Family Intake Insurance Please enable JavaScript in your browser to complete this form.1st Parent/Partner Name *FirstMiddleLast1st Parent/Partner phone number *1st Parent/Partner Address Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code1st Parent/Partner Date of Birth mm/dd/yy1st Parent/Partner Gender1st Parent/Partner Religious Affiliation1st Parent/Partner Employer1st Parent/Partner Occupation2nd Parent/Partner Name *FirstMiddleLast2nd Parent/Partner phone number *2nd Parent/Partner Address (if different than 1st)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code2nd Parent/Partner Date of Birth mm/dd/yy 2nd Parent/Partner Gender 2nd Parent/Partner Religious Affiliation2nd Parent/Partner Employer2nd Parent/Partner OccupationMartial Status (single/engaged/married/divorce/seperated) & number of yearsPlease list Children's Names & DOBHas anyone in the immediate family currently or historically had suicidal thoughts? *YesNoIf yes, who and when? (copy)Has anyone in the immediate family recently or historically had a suicide attempt?YesNoIf yes, who and when?Has anyone in the immediate family been hospitalized for mental health related issues? *YesNoIf yes, who and when?Has anyone in the immediate family recently or historically struggled with self-injurious behavior? *YesNoIf yes, who and when?Has anyone in the immediate family been diagnosed with a mental health condition? *YesNoIf yes, please describe belowHas anyone in the immediate family been diagnosed with developmental delays? *YesNoIf yes please describe belowHas anyone in the family ever struck, physically restrained, used violence against, or injured any person within the family? *YesNoIf yes please explain below Other InformationPlease describe your reason for seeking family counseling:How would you know that your time in therapy has been successful? What would look different in your family?List some strengths in your family:List some weaknesses in your family:How does your family deal with conflict? How does your family celebrate/play together?What are things that your family does together on a regular (weekly) basis?How does your family deal with major life events (i.e. weddings, deaths, life threatening illnesses, job loss)?Consent For CommunicationPatients/Clients frequently request that we communicate with them by phone, voicemail, email or text. Suffolk Family Therapy LCSW P.C. respects your right to confidential communications about your protected health information (PHI) as well as your right to direct how those communications occur. Since email and texting can be inherently insecure as a method of communication, we will only communicate with you by email or text with your written consent at the email address or phone number you provide to us below. Please be aware that if you have an email account through your employer, your employer may have access to your email. When you consent to communicating with us by email or text you are consenting to email and texting communications that may not be encrypted. As well voicemail or answering machine messages may be intercepted by others. Therefore, you are agreeing to accept the risk that your protected health information may be intercepted by persons not authorized to receive such information when you consent to communicating with us through phone, voicemail, email or text. Suffolk Family Therapy LCSW P.C. will not be responsible for any privacy or security breaches that may occur through voicemail, email or text communications that you have consented to. You may choose to limit the type of voicemail, email or text communication you have with us if you wish to limit your risk of exposing your protected health information to unauthorized persons. Please indicate below what types of correspondence you consent to receive by email or text. Do you consent to any voicemail, emial, or texting communication? *EmailTextVoicemailI do not consentEmail address you are consenting to communicate through:Home number you are consenting to communicate through:Cell Number(s) you are consenting to communicate through:No Show, Late Cancellation and Co-payment Policy1. I understand that I will be charged a LATE CANCELLATION fee of the full session fee if I fail to give at least 24 hour notice prior to cancelling my appointment. 2. I understand that I will be charged a NO-SHOW fee of the full session fee if I fail to show for my appointment. 3. I understand that I am responsible for knowing my co-payment amount and deductible amount. 4. I understand that I will be charged a $15 service charge if I fail to make my payment and/or co-payment at the time of my appointment. 5. I understand that these charges are an out of pocket expense and that my insurance carrier will not cover these charges. 6. I understand that the therapy session will last 45 minutes. I understand that if I am late to the appointment, I will still have to end the session at the allotted time. 7. I understand that if I miss 2 or more scheduled appointments in a 30 day period my case will be reviewed for discharged and I may be discharged from the practice. By signing this, I am agreeing to the above stated terms and stipulations regarding the services I receive from this therapist.I authorize Suffolk Family Therapy LCSW P.C. to charge my credit/debit/health account card for professional services 24 hour before my appointment for copays or direct session fees. If I do not cancel before 24 hours, I recognize that Suffolk Family Therapy LCSW, P.C. will charge my card as a late cancel or no show if I do not show up for the appointment. I will be billed my full session fee for late cancel or no show fees. I verify that my credit card information, provided above, is accurate to the best of my knowledge. If this information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied. I also understand by signing and initialing this form that if no payment has been made by me, my balance will go to collections if another alternative payment is not made within thirty days. Client Name *FirstMiddleLastName on card if different than client *FirstLastCard NumberExpiration Date:CVC:Address:Patient or Authorized Guardian Signature: *Clear SignatureHealth Insurance Claim FormEmergency Contact Name *FirstLastEmergency Contact Relationship to PatientEmergency Contact Phone Number(s)Insurance FormPrimary Insurance InformationInsurance Company Name *Insurance ID *Group IDInsurance Provider Phone Number *Insured's Name (Person insurance is under) *Insured's Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsured's Date of Birth (MM/DD/YYYY) *Secondary Insurance InformationInsurance Company NameInsurance ID Group ID Insurance Provider Phone Number Insured's Name (Person insurance is under) Insured's AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsured's Date of Birth (MM/DD/YYYY) Signature *Clear SignaturePatient’s or Authorized Person’s Signature: I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment claims related to medial services provided.INFORMED CONSENT TO INDIVIDUAL & FAMILY PSYCHOTHERAPYThis form documents that WE,give our consent to Suffolk Family Therapy LCSW P.C. to provide psychotherapeutic treatment to myself and my family. While we expect benefits from treatment, we fully understand that no particular outcome can be guaranteed. We understand that we are free to discontinue treatment at any time but that it would be best to discuss with the psychotherapist any plans to end therapy before doing so. we have fully discussed with the psychotherapist what is involved in psychotherapy and we understand and agree to the policies about scheduling, fees and missed appointments. We understand that we are fully financially responsible for treatment. We understand that the frequency of our sessions will be weekly that we are fully responsible for payment at time of session, and that we will be responsible for payment in full for any cancellation. Our discussion about therapy has included the psychotherapist’s evaluation and diagnostic formulation of our problems, the method of treatment, goals and length of treatment, and information about record keeping. We have been informed about and understand the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment. We understand that therapy can sometimes cause upsetting feelings to emerge, that we may feel worse temporarily before feeling better, and that we may experience distress caused by changes we may decide to make in our lives as a result of therapy. We understand that the psychotherapist cannot provide emergency services. The psychotherapist has told me whom to call if an emergency arises and the psychotherapist is unavailable. In any cases. we understand that in any emergency, we may call 911 or go to the nearest hospital emergency room. I understand that information about psychotherapy is almost always kept confidential by the psychotherapist and not revealed to others unless I give my consent. There are few exceptions as follows: The psychotherapist is required by law to report suspected child abuse or neglect to the proper authorities. The psychotherapist is also mandated to report authorities patients who are at imminent risk of harming themselves or others for the purpose of those authorities checking to see whether such patients are owners of firearms, and if they are or apply to be, then limiting possibly removing their ability to possess them. If anyone tells the psychotherapist that they intend to harm another person, the psychotherapist must try to protect that person, including by telling the police or person or other health care providers. Similarly, if anyone threatens to harm themselves, or their life or health is in any immediate danger, the psychotherapist will try to protect them, including by telling others such as relatives or the police or other health care providers, who can assist in protecting or assisting them. If my family is involved in certain court proceedings the psychotherapist may be required by law to reveal information about my treatment. These situations include child custody disputes, vases where therapy patient’s psychological condition is an issue, lawsuits or formal complaints against the psychotherapist, civil commitment hearings, and court-related treatment. The psychotherapist may consult with other psychotherapists about my treatment, but in doing so will not reveal my name or other information that might identify me. Further, when the psychotherapist is away or unavailable, another psychotherapist might answer calls and so will need to have some information about my treatment. If my account with the psychotherapist becomes overdue and we do not pay the amount due or work out a payment plan, the psychotherapist will reveal a limited amount of information about my treatment in taking legal measures to be paid. This information will include my name, social security number, address, dates and type of treatment and the amount due. In all of the situations described above we understand that the psychotherapist will try to discuss the situation with me, or notify me before any confidential information is revealed, and will reveal only the least amount of information that is necessary. We understand that we have a right to ask the psychotherapist about the psychotherapist’s training and qualifications and about where to file complaints about the psychotherapist’s professional conduct. By signing below we are indicating that we have read and understood this form and that we give our consent to treatment. *Please InitialPARENT/PARTNER 1 Signature *Clear SignaturePARENT/PARTNER 1 Name *FirstLastPARENT/PARTNER 2 Signature *Clear SignaturePARENT/PARTNER 2 Name *FirstLastDate / Time *DateTimeSubmit
