Adult Intake (online) – The Psychology Clinic

– Step 1 of 17

Date *

Name *

First

Last

Date of Birth *

Age

Selected Value: 0

Gender *

Male
Female

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Place of Employment *

How did you hear about The Psychology Clinic? *

A message may be left on:

Home phone
Cell phone
Work phone
None

Presenting Problems *

Distractibiliity
Change in appetite
Hyperactivity
Lack of motivation
Impulsivity
Withdrawal
Boredom
Anxiety/worry
Poor memory/confusion
Panic attacks
Seasonal mood changes
Fear away from home
Sadness/depression
Social discomfort
Loss of pleasure/interest
Obsessive thoughts
Hopelessness
Compulsive Behavior
Thoughts of death
Aggression/fights
Self-harm behaviors
Frequent arguments
Suspicion/paranoia
Racing thoughts
Excessive energy
Wide mood swings
Sleeping problems
Nightmares
Eating problems
Gambling problems
Computer addiction
Pornography
Parenting problems
Crying spells
Irritability/anger
Sexual problems
Loneliness
Homocidal thoughts
Low self-worth
Flashbacks
Work/school
Guilt/shame
Hearing voices
Alcohol use
Fatigue
Visual hallucinations
Disturbed memories
Other

Other problems/concerns

Are you having problems related to the following? *

Handling everyday tasks
Hygiene
Legal matters
Sexual activities
Self-esteem
Work/school
Finances
Health
Relationships
Housing
Recreational
None

Have you ever had thoughts, made statements, or attempted to hurt yourself? *

If 'yes'please describe.

Have you ever had thoughts, made statements, or attempted to hurt someone else? *

If 'yes'please describe.

Have you recently been physically hurt or threatened by someone else? *

If 'yes'please describe.

With whom do you live? *

Relationship with father *

Good
Average
Poor
None

Relationship with mother *

Good
Average
Poor
None

Relationship with stepfather *

Good
Average
Poor
None
n/a

Relationship with stepmother *

Good
Average
Poor
None
n/a

Relationship with sibling 1 *

Good
Average
Poor
None
n/a

Relationship with sibling 2 *

Good
Average
Poor
None
n/a

Relationship with sibling 3 *

Good
Average
Poor
None
n/a

Relationship with spouse/partner *

Good
Average
Poor
n/a

Relationship with child 1 *

Good
Average
Poor
n/a

Relationship with child 2 *

Good
Average
Poor
n/a

Relationship with child 3 *

Good
Average
Poor
n/a

Relationship with child 4 *

Good
Average
Poor
n/a

Describe any family history of mental illness or health problems. *

Please check if you have experienced any of the following types of trauma or loss:

Emotional abuse
Sexual abuse
Physical abuse
Neglect
Violence in the home
Crime victim
Parent illness
Placed a child for adoption
Foster home
Multiple moves
Homeless
Loss of a loved one
Financial problems

Please briefly explain the context of this/these trauma(s), if possible:

Describe any mental health treatment *

Describe substance use/treatment *

Describe problems with law enforcement. *

Name and contact number of primary care physician: *

Please list any current health concerns. *

Please list any current medication. *

Please select your social support network (check all that apply): *

Family
Students
Community Group
Neighbors
Co-workers
Friends
Support Group
Religious/SpiritualCenter
None

To which cultural group do you belong? *

Do we have permission to communicate with the person/organization referring you to this office? *

Signature allowing or disallowing communication with referral source: *

Electronic signature

Date: *

Electronically dated

Name of Primary Insurance: *

Policyholder's Full Name: *

Policyholder's Date of Birth: *

Policyholder's Social Security Number: *

Policyholder's Address: *

Policyholder's Employer: *

Policyholder's ID Number: *

Group Number:

Insurance Telephone Number: *

Client’s or authorized signature. I authorize both the release of any medical information necessary to process my claim and authorized payment or medical benefits to The Psychology Clinic and the providing therapist. *

Electronic signature

Date: *

Electronically dated

Do you have a secondary insurance? *

Name of Secondary Insurance:

Policyholder's Full Name:

Policyholder's Date of Birth:

Policyholder's Social Security Number:

Policyholder's Address:

Policyholder's Employer:

Policyholder's ID Number:

Group Number:

Insurance Telephone Number:

Electronic signature

Date:

Electronically dated

__Policies and Procedures Health Insurance Portability and Accountability Act___ (Signature required) *

Policies and Procedures Health Insurance Portability and Accountability Act This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. The Georgia Notice, which is attached to this agreement, explains HIPPA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information at the end of this session. Confidentiality All communications between client and therapist will be held in confidence, and will not be revealed to anyone unless you give written authorization to release this information. Your legal right to privileged communication between a licensed professional counselor and a client will be upheld unless overruled in a court of law during a legal proceeding. Georgia law required that confidentiality be waived when the client’s or other’s personal safety is threatened or when disclosure of neglect/abuse of vulnerable populations, is made to the therapist. If we determine that a client presents a serious danger of violence to another, we may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the client. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary. Financial Arrangements and Insurance The 50-minute individual and/or family sessions are billed at a range of $75- $200 per clinical hour. It is your responsibility to pay your bill. Our office will be glad to file your primary and secondary insurance for you (please provide our office with a copy of your insurance card). We cannot file tertiary insurance. If your insurance company is unwilling to pay, it is your responsibility to make payment and contact the insurance company. Your signature below indicates that you have read and understand the policies and procedures of The Psychology Clinic and agree to abide by these terms. It also serves as an acknowledgment that you have received/reviewed the HIPPAA notice form described above.

Georgia Notice Form (Signature Required) *

Notice of Counselor’s Policies and Practices to Protect the Privacy of Your Health Information This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. I. Uses and Disclosures for Treatment, Payment, and Health Care Operations We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: • “PHI” refers to information in your health record that could identify you. • Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider such as your family physician or another psychologist. • Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. • Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business matters such as audits and administrative services, and case management and care coordination. • “Use” applies only to activities within our [office, clinic, practice] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. • “Disclosure” applies to activities outside of our [office, clinic, practice], such as releasing, transferring, or providing access to information about you to other parties. II. Uses and Disclosures Requiring Authorization We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information The Psychology Clinic Adult Intake Form 12 for purposes outside of treatment, payment or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes we have made about our conversations during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given more protection than PHI. You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided that each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage. Law provides the insurer the right to contest the claim. III. Uses and Disclosures with Neither Consent nor Authorization We may use or disclose PHI without your consent or authorization in the following circumstances: • Child Abuse – If we have reasonable cause to believe that a child has been abused, we must report that belief to the appropriate authority. • Adult and Domestic Abuse – If we have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, we must report that belief to the appropriate authorities. • Health Oversight Activities – If we are the subjects of an inquiry by the Georgia Board of Professional Counselors, we may be required to disclose protected health information regarding you in proceedings before the Board. • Serious Threat to Health or Safety – If we determine, or pursuant to the standards of our profession should determine, that you present a serious danger of violence to yourself or another, we may disclose information in order to provide protection against such danger for you or the intended victim. I have read the above and understand that it is my responsibility to make sure all insurance requirements are fulfilled. It is also my responsibility to notify this office of any changes in my insurance. I agree to be responsible for all charges incurred with The Psychology Clinic that result from non-covered services or client’s failure to meet insurance requirements

Late Cancellation/Missed Appointment Policy (Signature required) *PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING.* *

The Psychology Clinic, effective January 1, 2021, will begin collecting a $75.00 refundable deposit (unless contractually prohibited by insurance/provider) prior to scheduling initial intakes. This practice helps offset losses due to no-shows or late cancellations not covered by insurance. If someone cancels late or misses an appointment, we incur a loss of income for that hour and are not able to offer that time to someone who may be waiting, possibly in crisis. Typically, the credit card information is taken ahead of time due to the difficulty of calling and charging a client the cancellation fee once they have missed the appointment. Many people will not answer the phone or willingly hand over their credit card information. Deposits are returned at the conclusion of therapy for those having attended scheduled appointments and without no shows and late cancellations. The initial $75 deposit covers only the first no show or missed appointment; another deposit is required to cover an upcoming appointment(s). We reserve a therapeutic hour for each person(s) scheduling an appointment; and our income is based entirely on the hours we see clients. Therefore, we must have an agreement that the appointment will be kept or, if you must cancel, we need to have ample notice to prevent this type of loss. Regardless of cause, The Psychology Clinic requires a 48-hour notice on cancellation to release you from your responsibility for that time scheduled. I agree to the terms of the late cancellation/missed appointment policy of The Psychology Clinic and will make prompt payment on any charge I incur for a late cancellation or missed appointment. I understand the therapeutic and economic necessity of such a policy. – I/we agree to the above terms of the late cancellation/missed appointment policy of The Psychology Clinic and will make prompt payment on any charge I/we incur for a late cancellation or missed appointment. Your signature above indicates that you have read and understand the policies and procedures described above.

___FCR Collection Services Authorization & Prior Consent to Current Service Agreements/Contracts__ (Signature required) *

I understand that if I have an unpaid balance to The Psychology Clinic and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of any fees from the collection agency, including all costs and expenses incurred collecting my account, and possibly including reasonable attorney’s fees if so incurred during collection efforts. In order for The Psychology Clinic or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that The Psychology Clinic and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable.

Submission Notice

Survey Completed

The submit button does not issue a verification. Please click (survey completed) and then the “Submit” button only once. We will review your intake and contact you within 1-2 business day.