Download Theresa Lynn Taylor Kellam, Ph

Dr Kellam
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SEADOCS:144226.2
TEXAS NOTICE FORM
Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT
YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and
health care operations purposes with your consent. To help clarify these terms, here are some
definitions:
•
“PHI” refers to information in your health record that could identify you.
•
“Treatment, Payment and Health Care Operations” – Treatment is when I provide,
coordinate or manage your health care and other services related to your health care. An
example of treatment would be when I consult with another health care provider, such as your
family physician or another psychologist. - Payment is when I obtain reimbursement for your
healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain
reimbursement for your health care or to determine eligibility or coverage. - Health Care
Operations are activities that relate to the performance and operation of my practice. Examples
of health care operations are quality assessment and improvement activities, business-related
matters such as audits and administrative services, and case management and care
coordination.
•
“Use” applies only to activities within my [office, clinic, practice group, etc.] such as
sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
•
“Disclosure” applies to activities outside of my [office, clinic, practice group, etc.],
such as releasing, transferring, or providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care
operations when your appropriate authorization is obtained. An “authorization” is written
permission above and beyond the general consent that permits only specific disclosures. In
those instances when I am asked for information for purposes outside of treatment, payment
and health care operations, I will obtain an authorization from you before releasing this
information. I will also need to obtain an authorization before releasing your psychotherapy
notes. “Psychotherapy notes” are notes I have made about our conversation during a private,
group, joint, or family counseling session, which I have kept separate from the rest of your
medical record. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided
each revocation is in writing. You may not revoke an authorization to the extent that (1) I have
relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining
insurance coverage, and the law provides the insurer the right to contest the claim under the
policy.
III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: If I have cause to believe that a child has been, or may be, abused, neglected,
or sexually abused, I must make a report of such within 48 hours to the Texas Department of
Protective and Regulatory Services, the Texas Youth Commission, or to any local or state law
enforcement agency.
Adult and Domestic Abuse: If I have cause to believe that an elderly or disabled person is in
a state of abuse, neglect, or exploitation, I must immediately report such to the Department of
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Protective and Regulatory Services.
Health Oversight: If a complaint is filed against me with the State Board of Examiners of
Psychologists, they have the authority to subpoena confidential mental health information from
me relevant to that complaint.
•
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a
request is made for information about your diagnosis and treatment and the records thereof,
such information is privileged under state law, and I will not release information, without written
authorization from you or your personal or legally appointed representative, or a court order.
The privilege does not apply when you are being evaluated for a third party or where the
evaluation is court ordered. You will be informed in advance if this is the case.
Serious Threat to Health or Safety: If I determine that there is a probability of imminent
physical injury by you to yourself or others, or there is a probability of immediate mental or
emotional injury to you, I may disclose relevant confidential mental health information to medical
or law enforcement personnel.
Worker’s Compensation: If you file a worker's compensation claim, I may disclose records
relating to your diagnosis and treatment to your employer’s insurance carrier.
IV. Patient's Rights and Psychologist's Duties Patient’s Rights:
•
Right to Request Restrictions –You have the right to request restrictions on certain
uses and disclosures of protected health information about you. However, I am not required to
agree to a restriction you request.
•
Right to Receive Confidential Communications by Alternative Means and at
Alternative Locations – You have the right to request and receive confidential communications
of PHI by alternative means and at alternative locations. (For example, you may not want a
family member to know that you are seeing me. Upon your request, I will send your bills to
another address.)
•
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of
PHI and psychotherapy notes in my mental health and billing records used to make decisions
about you for as long as the PHI is maintained in the record. I may deny your access to PHI
under certain circumstances, but in some cases you may have this decision reviewed. On your
request, I will discuss with you the details of the request and denial process.
•
Right to Amend – You have the right to request an amendment of PHI for as long as
the PHI is maintained in the record. I may deny your request. On your request, I will discuss with
you the details of the amendment process.
•
Right to an Accounting – You generally have the right to receive an accounting of
disclosures of PHI for which you have neither provided consent nor authorization (as described
in Section III of this Notice). On your request, I will discuss with you the details of the accounting
process.
•
Right to a Paper Copy – You have the right to obtain a paper copy of the notice from
me upon request, even if you have agreed to receive the notice electronically.
Psychologist’s Duties:
•
I am required by law to maintain the privacy of PHI and to provide you with a notice of
my legal duties and privacy practices with respect to PHI.
•
I reserve the right to change the privacy policies and practices described in this
notice. Unless I notify you of such changes, however, I am required to abide by the terms
currently in effect.
•
If I revise my policies and procedures, I will notify you in person or by mail and post
changes on the web site www.dgapractice.com.
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V. Complaints
If you are concerned that I have violated your privacy rights, or you disagree with a
decision I made about access to your records, you may contact me at the above phone or
address.
You may also send a written complaint to the Secretary of the U.S. Department of Health
and Human Services. The person listed above can provide you with the appropriate address
upon request.
VI. Effective Date, Restrictions and Changes to Privacy Policy
I reserve the right to change the terms of this notice and to make the new notice provisions
effective for all PHI that I maintain. I will provide you with a revised notice by in person or by mail
and posting on the web site.
SEADOCS:144226.2
Theresa
K e l l a m, P h.D., H. S. P.
LICENSED
PSYCHOLOGIST
2201 Dottie Lynn Parkway, Suite 127, Fort Worth, Texas 76120
817-313-7899
Client Information Questionnaire
Today's date: ____________________________
Note: If you have been a patient here before, please fill in only the information that has changed.
A. Identification
Your name: ______________________________Date of birth: _________________________ Age: ________
Your nicknames or aliases: ______________________________ Social Security #: _____________________
Cell _______________________________________Email ____________________________________
Spouses name: ______________________________Date of birth: _________________________ Age: ________
Spouses nicknames or aliases: ______________________________ Social Security #: _____________________
Cell _______________________________________Email ____________________________________
Home street address: ___________________________________________________ Apt.:_______________
City: _________________________________________ State: ______________Zip: ____________________
Home/evening phone: _______________ Calls will be discreet, but please indicate any restrictions:_________
Cell _______________________________________Email ____________________________________
B. Referral: Who gave you my name to call?
Name: ___________________________________________ Phone: ________________________________
Address: ________________________________________________________________________________
________________________________________________________________________________________
May I have your permission to thank this person for the referral?  Yes  No
How did this person explain how I might be of help to you? _________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
C. Your health care
From whom or where do you get your medical care?
Clinic/doctor's name: __________________________________________ Phone: ______________________
Address: ________________________________________________________________________________
If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can be
fully informed and we can coordinate your treatment?  Yes  No
Have you ever been or are you currently in therapy?
long?
If so, why did you seek treatment, with whom and for how
Have you ever taken or are you currently taking any psychotropic medications? If so, what medications did you
take, for what symptoms and for how long?
Please list all current medications:
Name:
_______________________
_______________________
_______________________
_______________________
Dose:
_______
_______
_______
_______
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D. Your current employer
Employer: ________________________________ Address: _______________________________________
________________________________________________________________________________________
Work phone: ________________Calls will be discreet, but please indicate any restrictions: _______________
Spouses Employer: ____________________________ Address: _______________________________________
________________________________________________________________________________________
Work phone: ________________Calls will be discreet, but please indicate any restrictions: _______________
________________________________________________________________________________________
E. Your education and training
Dates
From
To
Schools
______ _______ ________________
______ _______ ________________
______ _______ ________________
______ _______ ________________
______ _______ ________________
Spouses education and training
Dates
From
To
______ _______
______ _______
______ _______
______ _______
______ _______
Schools
________________
________________
________________
________________
________________
Special Classes?
__________________
__________________
__________________
__________________
__________________
Adjustment
to school
_____________________
_____________________
_____________________
_____________________
_____________________
Did you
graduate?
___________
___________
___________
___________
___________
Special Classes?
__________________
__________________
__________________
__________________
__________________
Adjustment
to school
_____________________
_____________________
_____________________
_____________________
_____________________
Did you
graduate?
___________
___________
___________
___________
___________
F. Employment and military experiences
Dates
From
To
Name of military or employers
______ _______ _____________________________
______ _______ _____________________________
______ _______ _____________________________
______ _______ _____________________________
______ _______ _____________________________
Spouses Employment and military experiences
Dates
From
To
______ _______
______ _______
______ _______
______ _______
______ _______
Name of military or employers
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
Job title or duties
Reason for leaving
_________________________ _______________
_________________________ _______________
_________________________ _______________
_________________________ _______________
_________________________ _______________
Job title or duties
Reason for leaving
_________________________ _______________
_________________________ _______________
_________________________ _______________
_________________________ _______________
_________________________ _______________
G. Family-of-origin history
Current age
Illness (or cause of
Relative
Name
(or age at death) death, if deceased)
Education
Occupation
Father
___________________ _____________ _____________ ________________ __________
Mother
___________________ _____________ _____________ ________________ __________
Stepparents ___________________ _____________ _____________ ________________ __________
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Grandparents __________________
Uncles/aunts __________________
Brothers
____________________
Sisters
_____________________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
_____________
________________
________________
________________
________________
_________
__________
__________
__________
(cont.)
Spouses Family-of-origin history
Current age
Illness (or cause of
Relative
Name
(or age at death) death, if deceased)
Education
Occupation
Father
___________________ _____________ _____________ ________________ __________
Mother
___________________ _____________ _____________ ________________ __________
Stepparents ___________________ _____________ _____________ ________________ __________
Grandparents __________________ _____________ _____________ ________________ _________
Uncles/aunts __________________ _____________ _____________ ________________ __________
Brothers
____________________ _____________ _____________ ________________ __________
Sisters
_____________________ _____________ _____________ ________________ __________
H. Marital/relationship history
Spouse’s name
Spouse’s age at
marriage
Your age at
marriage
Your age
when divorced/widowed
First ____________________ ________ _________
Second____________________ ________ _________
Third____________________ ________ _________
Spouses Marital/relationship history
Spouse’s name
Spouse’s age at
marriage
Your age at
marriage
Second____________________ ________ _________
Third____________________ ________ _________
______________________
_____________
____________________
_____________
______________________
_____________
Your age
when divorced/widowed
First ____________________ ________ _________
Is spouse
remarried?
Is spouse
remarried?
______________________
_____________
____________________
_____________
______________________
_____________
I. Significant nonmarital relationships
Name of person
Person’s age
when started
Your age
when started
First ______________________________ _______ ____________
Second _____________________________ _______ ____________
Third ______________________________ _______ ____________
Your age
when ended
Reasons for ending
___________ ________________
___________ ________________
___________ ________________
Spouses Significant nonmarital relationships
Name of person
Person’s age
when started
Your age
when started
First ______________________________ _______ ____________
Second _____________________________ _______ ____________
Your age
when ended
Reasons for ending
___________ ________________
___________ ________________
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Third ______________________________ _______ ____________
___________ ________________
J. Children (Indicate which are from a previous marriage or relationship with the letter P in the last column)
Name
Current age
_________________________ ______
_________________________ ______
_________________________ ______
_________________________ ______
_________________________ ______
_________________________ ______
Sex
______
______
______
______
______
______
School
Grade
_________________ ____
_________________ ____
_________________ ____
_________________ ____
_________________ ____
_________________ ____
Adjustment problems?
____________________
____________________
____________________
____________________
____________________
____________________
__
__
__
__
__
__
SEADOCS:144226.2
Theresa
LICENSED
K e l l a m, P h.D.
PSYCHOLOGIST
817-313-7899
[email protected]
Adult Checklist of Concerns
Name:________________________________________________________ Date: _____________________
Please mark all of the items below that apply, and feel free to add any others at the bottom under "Any other
concerns or issues." You may add a note or details in the space next to the concerns checked. (For a child, mark
any of these and then complete the "Child Checklist of Characteristics.")
I have no problem or concern bringing me here
Abuse—physical, sexual, emotional, neglect (of children or elderly), cruelty to animals
Aggression, violence
Alcohol use
Anger, hostility, arguing, irritability
Anxiety, nervousness
Attention, concentration, distractibility
Career concerns, goals, and choices
Childhood issues (your own childhood)
Children, child management, child care, parenting
Codependence
Confusion
Compulsions
Custody of children
Decision making, indecision, mixed feelings, putting off decisions
Delusions (false ideas)
Dependence
Depression, low mood, sadness, crying
Divorce, separation
Drug use—prescription medications, over-the-counter medications, street drugs
Eating problems—overeating, undereating, appetite, vomiting (see also "Weight and diet issues")
Emptiness
Failure
Fatigue, tiredness, low energy
Fears, phobias
Financial or money troubles, debt, impulsive spending, low income
Friendships
Gambling
Grieving, mourning, deaths, losses, divorce
Guilt
Headaches, other kinds of pains
(cont.)
FORM 28. Adult checklist of concerns (p. 1 of 2). From The Paper Office, pp. 224– 225. Copyright 1997 by
Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal
use only (see copyright page for details)
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Adult Checklist of Concerns (p. 2 of 2)
Health, illness, medical concerns, physical problems
Inferiority feelings
Interpersonal conflicts
Impulsiveness, loss of control, outbursts
Irresponsibility
Judgment problems, risk taking
Legal matters, charges, suits
Loneliness
Marital conflict, distance/coldness, infidelity/affairs, remarriage
Memory problems
Menstrual problems, PMS, menopause
Mood swings
Motivation, laziness
Nervousness, tension
Obsessions, compulsions (thoughts or actions that repeat themselves)
Oversensitivity to rejection
Panic or anxiety attacks
Perfectionism
Pessimism
Procrastination, work inhibitions, laziness
Relationship problems
School problems (see also "Career concerns . . .")
Self-centeredness
Self-esteem
Self-neglect, poor self-care
Sexual issues, dysfunctions, conflicts, desire differences, other (see also "Abuse")
Shyness, oversensitivity to criticism
Sleep problems—too much, too little, insomnia, nightmares
Smoking and tobacco use
Stress, relaxation, stress management, stress disorders, tension
Suspiciousness
Suicidal thoughts
Temper problems, self-control, low frustration tolerance
Thought disorganization and confusion
Threats, violence
Weight and diet issues
Withdrawal, isolating
Work problems, employment, workaholism/overworking, can't keep a job
Any other concerns or issues:
___________________________________________________________________________________
___________________________________________________________________________________
Please look back over the concerns you have checked off and choose the one that you most want help with. It is:
_____________________________________________________________________________________
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
SEADOCS:144226.2
Theresa
LICENSED
K e l l a m, P h.D.
PSYCHOLOGIST
817-313-7899
[email protected]
Adult Checklist of Concerns
Name:________________________________________________________ Date: _____________________
Please mark all of the items below that apply, and feel free to add any others at the bottom under "Any other
concerns or issues." You may add a note or details in the space next to the concerns checked. (For a child, mark
any of these and then complete the "Child Checklist of Characteristics.")
I have no problem or concern bringing me here
Abuse—physical, sexual, emotional, neglect (of children or elderly), cruelty to animals
Aggression, violence
Alcohol use
Anger, hostility, arguing, irritability
Anxiety, nervousness
Attention, concentration, distractibility
Career concerns, goals, and choices
Childhood issues (your own childhood)
Children, child management, child care, parenting
Codependence
Confusion
Compulsions
Custody of children
Decision making, indecision, mixed feelings, putting off decisions
Delusions (false ideas)
Dependence
Depression, low mood, sadness, crying
Divorce, separation
Drug use—prescription medications, over-the-counter medications, street drugs
Eating problems—overeating, undereating, appetite, vomiting (see also "Weight and diet issues")
Emptiness
Failure
Fatigue, tiredness, low energy
Fears, phobias
Financial or money troubles, debt, impulsive spending, low income
Friendships
Gambling
Grieving, mourning, deaths, losses, divorce
Guilt
Headaches, other kinds of pains
(cont.)
FORM 28. Adult checklist of concerns (p. 1 of 2). From The Paper Office, pp. 224– 225. Copyright 1997 by
Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal
use only (see copyright page for details)
SEADOCS:144226.2
Adult Checklist of Concerns (p. 2 of 2)
Health, illness, medical concerns, physical problems
Inferiority feelings
Interpersonal conflicts
Impulsiveness, loss of control, outbursts
Irresponsibility
Judgment problems, risk taking
Legal matters, charges, suits
Loneliness
Marital conflict, distance/coldness, infidelity/affairs, remarriage
Memory problems
Menstrual problems, PMS, menopause
Mood swings
Motivation, laziness
Nervousness, tension
Obsessions, compulsions (thoughts or actions that repeat themselves)
Oversensitivity to rejection
Panic or anxiety attacks
Perfectionism
Pessimism
Procrastination, work inhibitions, laziness
Relationship problems
School problems (see also "Career concerns . . .")
Self-centeredness
Self-esteem
Self-neglect, poor self-care
Sexual issues, dysfunctions, conflicts, desire differences, other (see also "Abuse")
Shyness, oversensitivity to criticism
Sleep problems—too much, too little, insomnia, nightmares
Smoking and tobacco use
Stress, relaxation, stress management, stress disorders, tension
Suspiciousness
Suicidal thoughts
Temper problems, self-control, low frustration tolerance
Thought disorganization and confusion
Threats, violence
Weight and diet issues
Withdrawal, isolating
Work problems, employment, workaholism/overworking, can't keep a job
Any other concerns or issues:
___________________________________________________________________________________
___________________________________________________________________________________
Please look back over the concerns you have checked off and choose the one that you most want help with. It is:
_____________________________________________________________________________________
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
SEADOCS:144226.2
Theresa
LICENSED
K e l l a m, P h.D.
PSYCHOLOGIST
817-313-7899
[email protected]
Consent to Treatment
I acknowledge that I have received, have read (or have had read to me), and understand the "Information for
Clients" brochure and/or other information about the therapy I am considering. I have had all my questions
answered fully.
I do hereby seek and consent to take part in the treatment by the licensed psychologist named below. I
understand that developing a treatment plan with this licensed psychologist and regularly reviewing our work
toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.
I understand that no promises have been made to me as to the results of treatment or of any procedures
provided by this licensed psychologist.
I am aware that I may stop my treatment with this licensed psychologist at any time. The only thing I will still be
responsible for is paying for the services I have already received. I understand that I may lose other services or
may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I
will have to answer to the court.)
I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not
cancel or do not show up, I will be charged for that appointment.
I am aware that this licensed psychologist accepts third-party payments. I understand that if payment for the
services I receive here is not made, the licensed psychologist may stop my treatment.
My signature below shows that I understand and agree with all of these statements.
______________________________________________________
Signature of client
__________________
Date
______________________________________________________
Printed name
__________________________________________________
Signature of client
__________________
Date
______________________________________________________
Printed name
(
I, Theresa Kellam, have discussed the issues above with the client (and/or his or her parent, guardian, or other
representative). My observations of this person's behavior and responses give me no reason to believe that this
person is not fully competent to give informed and willing consent.
______________________________________________________
Theresa Kellam, Ph.D.
Licensed Psychologist
____________________________
Date
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