Initial Patient Information

INITIAL PATIENT INFORMATION

Date:

/

Client Information:

Last Name: / First Name: / M.I.:
Address:
City: / State: / Zip:
HM Phone: / ( ) / Social Security #:
Age: / Sex: / DOB: / Marital Status: / Yes | No
Parent(s) or Guardian(s) Name:
Address: / Same as above or:
City: / State: / Zip:
Is Client a Minor Child: / Yes | No / Custody Resides With: / Parent(s) | Guardian(s)
Child’s School: / Grade:

Employment Information:

Employer: / Occupation:
Address:
City: / State: / Zip:
Work: / ( ) / Cell: / ( )

Responsibility / Referral / Emergency Information:

In Case of An Emergency, Who May We Contact:
Address: / Same as above or:
City: / State: / Zip:
Phone: / ( ) / Work: / ( )
Person Responsible for Bill: / Phone: / ( )
Referred By: / Phone: / ( )

Current Household Members:

Name: / Age: / Relationship:
Name: / Age: / Relationship:
Name: / Age: / Relationship:
Name: / Age: / Relationship:
Name: / Age: / Relationship:

- Please complete other side –

Medical Information:

Doctor Name: / Phone :
State Briefly The Reason You Are Seeking Counseling At This Time:
Please List Any Known Allergies To Medications: / None / or:
Current Medications: / None / or:
Physical/Medical Conditions Pertinent To Counseling: / None / or:
Do You Currently Smoke: / Yes | No

Previous Psychiatric Hospitalizations and/or Outpatient Counseling Dates:

List: / Date:
List: / Date:

Insurance/EAP Information:

Primary Insurance Company Or EAP:
Address:
Contract #: / Group #: / Subscriber #:
Name of Insured: / Relationship to Client:
Insured’s DOB: / Insured’s SSN#:
Employer of Insured: / Same as Above / or:
Secondary Insurance (if any):
Address:
Contract #: / Group #: / Subscriber #:

Assignment Of Insurance Benefits:

The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician/therapist to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or my dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim.

I, / , hereby authorize
(Name of Insured) / (Name of Insurance Company)

to pay and hereby assign directly to Molly Sanford, LCSW, all benefits, if any, otherwise payable to me for her services as described on the attached forms. I understand that I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received by and paid to Molly Sanford, LCSW, will be credited to my account, in accordance with above said assignment.

(Authorized Signature of Subscriber) / (Date)
Patient Name: / Date:

Symptom Checklist: Please check any of the statements you believe may be true of yourself

I have had feelings of depression:

At times
Constantly, for about how long?
Periodically, for about how long?
I am having difficulty remembering: / Short Term / Long Term

Please check any of the statements you believe may be true of yourself:

My sleeping habits have changed / I am having difficulty concentrating / I have less energy than I did before
I am having trouble sleeping / I am having difficulty making decisions / I feel restless
I sleep too much / I have little or no appetite / I think about dying
I want to eat more than usual / I don’t enjoy many of the things I used to / I am more talkative than usual
I feel great about myself / I am easily distracted
Sometimes my thoughts are racing / Sometimes I sweat too much / Sometimes I feel like I am choking
Sometimes I have chest pain or discomfort / Sometimes I am afraid I am dying / I am driven to meet my goals
Sometimes I have chills or hot flashes / Sometimes I am restless / I am easily fatigued
Sometimes I tremble / Some behaviors I do over and over again
Sometimes I have feelings of being detached from myself / I am irritable or others have indicated that they think I am irritable
I don’t need much sleep; I feel rested with only a little sleep / Sometimes my heart pounds or beats very rapidly
Sometimes I have sensations of shortness of breath or smothering / Sometimes I feel dizzy, unsteady, lightheaded, or faint
Sometimes I have nausea or abdominal distress / Sometimes I think my thoughts or actions are crazy
Sometimes I have numbness or tingling sensations
I have cycling thoughts, pictures or fears in my head that I find it difficult to stop
I am doing things I enjoy, but it has gotten me in trouble or has the potential to get me in trouble
Some things I feel I must do or I just don’t feel right or comfortable or I can’t relax
Sometimes I have feelings that I am dying, losing control, or going crazy
Sometimes I have excessive fears of
I never drink beer, wine or liquor drinks / I sometimes drink beer, wine, or liquor drinks
I drink some type of alcoholic drink at least three times a week / I drink some type of alcoholic drink more than three times a week
I think I have a drinking problem / Someone has told me that they think I have a problem with drinking
I used to drink alcoholic drinks, but I no longer do / I used to drink “too much” alcohol
I used to have a problem with alcohol but I no longer do
I smoke cigarettes. How many packs/day?
I used to smoke cigarettes. How many packs/day?
I quit smoking (when?):
I have the following medical conditions:
I take the following medications (please include dosage):

Informed Consent for Treatment

Client Name:
Social Security #: / Date of Birth:
I, / , am voluntarily seeking treatment for
Responsible Party
From
Patient Name / Therapist

1.  I understand that it is my responsibility to understand my mental health insurance benefits and to notify Molly Sanford, LCSW, of any changes as soon as I am aware of such changes. It is the responsibility of Molly Sanford, LCSW, to bill for services provided. It is my responsibility to pay for services not covered by my insurance company unless restricted by contract. Co-payments are required by insurance companies to be collected at the time the service is rendered.

2.  I understand that if I have a scheduled appointment and I need to cancel it, I will do so at least 24 hours in advance or more if possible. If I do not provide 24 hours notice, I may be charged for the appointment.

3.  My therapist will recommend a specific type of treatment for me and will explain the advantages and risks. It is my responsibility to ask questions if I am not clear about my treatment plan.

4.  I understand that what I talk about in sessions with my therapist is considered confidential and that my therapist will not disclose that information to anyone without a release of information except for the following as required by law: physical or sexual abuse of a minor child or an elderly adult, clear intent to harm oneself or someone else, court order from a judge.

5.  I also understand that my therapist, in keeping with generally accepted standards of practice, may seek confidential clinical supervision regarding my treatment plan. The purpose of such consultation is to assure quality care. Every effort is made to protect my identity.

6.  I understand that an on-call therapist (who may or may not be my regular therapist) is available for emergency situations only. (Immediate consultation needed to avert harm to self or others.) If a situation is urgent, I will leave a message with the office and can expect a call within 12 hours. I also understand that if needed, I will call 911 first.

7.  A copy of my clinical records will be maintained for seven years. Should I require a copy, I will submit a written request to release records to a person specified in the request.

8.  I understand that I and my therapist alone are responsible for my treatment and that no other therapist sharing office space or in affiliation with my therapist will be responsible for any aspect of my on-going treatment.

9.  I understand that mental health providers are required to submit psychiatric diagnosis and a “treatment plan” including diagnosis, description of the problem, personal background information, treatment goals, and therapy methods to my mental health managed care company. I permit the therapy staff to submit any information required to use my benefits.

10.  I have read a copy of the “Notice of Information Practices” and I understand that I may request a hard copy of this document for my personal records.

Signature of Patient / Date
Signature of Witness / Date

Uses and Disclosures Other than for Treatment, Payment, or Health Care Operations

Business Associates: We provide some services through contracts with business associates. Examples include certain diagnostic tests, a copy service to copy your records, computer technician, attorney, and the like. When we use these services, we may disclose your health information to the business associate so that they can perform the function(s) we have contracted with them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, you location, and general condition.

Communication with Family: Unless you object, health professionals using their best judgment, may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Continuity of Care: We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse effects/events with respect to food, drugs, supplements, product or product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Workers Compensation: We may disclose health information to the extent authorized by and the to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law. In these cases, you will be notified and asked to sign a release of information.

Law Enforcement: We may disclose health information purposes as required by law or in response to a court order. If subpoenaed, you will be notified and asked to sign a release of information.

Health Oversight agencies an public health authorities: If a member of our work force or a business associate believes in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical standards and are potentially endangering one or more patients, workers or the public, they may disclose your health information to health oversight agencies and/or public health authorities, such as the department of health.

The federal Department of Health and Human Services (DHHS): Under the privacy standards, we must disclose your health information to DHHS as necessary for them to determine our compliance with those standards.

State law: Under the laws of the State of Florida, certain information must be disclosed. This information includes knowledge of physical or sexual abuse of a minor, senior, or other person considered protected under state law. It also includes the duty to protect a person from harm from themselves and the duty to warn anyone who the therapist determines in his/her clinical judgment may be at risk for harm from someone else.

Release of Information: You may request, in writing, that information be released to another party. We will at that time release the information requested to the person or persons requested.

Effective Date:
|
Signature of Patient / Signature of Witness

Acknowledgement of Information Practices

Patient Name / Date
Address / FL DR LIC #
City / State / Zip
I, / have read the Statement of information
Patient Name

Practices of Molly Sanford, LCSW, and agree to the information contained therein. I understand that this Statement meets HIPAA requirements to protect my privacy.

Signature of Patient / Date
Signature of Witness / Date

A personal copy of this acknowledgement and a copy of the Statement of Information Practices of Molly Sanford, LCSW, will be made available to you.

Please Choose One: / NO, I do not require a copy
YES, I received a copy on
Date
Signature of Patient / Date
Signature of Witness / Date