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MKM Counseling Services, Inc. Monica Marterella, MS, LMFT, LPC New Patient Registration Patient Name __________________________________________ Date of Birth _____________________ Social Security Number ____________________ Marital Status Single Married Gender Domestic Partner Male Divorced Female Separated Widowed Emergency Contact _____________________________ Relationship to Patient __________________________ Emergency Contact Phone #__________________________ Emergency Contact Phone # _____________________ Name of Guardian if Patient is under age 18 ____________________________________________________________ Referral Source Who may we thank for referring you to our clinic?______________________________________________ Chief Complaint Problem(s) and symptoms for which you are seeking treatment: __________________________________ __________________________________________________________________________________________ When did you begin experiencing these problems/symptoms?_____________________________________ Do you experience these problems/symptoms every day?_________________________________________ On a scale of 1-10 (1 being the least severe, 10 being the most severe), where do you rate your presenting problem(s) at this time?_____________________________________________________________________ What prompted you to seek treatment now? ___________________________________________________ Previous Treatment List all previous psychotherapy, counseling or other treatment you have received in the past (Please include Date, Type, and Provider):____________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Medical History How would you rate your present physical health? Excellent Good Poor When was your last physical exam? _____________________________________________________ Findings from that exam & lab results___________________________________________________ Current Medications (Prescription and Over-the-Counter - Please include Name, Dosage, Frequency & Prescribing Doctor): _______________________________________________________________________ _________________________________________________________________________________________ Allergies _________________________________________________________________________________ Adverse reactions or sensitivities to foods, drugs or other substances?______________________________ 1 Symptoms Sleep Disturbance (Circle all that apply) Poor Concentration Depressed Mood Panic Attacks Low Energy Hallucination Appetite Disturbance Mood Swings Phobias Paranoid Thoughts Irritability Sexual Problems Oppositional Behaviors Crying Spells Anxiety Obsessions/Compulsions Thoughts of Self-harm Aggressive Behavior Delusions Anorexia Bingeing/Purging Attempted Suicide Thoughts of Harm to others Substance Amount Frequency For How Long First Use Last Use Caffeine Tobacco Alcohol Marijuana Opioids/Narcotics Amphetamines Cocaine Hallucinogens Other Family History Number of Children ________ Age(s) of Children ____________________________________________ Number of Siblings ________ Age(s) of Siblings ____________________________________________ Age of Parents Mother ________ Father _________ Is there a family history (parents, siblings, children) of psychiatric conditions or substance abuse? ________ If Yes, who and for what condition? _________________________________________________________ Development History Were your development milestones (crawl, sit, walk, talk, etc.) met early, late or normal? ______________ Any complications during pregnancy or with labor/delivery? _____________________________________ Social History Education Completed (grade or degree) ______________________________________________________ Marital History _________________________________________________________________________ Occupation (# years at current job)_________________________________________________________________________________________ Legal History __________________________________________________________________________________________________________________ Military Service (Branch, Rank, # years)____________________________________________________________________________________ Support Systems ______________________________________________________________________________________________________________ Spiritual Beliefs ______________________________________________________________________________________________________________ Patient/Guardian Signature __________________________________________________________ Date _______________________________ 2 MKM Counseling Services, Inc. Monica Marterella, MS, LMFT, LPC NEW PATIENT INFORMATION Last Name: _____________________ First Name: ____________________ Middle: ______________________ SS#: ___________________________ Birth date: _______________________ Address: ____________________________________________________________________________________ Ok to send mail to this address? Yes No Drivers license: (Please Circle) Number __________________ Employed Relation to Insured: Student(full-time) Self Spouse State __________________________ Student(part-time) Child Male Female Other Home Phone: ________________________________ Work Phone: _______________________________________ Ok to leave message at these numbers? Yes No E-mail: _____________________________________________________________________________________________________________________ Ok to leave message via email? Yes No Marital Status: Single Married Other Appointment Date: ______________________________ INSURED'S INFORMATION Last Name: ____________________________ First Name: ________________________ Middle: ______________ SS#: _________________________________ Birth date: ____________________________ Address: _______________________________________________________________________________________ Home Phone: _______________________________ Work Phone: ________________________________________ Male Female Insurance Plan Name: _____________________________________________________________________ Insured's ID#: _________________________________ Group/Policy #: ___________________________ Employer: __________________________________________________________________________________________ 3 SECONDARY INSURED'S INFORMATION Last Name: ____________________________ First Name: ________________________ Middle: ______________ SS#: _________________________________ Birth date: ____________________________ Address: _______________________________________________________________________________________ Home Phone: _______________________________ Work Phone: ________________________________________ Male Female Insurance Plan Name: _____________________________________________________________________ Insured's ID#: ______________________________ Group/Policy #: ___________________________ Employer: __________________________________________________________________________________________ Will you need documentation for insurance reimbursement? Yes No Who referred you to this office? ____________________________________________ 4 ASSIGNMENT OF BENEFITS & RELEASE OF INFORMATION I hereby assign, transfer and set over to MKM Counseling Services, Inc. (Monica Marterella, MS, LMFT, LPC), all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine benefits, payment, concurrent review, and quality assurance activities, including medical, surgical, psychiatric and/or substance abuse (drug or alcohol) information. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that this order does not relieve me of my obligation to pay such bills if not paid by my Insurance Company, or of any balance due after payments by my Insurance Company. Patient/Guardian Signature: _______________________________ Date: _____________________ Witness: _____________________________________________ Date: _____________________ COORDINATION WITH PRIMARY CARE PHYSICIAN Providers wish to provide diagnosis, treatment plan, medication, and prognosis information to your Primary Care Physician in order to help ensure that you receive comprehensive and quality health care. This information will not be released without your consent. I, ________________________________________________________________ authorize MKM Counseling Services, Inc. (Monica Marterella, MS, LMFT, LPC), for the purpose of continuity of care/case consultation, to release the information below related to the evaluation and treatment of _________________________________________ to: Primary Care Physician:_______________________________________________________________________ Address: ___________________________________________________________________________________ Phone: ____________________________________________________________________________________ I, the undersigned, understand that I may revoke this consent at any time to the extent that action has been taken in reliance upon it and that in any event this consent shall expire six (6) months from the date of signature, unless another date is specified. I have read and understand the above information: ( ) I give my consent to release the information to my Primary Care Physician. ( ) I DO NOT give my consent to release the information to my Primary Care Physician. Date Consent Expires: _____________________________________________________ Patient/Guardian Signature: __________________________________________ Date: _____________________ Witness: _________________________________________________________ Date: _____________________ To The Party Receiving This Information: This information has been disclosed to you from records which are protected by Federal and State Laws regarding confidentiality. Such laws prohibit you from making any further disclosure of this information. To Be Completed by Provider: Axis I: Treatment Plan: Axis II: Medications: Axis III: Prognosis: Axis IV: Date contact made by phone to PCP: Axis V: Date mailed/faxed to PCP: 5 Your Present Health Excellent ____ Average ____ Poor ____ Date of last physical: ______________________________________________ Findings _____________________________________________________________________________________________________________ Are you presently on any medications? Yes ____ No ____ If yes, what kind, for what? _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Name of primary care physician ____________________________________________ Phone _______________________________ List previous psychotherapy, counseling, or personal/marital treatment; Also list if you have ever been diagnosed with a mental health or substance abuse disorder: Date Type of problem Name of practitioner or agency _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Have you ever been hospitalized for psychiatric care? Yes ____ No ___ If yes, when, where, for what? _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Any other information that could help the therapist not otherwise included here? _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 6 Personal Health History Please check which of the following you have had: Condition Yes Date Condition Asthma Tuberculosis Pneumonia Hemorrhoids Meningitis Bad Headaches High Blood Pressure Low Blood Pressure Constipation Diarrhea Diabetes Thyroid trouble Tumors Cancer Accident (serious) Sterility Surgery Fainting Convulsions Hearing Problems Back trouble Yes Date Paralysis Shaking Impotence Miscarriage Menstrual trouble Nerve Trouble Ulcer Discouragement Worries Tension Irritableness Depression Alcoholism Hysterectomy Insomnia Appetite Loss Vasectomy Sexually unresponsive Heart Trouble Other Other Any current legal issues? ______________________________________________________________________________ Any past legal issues? ________________________________________________________________________________ Have you ever filed a complaint against a professional? ________ If yes, please explain: __________________________________________________________________________________________________ Do you have thoughts of self harm? Yes _____No ____ Explain ______________________________________________ Any thoughts of harming someone else? Yes ____ No ____ Explain __________________________________________________________________________________________________ Please circle a number for each below, if it does not apply leave blank: Concern Very Dissatisfied to Very Satisfied Household responsibilities 1 2 3 4 5 6 7 8 9 10 Children 1 2 3 4 5 6 7 8 9 10 Sex 1 2 3 4 5 6 7 8 9 10 Social activities 1 2 3 4 5 6 7 8 9 10 Money 1 2 3 4 5 6 7 8 9 10 Communication 1 2 3 4 5 6 7 8 9 10 7 Concern Very Dissatisfied to Very Satisfied Sexual identity 1 2 3 4 5 6 7 8 9 10 Independence/dependence 1 2 3 4 5 6 7 8 9 10 Partner 1 2 3 4 5 6 7 8 9 10 Relatives 1 2 3 4 5 6 7 8 9 10 Spirituality 1 2 3 4 5 6 7 8 9 10 Alcohol 1 2 3 4 5 6 7 8 9 10 Non-prescription drugs 1 2 3 4 5 6 7 8 9 10 Jealousy 1 2 3 4 5 6 7 8 9 10 Infidelity 1 2 3 4 5 6 7 8 9 10 Career/work 1 2 3 4 5 6 7 8 9 10 Physical health 1 2 3 4 5 6 7 8 9 10 8 MKM Counseling Services, Inc. Monica Marterella, MS, LMFT, LPC Please read and sign. Keep the second copy for your records. CONSENT TO TREATMENT A "therapist-patient" or "treatment" relationship does not exist until after initial assessment is completed and we have decided to move ahead as evidenced by your signature on this form. It is important that we both agree that we are a good match in working together towards your goals. We will discuss this during the first visit and decide whether or not to proceed, and whether we need to continue the assessment for one or more subsequent visits. It is also important for you to be aware of the benefits and limitations of psychotherapy or other services you will be receiving. While it is generally expected that you will benefit from therapy, there may be periods of feeling worse before feeling better and there is no guarantee of success in therapy. There may be alternative treatments or modes of therapy to consider. I encourage you to become aware of these factors and to ask any questions you may have at any time during our work together. CONFIDENTIALITY State law protects the confidential nature of the therapist-patient relationship but this protection is not absolute. I will not release clinical information to anyone unless given written permission to do so by the patient (or if the patient is a minor, by his or her parent or guardian). However, there are a few exceptions that allow or require the release of confidential information even in the absence of patient consent. Examples Include: 1) The therapist must act appropriately when there is danger to the patient or to another person at the patients hands. This generally means that the therapist may involve others when necessary to protect the patient if he or she is suicidal or is unable to provide self-care at a level necessary for basic survival, or to prevent harm to another person. State law also requires the reporting of abuse to or neglect of a child or an elderly or disabled person when there is reason to believe it has occurred. 2) In response to a court order, the therapist must testify or release records. However, a therapist does not release records, depose or testify in response to a subpoena unless the patient or patient's guardian has given written authorization to do so or if the therapist is required by law to do so. 3) As professionals, we do consult with one another from time to time. Any clinical material is conveyed without identification whenever possible. At other times, it will be necessary (for example, if another therapist is covering calls during a vacation). Finally, case material is sometimes used in training, research, writing, etc. This is always done with identifying information removed and with great care and respect for your privacy. Any other release of information requires you or your guardian's written authorization. OFFICE & FINANCIAL POLICIES Fees: Payments are due at the time services are rendered; payments will be received at the beginning of each session. It is up to the discretion of the therapist to allow for a deferred payment. Insurance: We will be glad to provide necessary documentation for filing insurance claims. The therapist may bill excessive insurance paperwork demands separately after consultation with the patient. Generally routine notes or other documentation will not be considered excessive. However, you will be responsible for the full fee at the time of service unless we make other arrangements. Information regarding out-of-network payments is available and we will work to help answer any questions you may have regarding reimbursement through your insurance carrier. 9 OFFICE & FINANCIAL POLICIES CONTINUED Emergencies: I do not provide formal emergency services, yet I wish to be as available as much as is reasonably possible. You may call the office number at any time and leave a message if I do not answer. During the business day I can often, though not always, return calls fairly quickly. Nighttime and weekend calls will usually be returned the next business day. If you find yourself in an urgent situation, make a judgment about the prudence of waiting for my call versus calling 911 or going to the nearest emergency room for immediate care. If I am away for more than a day, my voice mail message will indicate that and state my expected date of return. Death or Incapacity: In the event that the therapist dies or is otherwise incapable of providing for the clinical services of this office the patient consents for the therapist to designate _____________________________as conservator for the records of this office, including all patient records, and at the time of death or incapacity of the therapist he will take possession of the patient records and make those available to the patient or a mental health professional of the patient's choosing at such time that a written request is made to this office. Complaints: We strive to always provide competent and professional services to our patients. From time to time there may be an issue that we need to address. Please notify the office immediately of any problems or complaints and we will work with you to solve these together. If we are unable to reach a satisfactory solution you can direct inquiries to: Complaints Management and Investigative Section, P.O. Box 141369, Austin, Texas 78714-1369. Or call: 1-800-942-5540 to request the appropriate form or obtain more information . Other fees: If report preparation is requested or required, the time rate charged for our therapy sessions will apply. Extended or frequent telephone contact will also be charged for. These services are not usually reimbursed by insurance. I will not agree to court appearances or other legal involvements unless we have discussed the matter thoroughly and both agree that such involvement is within my range of competence and will not interfere with the treatment relationship. Professional fees for court appearances, depositions and attorney consultations are $300 per hour including travel and waiting time, are non-discountable, and are payable in advance only. Accounts: Payment may be made with cash, credit card, or by check. I do not extend credit. In any such arrangement, late payment fees of $10 per month will be charged on any balance not paid within 30 days. I do not depend on an outside collection service unless accounts are overdue by 90 days. I would much rather communicate with patients and find some solution to overdue accounts. Patient hereby consents to the delegation of collection activities to an outside collection agency, including the release of necessary information required by the collection agency. A delinquency fee of 40% of the outstanding balance will be added if a collection agency is required. There is a returned check processing fee of $25 in addition to reimbursement for charges assessed by my bank. Statements, receipts, or other documentation will not be issued to any delinquent account until paid in full. Payment by credit cards will be in accordance with the pre-authorization for health care form provided by this office. Missed appointments: Unless waived by mutual agreement on a case-by-case basis, no-shows and cancellations will be charged for unless you cancel at least 24 hours in advance of the appointment time. The fee for late cancellations (less than 24 hours notice) is 50%, and for no-shows 100%, of the full fee. Patients arriving 15 minutes or more late to the appointment will be considered a no-show and must be rescheduled unless other arrangements are made with the therapist. Authorization is given, where applicable, to charge credit/debit cards for late or no-show appointment fees when incurred. Patient understands the appointment policies of the office and assumes responsibility for payment of fees related to late cancellations or no-show appointments. Such charges are payable immediately and will be automatically deducted, where applicable, and are not normally reimbursable by insurance. Please sign below indicating that you have read, understand, and agree to the information and terms on both pages of this document. ___________________________________________________ Signature of patient or other responsible person __________________________________ Date ____________________________________________________ Print Name 10 MKM Counseling Services, Inc. Monica Marterella, MS, LMFT, LPC Notice of Privacy Practices Patient Acknowledgement Patient Name: ___________________________________________ Date of Birth:____________________________ I have received and understand this practice's Notice of Privacy Practices written in plain language. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, and the practice's legal duties with respect to my protected health information (hereafter called PHI). This includes but is not limited to: • A statement that this practice is required by law to maintain the privacy of PHI. • A statement that this practice is required to abide by the terms of the notice currently in effect. • Types and uses of disclosures that this practice is permitted to make for each of the following purposes: treatment, payment, and health care operations. • A description of each of the other purposes for which this practice is permitted or required to use or disclose PHI without my written consent or authorization. • A description of uses and disclosures that are prohibited or materially limited by law. • A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization. • My individual rights with respect to PHI and a brief description of how I may exercise these rights in relation to: • The right to complain to this practice and to the Secretary of HHS if I believe my privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such a complaint. • The right to request restrictions on certain uses and disclosures of my PHI, and that this practice is not required to agree to a requested restriction. • The right to receive confidential communications of PHI. • The right to inspect and copy PHI. • The right to amend PHI. • The right to receive an accounting of disclosures of PHI. • The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request. This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all PHI that it maintains. If changes occur, this practice will provide me a revised Notice of Privacy Practices on request. Signature: ___________________________________________________ Date: _______________________________ 11 MKM Counseling Services, Inc. Monica Marterella, MS, LMFT, LPC PRE-AUTHORIZATION FOR HEALTH CARE Date:___________________________ I authorize MKM Counseling Services, Inc. ( Monica Marterella, MS, LMFT,LPC) to keep my signature on file and to charge my credit card account listed below for the following: 1. Balances of charges not paid within 30 days. 2. Recurring charges (for on-going treatment) of _________ per session from ____________________ for one year from this date. I understand that a statement of charges can be made available to me at my written request. I also understand that I may revoke this agreement at any time by providing a request in writing. Patient's Name: ___________________________________________ Cardholder's Name: ________________________________________ Cardholder's Address: _______________________________________ City, State, Zip Code: ________________________________________ ____ Visa ____ MasterCard ____ American Express Account Number: _____________________________________ Expiration Date: _______________________________________ Signature: ____________________________________________ By signing this authorization, I allow MKM Counseling Services, Inc. (Monica Marterella, MS, LMFT, LPC) to charge the above account for services rendered, for a cancellation fee if appointment is not cancelled within 24 hours, or for the no show fee. 12 CONFIDENTIALITY OF PATIENT RECORDS AND INFORMATION It is the policy of this office that: 1. All clinical records are protected from public viewing and access. 2. All clinical records are in individual file folders, identified by patient name and #. 3. All clinical records are kept under lock and key. 4. Computer patient records may only be accessed with a password known to the therapist and authorized office personnel. Any backup files are kept in a locked filing cabinet. 5. Only office personnel authorized to access clinical records are given access to files. 6. Client information will not be shared without the written consent of the client, except as required by law, or in a situation determined to be potentially life threatening. 7. All office personnel have been trained on and will follow the above guidelines. 8. Any privacy guideline not followed by office personnel will be documented and appropriate disciplinary action will take place. 9. Patients may file a formal complaint regarding compliance with the privacy rule or policies and procedures related to the rule. Written patient complaints will be logged and filed. 10. All faxes originating from this office that contains PHI will include a cover sheet indicating to whom the information should be received as well as a disclaimer requiring the return of the information if received by the wrong party. A confidentiality notice will also be on the fax. 11. Any electronic PHI sent from this office will only be sent for claim payment or for approval of additional services from the patient’s insurance company. 12. Confidentiality procedures and Patients Rights regarding their records will be given to each patient. 13