|
The information below is available in downloadable PDF by clicking the link above.
Feel free to print form, fill it out, and bring it with you so you won't need to come in
early and we'll get a
good start. Thank you.
APPLICATION FOR SERVICES Name
Marital Status How
long
Address with zip code Telephones where messages can be left: Home Work Cell
.(Our cell phones may not be confidential.)
Date
of birth Today's date Email Social Security number If
using insurance: Company; HMO,PPO etc; ID; Group; 800 #s; Preauth. needed? Ded.+Copay?
Referred by: Yellow Book /Yellow Pages / Insurance online or by call /
My website / or If person, who
Years of education, training, certificates, degrees, and experiential knowledge in a
field
Your place of work
/ school, daytime activities, physical exercise and type of diet
Financial well-being (good, fair, poor)
List members in present household, relationship, ages, quality of
relationships and other
family and important people
Since many psychological difficulties are transmitted historically or genetically, please indicate any psychological
or medical difficulties experienced by other members of your family (grandparents, parents, siblings and children).
Your Psychiatrist(s) previous and current, diagnosis,
history of symptoms and treatment
Religious affiliation, amount of involvement; If none, specify how raised. Health concerns past and present, allergies, difficulty sleeping,
appetite changes
Prescriptions,
amounts, when taken, what are you using it for, and name of prescribing physician
Over the counter medications, herbs, homeopathic, nutritional
remedies etc. with amounts
Alcohol, street drugs, smoking and caffeine with amounts per week
APPLICATION FOR SERVICES
Name
Marital Status
How
long
Address with zip code
Telephones where messages can be left: Home
Work
Cell .(Our cell phones may not be confidential.)
Date
of birth Today’s date
Email
Social Security number If using insurance:
Company; HMO,PPO etc; ID; Group; 800 #s; Preauth. needed?
Ded.+Copay?
Referred by: Yellow
Book /Yellow Pages / Insurance online or by call / My website / or If person, who
Years of education, training, certificates, degrees, and experiential knowledge in a field Your place of work /
school, daytime activities,
physical exercise and type of diet
Financial well-being (good,
fair, poor) List members in present household, relationship, ages, quality of relationships and
other important people
Since many psychological difficulties are transmitted historically or genetically,
please indicate any psychological or medical difficulties
experienced by other members of your
family (grandparents, parents, siblings and children).
Your Psychiatrist(s) previous
and current, diagnosis, history of symptoms and treatment
Religious affiliation, amount of involvement;
If none, specify how raised.
Health concerns past and present, allergies, difficulty sleeping, appetite changes
Prescriptions, amounts, when taken, what are you using it for, and name of prescribing physician
Over the counter medications, herbs, homeopathic, nutritional remedies etc. with amounts Alcohol, street drugs,
smoking and caffeine with
amounts per week What happened that motivated you
to seek assistance now rather than in previous or future weeks?
Please circle any of the following problems which
pertain to you and include your history of it:
fears / butterflies / nervousness / anxiety / feelings of panic / social
withdrawal / fear of doing things
communication difficulties / marital or relationship concerns / separation /
divorce / restabilizing shyness / inferiority / not being heard /
being controlled / controlling smoking,
alcohol, drug, or medication use that ends up bothering you or others irritability / temper / angry outbursts /
self-control
concerns / other people not living up to expectations
restlessness / tiredness /sleep difficulties: getting to sleep,
staying asleep, early morning awakenings
grief / sadness / loss: of another person, of self, role, ability,
relationship, things, etc. / tearfulness
general unhappiness / blah / dull /empty / lonely / unmotivated / depression/
suicidal: thoughts, plans
confusion / memory / making decisions / concentration / my thoughts over energized /
lack of sleep / doing too much/
people who know you commenting about the change sexual concerns: for self / with
partner / uncomfortable or concerning sexual
behavior of another stress / tension / overwhelmed / headaches / nightmares
career: choices / path / fulfillment / change / the work itself / work relationships
becoming a parent / parenting
/ children
relationship with friends / parent(s) / children / siblings / associates / ex-spouse / authorities / public multiple
feelings or a flood of feelings
If legal problems: charges, history of lawsuits filed or pending
What would be the change you would most like to see in yourself as a result of your work with me (This
is the most important question)
CONSENT FOR RELEASE OF PROFESSIONAL INFORMATION
Client name:_________________________________________
Date of birth:_________________ Gwen Zechel, RN, LMHC
Hearby has authorization to secure and release all pertinent
psychological, medical, social, educational, and other clinical information regarding
the client named above for the
purpose of maintenance of health care benefits or completeness of care.
Signature:__________________________________________
Date:______________________
Please print name of signer:_______________________________________________________
This authorization applies only to the institutions / individuals named below. Please include addresses and phone
numbers as best you can.
Person(s) attending with and significant other______________________________________
_________________________________________________________________________
In case of emergency (suicidal, homicidal)______________________________________
_________________________________________________________________________
Insurance company or managed care company___________________________________
__________________________________________________________________________
Primary care physician and psychiatrist _________________________________________
_________________________________________________________________________
Someone else I can confer with (spouse, a friend, someone at school or on the job, parents,
children, roommate, significant other).___________________________________________
_________________________________________________________________________
___________________________________________________________________________
This expires one year after completion of treatment.
A copy of this form is the same as the original.
OFFICE POLICY STATEMENT APPOINTMENTS.
Please note my new phone number 356-7245 and schedule appointments as soon as you know you would like one. I answer
this as much
as possible 7 days a week. Please call from 9am to 9pm unless it is urgent.
In case of emergency, please call 911.
FEE. My fee is $100.00 per fifty minute hour.
This includes most printed materials (please return books and thick handouts), reports, letters, consultations and 5-10min.
telephone calls. If calls are longer they are billed at the regular rate. Reviewing journals is half price.
Court time is also according to my regular
hourly fee. You will be responsible for paying for each visit, each
time by cash, check, or credit card. If you are using insurance, the fee is
according to the deductible and copay
of your particular plan. If your insurance company does not cover your services, you may be responsible
for the
balance of payment. If payment is not forthcoming a collections company may be utilized and they may charge an additional
fee.
CANCELLATIONS AND MISSED APPOINTMENTS. Cancellations will be accepted up to 24 hours prior to the appointment.
If you know that
you have made an appointment that is inconvenient for you or one that you cannot meet, please make
arrangements to change it or cancel at
the earliest possible time. Missed appointments will be billed at the therapy
rate of $100.00/hour and need to be paid prior to making another
appointment. Scheduling an appointment means
that it will be held only for you and therefore cannot be used by another person.
TAX RECORDS. Keep
the receipts you are given for your own records. Depending upon your financial circumstances and your total medical
costs for any given year, psychotherapy may be a deductible expense. Retaining a copy for your own tax records
will help you to compute the
feasibility of an income-tax deduction at the end of the taxable year.
CONFIDENTIALITY.
The laws of Florida require that most issues discussed during the course of therapy are confidential. These laws permit
you to waive the privilege of confidentiality by signing a release of information form. However, the release of
confidential materials is required
in situations of suspected child abuse, of potential harm to oneself or others, and
in instances such as where the court may subpoena records.
THE DIRECTION SESSIONS TAKE. Usually working
on issues goes in the direction of the goals created, but therapy is a process that evolves
with insight and therefore
outcomes cannot always be predicted. A relationship, for example, may break up rather than come closer together.
But these are not common and by having clear personal and/or common relationship goals, most peoples’ work will
maintain the positive
direction intended and worked for.
ETHICS AND PROFESSIONAL STANDARDS. As
a Licensed Mental Health Counselor in the state of Florida, I uphold the most responsible
ethical and professional standards
possible. In signing this contract, you are agreeing to discuss any questions or concerns about your course
of
contact with me so that I can be sure you get your needs met. Additionally, I welcome any feedback you may have at any
point and may
provide evaluation forms that ask you to give me feedback.
PLEASE ASK BEFORE SIGNING
BELOW IF YOU HAVE ANY QUESTIONS ABOUT PSYCHOTHERAPY OR MY OFFICE POLICIES.
YOUR SIGNATURE INDICATES THAT
YOU HAVE READ MY OFFICE POLICIES AND AGREE TO ENTER THERAPY UNDER THESE
CONDITIONS. I have read this contract and
agree to abide by it.
Received and agreed:_________________________________________________________Date:________________
H.I.P.A.A. Information (Health Insurance Portability and Accountability Act of 1996)
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
HIPAA
requires that Gwen Zechel, RN, LMHC inform you of our privacy practices. These practices are included in the Application
For Services
paperwork that can be handed to you, available by looking behind the Application For Services forms in
the magazine rack on the wall in the
waiting area, available on our website at www.AdultCounseling.Net,
and is available to you in print at your request.
I acknowledge that the Notice of Privacy Practices for
Gwen Zechel, RN, LMHC have been made available to me.
________________________________________________
Date ______________________
Signature of Client or Client’s Representative ________________________________________________
Printed Name of Client or Client Representative ________________________________________________
If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual
(e.g. power of
attorney, healthcare surrogate, etc.).
|
