Download to Intake

Steven C. Holeman, Ph.D.
3720 Arrowhead Avenue, Suite 211, Independence, Missouri 64057
Phone: (816) 739-0876 Fax: (816) 461-3502 Email Address: [email protected]
INTAKE FORM
Client Name:________________________________
Date:________________________
SSN:________________ DOB:________________
Marital Status: Single / Married / Divorced / Separated / Widowed
Home Address:_______________________________________________________________________________________________
(street)
Home Phone:_______________
(city)
Cell Phone:_______________
(state)
(zip code)
Work Phone:________________
Employer:___________________________________________________________________________________________________
(name)
(street)
(city)
(state)
(zip code)
Responsible Party (If different from client):_________________________________________________________________________
(name)
(DOB)
(SSN)
Emergency Contact:___________________________________________________________________________________________
(name)
(relationship)
(phone)
Insurance carrier:______________________________ Certificate #:_________________________ Group #:____________________
Billing Address:______________________________________________________________________________________________
(PO Box/street)
(city)
(state)
Authorization #:______________________________
Visit #:___________
Co-pay:__________
Deductible Met: Yes / No
Deductible:_____________
(zip code)
CPT:__________ Expires:___________
Diagnosis Code:__________
Acknowledgement of Notice of Privacy Practices & Consent to Use & Disclose Your Health Information
This form is an agreement between you, ____________________________ and Living Solutions, LLC. When we use the
word we, we mean “you” below, it can mean you, your child, a relative or other person if you have written his or her
name here ____________________. When we examine, test, diagnose, treat or refer you we will be collecting what the
law calls Protected Healthcare Information (PHI) about you. We need to use this information to decide on what treatment
is best for you and to provide any treatment to you. We may also share this information with others who provide treatment
to you or need it to arrange payment for your treatment or for other business or governmental functions.
By signing this form you are acknowledging that you were given the opportunity to read, to discuss the content and to
receive a copy of Living Solutions, LLC Notice of Privacy Practices. You are also agreeing to let us use your information
here and send it to others for treatment, payment and operational purposes. The Notice of Privacy Practices explains, in
more detail, your rights and how we can use and share your information. Please read this before you sign this consent
form.
If you do not sign this consent form agreeing to what is in our Notice of Privacy Practices we cannot treat you. In the
future we may change how we use and share your information and so may change our Notice of Privacy Practices. If we
do change it, you can receive a copy from your therapist. If you are concerned about some of your information, you have
the right to ask us to not use or share some of your information for treatment, payment or operational purposes. You will
have to tell us what you want in writing. Although we will try to respect your wishes, we are not required to agree to these
limitations. However, if we do agree, we will do as you asked.
After you have signed this consent, you have the right to revoke it (in writing to your therapist telling us you no longer
consent) and we will comply with your wishes about using or sharing your information from that date on, but we may
already have used or shared some information and cannot change that.
_______________________________________________________________________________________________________________________________________
(signature of client or the client representative)
(printed name)
(date)
_______________________________________________________________________________________________________________________________________
(relationship to the client)
(authority)
Client:_____________________________
DOB:_____________
SSN/Case #:__________________________________
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PAYMENT ARRANGEMENTS AND CONSENT TO TREAT
Payment Arrangements:
I, ________________________________________, by my signature on this form hereby authorize LIVING SOLUTIONS, LLC
and/or my/my child’s therapist to release any medical or other information necessary to submit claims to my Employee Assistance
Program (EAP), insurance carrier, or its intermediaries, for all covered services rendered by him/her and authorize and direct my EAP,
insurance carrier, or its intermediaries, to issue payment checks directly to LIVING SOLUTIONS, LLC on my behalf for any services
furnished to me.
I further acknowledge that any portion of the charges for services rendered but not paid by my designated insurance carrier, EAP, or
guarantor agency are my responsibility to pay in full. I also agree that failure to give notice of cancellation at least 24 hours in advance
will result in my being charged for the session at the rate of $125.00 and that I will pay such charges. Insurance companies and EAPs
will not pay for appointments that are not kept or, for late cancellations.
X___________ (Client/Responsible party initials to verify understanding of this policy)
Often, insurance covers a limited number of sessions and/or a portion of charges. In most cases, your out of pocket cost is limited to
copayments and/or deductibles. Check with your health plan for information on deductibles and copayments. It is our policy to collect
copayments and other fees at the time the service is rendered unless other arrangements have been made with the therapist. The fee
for professional services is $125.00 per hour unless otherwise specified by contract. Fees for preparation of reports, letters, court
testimony and other non-therapy services are your responsibility and prorated at the hourly rate of $125.00.
I hereby agree to pay any amount due and unpaid by my insurance for services rendered within thirty (30) days from the date of
service unless other written arrangements have been made. After the thirty (30) day period any unpaid balance will accrue interest at
the rate on five percent (6%) per month, the account will be considered delinquent, and will be referred to a collection service, which
adds a minimum of 30% to the unpaid balance. I also agree that should my account become delinquent I will pay any additional fees,
equal to the actual costs of collecting this account including but not limited to all court costs, investigation costs, collection agency fees,
and reasonable attorney fees.
I further agree to pay a charge of thirty dollars ($30.00) for any check returned for insufficient funds, closed account, or for any other
reason.
X___________ (Client/Responsible party initials to verify understanding of this policy)
Confidentiality of Information: Matters discussed with your therapist are protected by laws insuring your right to privacy. In most
cases, your therapist is prohibited from disclosing information about your care without your written consent and then, only to the extent
you authorize. Your treatment record and related financial records are kept in an office or other area not accessible to the public.
Records will not be copied or otherwise made available to others, except as noted below, without a signed authorization to release
information.
Those cases where information may be disclosed without your consent are:
1. When child abuse is known or suspected. (Reporting is required by State Law)
2. When the abuse of an elderly or dependent person is known or suspected. (Reporting is required by State Law)
3. If you commit a crime against a staff member or another person on the premises.
4. If you bring charges against, or sue, your clinician.
5. If there is a situation that is potentially life threatening.
6. When ordered by the court.
7. In some cases, details of your treatment may be discussed with a clinical supervisor or another clinician for the purpose of
consultation. When this is done, no identifying information will be included (i.e., the client is anonymous).
8. If it becomes necessary to refer your account to a collection service. No clinical information (e.g., diagnosis, type of treatment)
will be released. Only information necessary to pursue collection will be released.
Special rules relating to the release of treatment records containing information regarding drug and alcohol use: CFR 42 part 2 prohibits
the disclosure of such information without the written consent of the client and only to the extent specifically authorized. This information
cannot be redisclosed to another source without written consent. A general release for medical or other information is not sufficient. Use
of information in the treatment record for criminal investigation and prosecution is prohibited.
Insurance Companies and National Medical Data Bank: Insurance companies and/or managed care organizations require that
information regarding diagnosis, medications, treatment goals, and other information be provided to them to justify your treatment.
Insurance companies routinely report information derived from claim forms (e.g., diagnoses, dates or treatment, type of treatment) to a
medical data bank. This information may be made available to insurance companies and other interested parties when they provide an
authorization, signed by you, to release information.
Client:_____________________________
DOB:_____________
SSN/Case #:__________________________________
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Retention of Records: Treatment records are retained for a period of seven (7) years following the termination of treatment for adults
and until age twenty0eight (28) in the case of minors. At the end of that period the records are destroyed in a manner that assures the
confidentiality of the information, unless the client request otherwise, in writing, prior to the destruction of the records. X______(initials)
Information Regarding Psychotherapy:
1. Psychotherapy may involve remembering unpleasant events and can arouse intense emotions of fear and anger. Feelings of
anxiety, depression, frustration, loneliness, or helplessness may be experienced. Of course, feelings of relief, energy, power,
self-acceptance, and well-being may also occur.
2. Psychotherapy is not always effective and may, in some cases, result in deterioration rather than improvement of a client’s
psychological functioning. Psychotherapy has been shown to be effective in about 75% of cases.
3. There are numerous forms of psychotherapy, which vary not only in underlying theory and methods employed, but also in terms
of time commitment and cost. We will attempt to provide treatment plans that are realistic in both areas.
4. Current research has failed to demonstrate that any one form of psychotherapy is necessarily more effective than any other.
5. Depending upon a client’s condition, there may be available alternatives to psychotherapy, such as medication or behavior
modification. We will make these recommendations if they are appropriate, based upon our assessment.
6. Your therapist will work with you to develop a treatment plan formulated to resolve your problem(s) as quickly as possible.
7. Whenever possible, a discharge plan will be developed as a part of terminating treatment.
8. Failure to keep scheduled appointments more than two (2) times may result in your care being terminated.
9. Unless it is part of your treatment plan, your treatment will be terminated if you have not contacted your therapist for more than
sixty (60) days.
Patient rights & responsibilities: I have received a copy of the Rights & Responsibilities form. X______(initials)
Consent to Treat: By my signature below, I agree to the payment arrangements as set forth in this agreement, affirm that all of my
questions have been satisfactorily answered, and give informed consent to my therapist to provide assessment and therapeutic
services to me/my child, within the scope of his or her license. I agree to cooperate with my therapist in the treatment process, to carry
out therapeutic homework assignments, and to take medications prescribed as part of my treatment in the manner directed by the
prescribing physician. I understand that I will be furnished a copy of this consent agreement upon request.
__________________________________________
Signature of client/parent/guardian Date
________________________________________
Client Name
__________________________________________
Relationship of above to client
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Client’s Consent to Exchange Information With Primary Care Physician
Insurance plans and managed care organizations encourage the exchange of information between therapist and Primary
Care Physician (PCP) in order to coordinate medical and psychiatric care. Please mark your choice below:
____ I authorize or, _____ I withhold authorization for me/my child between LIVING SOLUTIONS, LLC and the PCP,
____________________________, located at __________________________________________________________
_______________________________________________________________________________________________
Telephone: ________________________ Fax: _________________________ to exchange information regarding my/my
child’s medical and psychiatric care with no limitations placed on dates, history of illness, or diagnostic and therapeutic
information, including treatment for drug and/or alcohol abuse. A copy of this authorization shall be valid as the original.
__________________________________________
Signature of client/parent/guardian Date
_______________________________________
Client Name (If not the party signing)
__________________________________________
Relationship of signator to client
_______________________________________
Witness
Client:_____________________________
SSN/Case #:__________________________________
DOB:_____________
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