Download MKM Counseling Services, Inc. Monica Marterella, MS, LMFT, LPC

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?______________________________
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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 _______________________________
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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: __________________________________________________________________________________________
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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? ____________________________________________
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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:
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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?
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
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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
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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.
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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
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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: _______________________________
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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.
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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.
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