Download Forms for Dr. Nightingale`s office

Welcome to the Nightingale Center
PATIENT INFORMATION
Patient Name: _________________________________________________
Last
First
__
M
F
DOB________
Middle
Home Address: _____________________________________________________________________________________
Number
Street
(apt)
City
Zip
Phone: (___)______________________________ (___)___________________________ (___)_______________________
Home
Cell
work
Social Security #:_________________________Driver’s License:______________________ E-mail:__________________
Responsible Person (If different form above)_______________________________________Relationship___________________
Phone: (
)__________________________________ (
)_______________________________ (
Home
Cell
Social Security #: _____________________________
Emergency Contact________________________________
) ____________________
Work
Driver’s License:___________________________
Relationship___________________________
(Not Living with You)
Financial Responsibility
I authorize the treatment of the person named above and agree to pay all fees and charges for such treatment. I agree to pay all charges
promptly at time of service unless other arrangements are agreed upon in writing. In the event legal action is necessary to collect
unpaid balances, I agree to pay reasonable attorneys’ fees and other such cost as the court determines proper.
If unable to keep your appointment, kindly give 24 hour notice, otherwise an appointment fee will be charged for the time
reserved.
Signature____________________________________________ Date_________________
Fees

The fee for each 50 minute psychotherapy session is $200.00. (Sessions begin 10 minutes past the hour and conclude on the hour).

A discount of $25.00 is offered to patients who pay for their office visit at the time of service and maintain a “zero” balance ($175.00)
Payment is due at each visit. Discounts do not apply to fees paid later.
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Phone calls and consultations over 5 minutes are prorated at the rate of $200.00 an hour.
The filling out of Forms, Letters, Reports, Disability forms, Medical Releases, etc. are prorated at $200.00 hour with a $20.00
minimum.
All forensic and court work; reports, preparation for depositions or court appearances, are prorated at $350.00 hour with a three hour
minimum.
Psychological testing is charged by test/ inventory with charges for scoring, interpretation and report writing for each test administered.
After you have paid for your therapy appointment, we will gladly provide you a “super bill” for submission to your insurance company for
your reimbursement of fees they authorize according to your individual policy.
(initial)__________
Payment Options:

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We accept personal checks, cash, Visa, MasterCard and American Express.
You will be charged $25.00 for a returned check. (Initial)_______
Please ask questions of our office staff if any financial arrangement seems unclear or needs clarification.
Insurance Billing & Confidentiality of records:


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When you submit your “super bill” to your insurance company, there are some instances when your insurance company will contact our
office for further information. Disclosure of confidential information may be required by your health insurance carrier or
HMO/PPO/MCO/EAP in order to process the claims. If you so instruct the Nightingale Center, only the minimum necessary information
will be communicated to the carrier. Unless authorized by you explicitly the psychotherapy notes will not be disclosed to your insurance
carrier. Nightingale Center has no control or knowledge over what insurance companies do with the information. You must be aware that
submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to
obtain health or life insurance (as with any medical submission).
I have read and understand________________(please initial)
All insurance verifications include a disclaimer; they state that all verification of insurance is not a guarantee to pay and that contracts are
subject to change without notice.
I understand that I am ultimately responsible for any and all fees incurred by me, whether or not they are covered by my insurance carrier.
(initial) ________
Missed Appointments:

We consider failing to keep an appointment without notifying our office a sign of low motivation for treatment. After two
missed appointments without notification to our office a client will be terminated and given three alternative therapists’
phone numbers.
Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, Dr. Nightingale will discuss with
you (client or parent) her working understanding of the problem, treatment plan therapeutic objectives and her view of the possible
outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of therapy, their possible
risks, Dr. Nightingale’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also
have the right to ask about other treatments for your condition and their risks and benefits. (If you could benefit from any treatment
that Dr. Nightingale does not provide, she has an ethical obligation to assist you in obtaining those treatments).
Termination Policy: As set forth above, after the first couple meetings, Dr. Nightingale will assess if she can be of benefit to you, Dr.
Nightingale does not accept clients who, in her opinion, she cannot help. If at any point during psychotherapy, Dr. Nightingale
assesses that she is not effective in helping you reach the therapeutic goals, she is obligated to discuss it with you and, if appropriate,
to terminate treatment. If you request it and authorize in writing, Dr. Nightingale will talk to the psychotherapist of your choice in
order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, Dr.
Nightingale will assist you in finding someone qualified, and, if she has your written consent she will provide them with the essential
information needed. You have the right to terminate therapy at any time in all these cases. Dr. Nightingale will offer to provide you
with names of other qualified professionals whose services you might prefer.
Please sign:____________________________________________ Date:__________________
Patient Health Care History:
Have you been in therapy before?
(Please circle) yes
no
If yes, what year? __________
Name of Therapist: _____________________________________ Phone: __________________
Are you currently being treated for a medical condition? Yes No
If yes, What condition(s)?
____________________________________________________________________________________________________
___________________________________________________________________________________________________
Doctor’s Name: _________________________________________________ Phone: ___________________________
Medications: _________________________________________________________________________________________
What motivated you to seek treatment at this time? What would you like to resolve?
________________________________________________________________________________________________________________________
____________________________________________________________________________
To what issues are you committed to creating resolution in therapy?__________________________________________
__________________________________________________________________________________________________
Are you committed to participating fully and completing homework? Yes____ No____
About Therapy
(Informed Consent):
The intent of psychotherapy is to help people feel better about themselves. Help them learn new coping skills so they feel better about life, and learn
new communication patterns so they feel better about their relationships. Psychotherapy can also help people see themselves, their behaviors, past
experiences and current outlooks from new perspectives and learn new skills to lead more fulfilling and satisfying lives. AS with any form of
treatment, psychotherapy has positives and potential negatives. It is important for an individual entering therapy to have an understanding of these.
The type of therapy conducted by Dr. Nightingale is called talk therapy. The advantages of talk therapy include having a highly trained professional
assist you in a private and confidential environment to discuss and work on issues of concern to you. This includes, but is not limited to:
Cognitive Behavioral Therapy: where beliefs and behaviors are examined, and redirected if currently causing painful outcomes. (Scientifically
researched by Taylor, Marshall 1977, Rush 1977).
Insight Oriented Therapy: where held assumptions, past woundings, and how these were interpreted and dealt with are examined.
Relaxation and Stress Reduction with an emphasis on self-care, and in which relaxation techniques may be taught (scientifically researched,
Benson 1975, Ornstein 1971).
Sand Tray and Play therapy for children: where children have a fun and non-confrontational way to express their concerns and problems. They
have the ability to share issues and learn new coping skills and perspectives in a playful and age-appropriate modality.
Education; this includes suggestion of books to read, informative CDs to listen to , support groups to attend and new forms of communication to
practice.
Therapy usually begins 1 or 2 times a week moving to every other week or as symptoms subside. The majority of our patients are in treatment 6-15
sessions. Most patients who participate in psychotherapy report feeling better, gains toward personal goals and decreases in depression and anxiety.
Although we are focused on brief therapy, each person progresses at his or her own rate and toward his or her own goals. Each person coming to
therapy brings his or her own past experiences, expectations, resources, apprehensions and motivations. Life situations may change during the course
of therapy also affecting outcome. On rare occasions some patients have found as they feel better about themselves and their decisions they may
experience some negative reactions by people close to them. Resolution of one or more issues during psychotherapy does not necessarily lead to
resolution of other emotional and psychological conflicts in a patient. If you experience any difficult, confusing or negative reactions to therapy, it is
important to discuss these issues with your therapist.
Other therapies that many people find helpful include, reading self-help books and listening to self-help CDs, attending self-help groups such as 12step programs, therapist-led groups, hospital help, faith-based support groups, therapists with other orientations such as those with a psychoanalytic
focus, psychiatric evaluations for medication by a psychiatrist, pastoral counseling and biofeedback.
If at any time during therapy you have questions about your progress please do not hesitate to ask your therapist. If you are not sure that your
therapist is right for you, also discuss this. Not all therapists or therapies are appropriate for all patients. It is important to have a therapist and a
psychotherapy that fit with your personality and therapeutic goals.
We welcome your questions and comments.
I have read and understand this informed consent.
Patient (or guardian) _______________________________________________ Date:__________________
Confidentiality
A therapist is ethically and legally bound to keep in strictest confidence everything that is said between you and her. Without your
written consent we cannot give out any information. If you wish information to be given or exchanged with school, attorneys,
physicians, insurance companies, etc., you must first give authorization in writing. You may receive Holiday Greetings, newsletters,
event and lecture notification, etc. offered by the Nightingale Center.
Exceptions to Confidentiality Required by Law:
1.
2.
3.
4.
The therapist has reasonable cause to believe that a patient is in such a mental or emotional condition or is gravely
disabled as to be dangerous to themselves or another person or the property of another person.
The therapist suspects a patient is in anyway involved in the abuse of a minor or of an elderly person or has personal
knowledge of such abuse.
Where a patient waived confidentiality pursuant to any legal proceeding.
Where the services of the psychotherapist are sought or obtained to enable or aid anyone to commit or plan to commit
a crime or tort.
When disclosure may be required:
Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in a litigation by you, the defendant
may have the right to obtain the psychotherapy records and/or testimony by Dr. Nightingale. In couple and family therapy, or when
different family members are seen individually, confidentiality and privilege do not apply between the couple or among family
members. Dr. Nightingale will not release records to any outside part unless she is authorized to do so by all adult members who were
part of the treatment.
IN THESE CASES, DR. NIGHTINGALE IS ETHICALLY AND LEGALLY REQURED TO BREAK CONFIDENTIALTY TO
PRESERVE THE SAFETY OF THOSE INVLOVED.
IN CASE OF EMERGENCY OR DURING CASE OF EMERGENCY: If there is an emergency and Dr. Nightingale becomes
concerned about your personal safety she may also contact the person whose name you have provided as an emergency contact.
(initial)______
I have read and understand all of the above: _________________________________________ _____________
Signature
Date
Mediation and Arbitration: All disputes arising out of or in relation to this agreement to provide mediation services
shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a
nutria third party chosen by agreement of Dr. Nightingale and client(s). The cost of such mediation, if any, shall be split
equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this
agreement should be submitted to and settled by binding arbitration in Orange County, California in accordance with the
rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed.
Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment
plan, Dr. Nightingale can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in
arbitration or collection proceeding shall be entitled to recover a reasonable sum and attorney’s fees. In the case of
arbitration, the arbitrator will determine that sum.
________________________________
___________________
Signature of patient/legal guardian
Date
____________________________________
___________________
Witness
Date
I have read the H.I.P.P.A. Federal regulations binding Dr. Nightingale’s release of any of my health care information and
outlining my rights.
(A copy is available to you upon request)
_______________________________________________
_____________________
Signature
Date
Lois Nightingale, Ph.D.
Licensed Psychologist (lic # PSY 9503)
16960 E. Bastanchury. Rd. Suite J
Yorba Linda, Ca. 92886
714-993-5343 www.nightingalecenter.com
Consent for treatment for minor/s and dependents
I ______________________________________________________________give my consent that
Dr. Lois Nightingale, will be conducting psychotherapy with,
______________________________________________________________ (child’s name)
My relationship to the client is (parent, grandparent, legal guardian, etc.)_________________________
I have been notified that all material discussed during psychotherapy sessions is confidential and can be
released only with the permission of the holder of the privilege. I have been informed of the limitations to
confidentiality in the Office Policies form, which I have read and signed.
In case of a minor, special sensitivity may be required in releasing information about certain topics such as
drugs and sex. I will accept Dr. Nightingale’s judgment in regard to releasing or sharing information obtained
during course of psychotherapy with the minor that may endanger or jeopardize the patient’s wellbeing.
_______________________________ _____________________ __________________________ ________
Name (print)
Date
Relationship
Signature
_______________________________ _____________________ __________________________ ________
Name (print)
Date
Relationship
Signature
RELEASE OF INFORMATION
NIGHTINGALE CENTER, 16960 E. BASTANCHURY RD., SUITE J
YORBA LINDA, CA 92886
(714) 993-5343
FAX: (714) 993-3467
I, ____________________________________, authorize ___________________________________
(patient or guardian if patient is a minor)
(name of psychotherapist)
at the Nightingale Center to disclose, mutually discuss, release and/or obtain mental health records of patient, but not limited
to, therapist’s diagnosis of patient, to:
_________________________________________ (patient’s name) to/from:
 primary care physician, Dr. ________________________
Phone:_______________
 family member(s) ____________________________
Phone:_______________
 lawyer
Phone:_______________
_______________________________________
 person who referred me here ______________________
Phone:_______________
 previous therapist ____________________________
Phone:_______________
 other
Phone:_______________
_______________________________________
I understand that I have a right to receive a copy of this authorization. I understand that any cancellation or modification of
this authorization must be in writing. I understand that I have the right to revoke this authorization at any time unless Provider
has taken action in reliance upon it. And, I also understand that such revocation must be in writing and received by Provider
at 16960 E. Bastanchury Rd., Suite I, Yorba Linda, CA 92886 to be effective.
This disclosure of information and records authorized by Patient is required for the following purpose:
___________________________________________________________________________________
The specific uses and limitations of the types of medical information to be discussed are as follows (be as specific as you
choose to):
____________________________________________________________________________________________________
__________________________________________________________________
Information including but not limited to: treatment for mental health, diagnosis, social history, psychological tests, treatment
progress, information provided to therapist and/or services related thereto for above name patient.
I understand released information may be exchanged by mail, courier, fax, phone, cell phone and/or
e-mail.
I understand this authorization expires in one year from date signed unless requested by patient in writing.
This information shall remain valid until: _______________________
A photocopy or fax copy of this signed form is as good as an original.
________________________________
Patient Signature
__________________________________
Witness
________________________________
Print Name
________________________________
Parent, Guardian or Legal Representative
__________________________________
Date