Zip Code

Insurance claims

5 If we will be filing an insurance claim for you, (1) Please give us your insurance card to photocopy and (2) Please complete the following:

Name of Insured (if different than client): ______

Relationship to Client: ______Date of Birth: ______Social Security #:______

Insured’s Address (if different than client):______number street city zip code

Insured’s Phone # (if different than client): ______Insured’s Employer: ______

The PRISM Center 6750 West Loop South, Suite 950 Bellaire, TX 77401 Office: (832) 778-6750 Fax: (832) 778-6752 Informed Consent Form

Client’s Name: ______

Welcome to The PRISM Center (Programs for Innovative Self-Management). Please review the following policies carefully. We will discuss our policies at any time should you have questions. We appreciate your confidence in selecting us as your service provider.

Services Provided: We provide a wide variety of psychotherapy and consulting services including, but not limited to, the following:

 Evaluations and Consultation  Crisis Intervention and Crisis Management Services  Intensive Outpatient Program (IOP) for Adults  Dialectical Behavioral Therapy (DBT): both individual DBT and DBT Skills Training Groups for adults (17 and over)  Individual, Group, Marital, and Family Therapy / Education  Stress Management  Individualized Chemical Dependency Assessment and Treatment  Employee Assistance Services for Companies (EAP Services)  Career Coaching and Vocational Assessment

Each of these activities is covered by the rules of practice for practitioners in the state of Texas, and is governed by the Texas State Board of Social Work Examiners, the Texas State Board of Examiners of Professional Counselors, and other certifying agencies.

6 Records and Diagnosis: We are required by law to maintain records of each time we meet or talk on the phone. The records include a brief synopsis of the conversation along with any observations or plans for the next session. Your file will be kept in a locked file cabinet, and only staff members with a key will have access to records on an as needed basis. A judge can subpoena your records for a variety of reasons and, if this happens, we must comply. If we are called to testify about the contents of the records, we also must comply. Occasionally, we can negotiate with judges and attorneys to keep some information confidential.

Electronic Transmissions: Confidentiality cannot be assured using any form of electronic media communication (i.e. fax, internet communication, cell phones). Email: At The PRISM Center, we work primarily with clients via face-to-face therapy and via phone contact. Your individual psychotherapist or group therapist may also respond to emails, but the timeliness of response depends on the particular therapist, and some prefer not to communicate via email (unless a special circumstance occurs). Please discuss email with your therapist. There will be a charge for therapeutic/consulting activities via email and excessive text communications.

Fees: Payment is due at time of service. We accept MasterCard, VISA, Discover debit and charge cards, checks and cash. Frost Bank (in the building lobby) has an ATM machine which you are welcome to use. Delinquent accounts will be referred to a collection agency if not taken care of in a timely manner. Fee Schedule Self Pay Rates Brief Session: 30 minutes $ 67.50 Standard Session: 50 minutes $ 135.00 Intake Evaluations and Extended Session: 75 minutes $ 175.00 Extended Session: 90 minutes $ 202.50 Extended Session: 120 minutes $ 270.00 Group Therapy (60 to 120 min.) $ 50 - 115 /session DBT Group Therapy (2 to 2.25 hours) $ 100 /session* Intensive Outpatient Program per Session: $ 197.00/session* (2.25 – 2.5 hours/session) (*rates vary depending on contract with insurance company)

Professional time: Insurance does not pay for the following services: Routine reports, crisis phone sessions, disability reports, responding to email communication , etc.: $135/ hr. Legal reports, trial preparation, court appearances, depositions, etc.: $ 270 / hour Transportation time for court appearances: $ 135 / hour

Time Parameters and Scheduling: We have a busy schedule, as do the majority of our clients, so we make considerable effort to run on time, unless come unforeseen crisis occurs. Since we specialize in complex care, psychiatric emergencies do occasionally happen. Routine psychotherapy sessions are scheduled for 50 minutes, unless we are advised in advance that you prefer either a brief or extended session. During the course of a follow-up session, if you want additional time (i.e. extended session) please let the therapist know and we will be happy to accommodate you if our schedule allows.

The time allotted for your therapy session begins at the time of your scheduled appointment (e.g. 2:00 p.m. appointment means that the time from 2:00 until 2:50 p.m. has been reserved for you and will end at 2:50 p.m. regardless of your arrival time).

Cancellations: 24 hours notification prior to scheduled individual or family therapy appointments is required. Monday appointments must be cancelled on the preceding Friday to avoid any fee. If you 7 fail to give 24 hours notice and/or fail to appear for a session, you will be charged the full rate of the session. Insurance companies cannot be billed for a cancelled appointment.

Absences from Group Therapy and IOP: It is expected that you attend all scheduled group therapy sessions until you are discharged. If you have to miss group therapy or IOP, please call us in advance to discuss the absence. We have limited spaces available in our groups so, if you are a member, it is important to take advantage of your membership and attend group therapy when it is scheduled (plus, you maximize the therapeutic benefits of being in the program.)

Zero Tolerance Policy: Safety to clients and others is essential at all times. We adhere to a strict “zero tolerance” policy towards violence against people or property, and drugs, alcohol, or weapons on the property. We will call the police for violations of this policy to insure safety. Neither clients nor family members are to come intoxicated or impaired to any therapy session.

Confidentiality: Confidentiality is a legal protection and assurance of your right to privacy within the limits of the Texas state statutes and Federal HIPAA law. The attached HIPAA notice further explains our privacy practices. It is your right that all communication with us be completely private with the below exceptions:

Exceptions to confidentiality: (1) The clinicians in our practice may share information to collaborate in your care. (2) If we consider you a danger to yourself or to others, we must inform the police or a family member if you refuse to tell your family or seek hospitalization. (3) If a court subpoenas your records, we must cooperate with the court order. (4) If you are a minor and we believe that you are a victim of abuse, we must inform Children’s Protective Services per state law. (5) We must report abuse of disabled or elderly adults to Adult Protective Services. (6) If you want your insurance company to reimburse for treatment, we must be able to discuss your diagnosis and treatment with their representative (either verbally or in writing). (7) If you are under the age of 18 and your parent or legal guardian requests information that we consider necessary to the support of your treatment, we will ask your permission to discuss such issues with them, but will do so in cases of emergencies and fee/insurance questions. (8) State and Federal Law also mandates that we may have to disclose limited health information in matters regarding emergencies, national security, public health, research, and other similar matters.

Client Rights and Privacy Notice: Attached are copies for your review.

Client and Family Involvement in Treatment: It is expected that all clients and applicable family members actively participate in the assessment, treatment, and discharge planning process. We want and require your input, preferences, and objections in regard to treatment.

Emergencies: One of the therapists is always on call nights and weekends for true emergencies. In addition, we encourage you to go to your nearest emergency room or psychiatric hospital for psychiatric emergencies. Our day and after-hours cell phone number is (281) 974-0691.

8 Notice of Termination of Services: You are not obligated to seek services here for any specified number of sessions. You are important to us, however, and if you decide to end services here, we would appreciate notification of your completion of services either in a therapy session or via a phone call.

Questions, Concerns, or Complaints: Your satisfaction with our services is very important to us. Should you have any questions, concerns, or complaints, please feel free to openly discuss them with either your therapist or Owner/Clinical Director Martha Fontana, LCSW.

I have reviewed and understand these policies and procedures, and agree to the terms specified above. I have also received a notice of “Privacy Practices” on this date. I understand that if I have any questions regarding the Notice of Privacy Practices or my privacy rights, I may contact Martha Fontana, Privacy Officer, at (832) 778-6750.

( ) I am consenting to an initial intake evaluation and/or continuing treatment Initial or consultation services for myself or my child.

Client Signature:______Date: ______

Parent Signature: (if applicable; please print): ______

NOTICE OF PRIVACY PRACTICE S

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization. We may use PHI to remind you of appointments, or to provide information about treatment alternatives or other health-related benefits and services.

Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

9  Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or the health department)  Required by Court Order  Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer , Martha Fontana at 832-778-6750.

 Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.  Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.  Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.  Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.  Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  Right to a Copy of this Notice. You have the right to a copy of this notice.

COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer, Martha Fontana at 832-778- 6750, or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint. The effective date of this Notice is April 14, 2003.

The PRISM Center 6750 West Loop South, Suite 950 Bellaire, TX 77401 Office: (832) 778-6750 Fax: (832) 778-6752

CLIENT RIGHTS

It is the policy of The PRISM Center that this practice shall respect and protect all clients’ rights through implementation of the following:

1. You have the right to be free from abuse, neglect, and exploitation. 2. You have the right to be treated with dignity and respect. 3. You have the right to be told about program rules before you are admitted. 4. You have the right to be told before admission: 1. the condition to be treated; 2. the proposed treatment; 3. other treatments that are available and which ones, if any, might be appropriate for you. 5. You have the right to accept or refuse treatment after receiving this explanation. 6. If you agree to treatment, you have the right to change your mind at any time. 10 7. You have the right to a treatment plan designed to meet your needs, and you have the right to take part in developing that plan. 8. You have the right to meet with staff to review and update the plan on a regular basis. 9. You have the right to have information about you kept private and be told about the times when the information can be released without your written permission. 10. You have the right to be told in advance of all estimated charges and any limitations on the length of the services with which this facility is aware. 11. You have the right to receive an explanation of your treatment or your rights if you have questions while you are in treatment. 12. You have the right to make a complaint and receive a fair response from this facility within a reasonable amount of time. 13. You have the right to complain directly to the Secretary of Health and Human Services for privacy issues at (202) 619-0257. 14. You have the right to request a copy of these rights before you are admitted, and the phone number of the Department of Health and Human Services. 15) You have the right to make a complaint against your insurance company, HMOs, insurance agents or agencies, and other persons or entities regulated by the Texas Department of Insurance. Complaints generally involve such matters as claims and benefits, false advertising, misrepresentation of policies, and HMO quality of care. Texas Department of Insurance 512.463.6169 web site: www.tdi.state.tx.us Consumer Hotline 800.252.3439

I have reviewed and understand the rights listed above. If I have any concerns about rights or any complaint, in addition to calling the above listed agency, I may speak to the Privacy Officer, Martha Fontana, LCSW, at (832) 778-6750, or cell (281) 974-0691.

X______Client Signature Date

The PRISM Center 6750 West Loop South, Suite 950 Bellaire, TX 77401 Office: (832) 778-6750 Fax: (832) 778-6752

Appointment Payment & Cancellation Policy

Cancellation of a scheduled individual or family therapy appointment for any reason must be made at least 24 business hours prior to the appointment time or you will be charged the full appointment fee. (Insurance companies do not cover missed appointments.) If your appointment is on a Monday, cancellation must be made by 5:00 p.m. the previous Friday.

Since this appointment time has been reserved especially for you, and your clinician prepares for your session, cancellation or no-shows do not give us sufficient time to fill your time slot. No additional sessions may be scheduled until payment has been received on all previous appointments. 11 It is our policy to keep credit card information or a one-session Deposit On File: Credit card information will remain confidential and will be used only for “no-shows”, appointments not cancelled within 24 business hours, minors driving themselves to appointments without payment, outstanding balances, phone sessions (emergency calls, after-hours calls, etc.). Additionally, if we are unable to collect payment from client / financially responsible party within 30 days of rendered service, your card will be automatically charged for owed amount.

There will be a charge for any declined credit/debit cards or returned checks: 1 st time $10 and 2 nd time $20. After the 3 rd time, the client must pay on a cash only basis. Additionally, delinquent accounts will be turned over to our collection agency if we are not able to collect the balance from you within three (3) months of service.

I understand and agree to the payment & cancellation policy.

______Client Name ______Client Signature Date ______Name of Financially Responsible Party (if different from client)

______Signature of Financially Responsible Party Date

Type of card (please circle): Visa MasterCard Name (as it appears on card): ______

Credit Card #: ______

Expiration Date: ______3-digit code on back of card: ______

Billing Address/Zip Code: ______