Intake Child SP

Patient Name *

First

Middle

Last

Patient Phone Number *

Are you currently seeing more than one medical health specalist?

(If yes) Please list

When was your last physical?

Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabeties, etc.)

Are you currently on medication to manage a physical health concern? If yes, please list:

Are you having problems with your sleep habits?

Others

How many times per week do you exercise?

Approximately how long each time?

Are you having any difficulty with appetite or eating habits?

(If yes) Check where applicable:

Eating less
Eating more
Bingeing
Restricting

Have you experienced significant weight change in the last 2 months?

Do you regularly use alcohol?

In a typical month, how often do you have 4 or more drinks in a 24 hour period?

How often do you engage in recreational drug use?

Daily
Weekly
Rarely
Never

Do you smoke cigarettes or any other tobacco products?

Have you had suicidal thoughts recently?

Frequently
Sometimes
Rarely
Never

Have you had them in the past?

Frequently
Sometimes
Rarely
Never

Have you ever been arrested or had legal difficulties?

Are you currently in a romantic relationship?

(If yes) How long have you been in this relationship?

On a scale of 1-10 (10 being the highest quality), how would you rate your current relationship?

Selected Value: 0

In the last year, have you experienced any significant life changes or stressors? If yes, please explain:

Have you ever experienced any of the following?

Physical Abuse *

Emotional Abuse *

Sexual Abuse *

Extreme depressed mood *

Dramatic mood swings *

Rapid Speech *

Extreme Anxiety *

Panic Attacks *

Phobias *

Sleep Disturbances *

Hallucinations *

Unexplained losses of time *

Unexplained memory lapses *

Alcohol / Substance abuse *

Eating Disorder *

Body image problems *

Repetitive thoughts (e.g. obsessions) *

Homicidal thoughts *

If yes please describe below:

Suicide attempts

If yes please describe below:

Psychiatric hospitalizations *

If yes please describe below:

Self-injurious behavior *

If yes please describe below:

Developmental Delays *

If yes please describe below

Occupational Information

Are you currently employed? *

(If yes) Who is your current employer / position?

If yes, are you happy with your position?

Please list any work-related stressors, if any

Educational Information

Is the client currently attending school? *

Name of School

Grade

Major

Level of Education Completed *

Does the client have an IEP or 504? *

Religious / Spiritual Information

Do you consider yourself to be religious? *

(If yes) What is your faith?

(If no) Do you consider yourself to be spiritual?

Marital Information

Marital Status *

Single
Married
Divorced
Widowed

Date of Union

Date of Separation (if applicable)

Family Composition

Family Member - Age - Date of Birth - Relationship *

Family health or substance abuse concerns? *

If yes - Family Member & Diagnostics / Difficulty

Other Information

Have there been any significant events in the household environment in the last year? (For example: births, deaths, divorces, adoptions, pregnancy, change in employment/occupation, job loss, remarriage, miscarriage)

What do you consider to be your strengths?

What do you like most about yourself?

What are effective coping strategies that you have learned?

What are your goals for therapy?

Consent For Communication

Patients/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? *

Email
Text
Voicemail
I do not consent

Email 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 Policy

1. 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.

Patient or Authorized Guardian Signature: *

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 *

First

Middle

Last

Name on card if different than client *

First

Last

Card Number *

Expiration Date: *

CVC: *

Address: *

Patient or Authorized Guardian Signature: *

Health Insurance Claim Form

Patient Name *

First

Middle

Last

Patient Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth (MM/DD/YYYY) *

Patient Marital Staus

Emergency Contact Name *

First

Last

Emergency Contact Relationship to Patient

Emergency Contact Phone Number(s)

Self Pay Agreement:

By signing the form below, you state your understanding of the following information: The fee for individual counseling is

for 45 minutes. Your fee will be charged to your credit card within 24- hours of your appointment. If you do not have the fee at the end of the session, there will be only one follow-up session scheduled until payment is received. The fees associated with counseling are your responsibility. Refunds are not available. If you are unable to make an appointment, 24-hour notice is required. If you do not give 24- hour notice, full fee will be assessed. If you do not show for an appointment, full fee will be assessed. Services may be terminated at any time, for any reason by either client or therapist. I may refer you to another provider. It is your responsibility to arrange an appointment with that provider. *

Please Initial

Signature *

Patient’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 PSYCHOTHERAPY

This form documents that we (the parents), *

give our consent and agreement to Suffolk Family Therapy LCSW PC and it's associated counselors to provide psychotherapeutic treatment to our child, *

and to include us, the parents, as necessary, as adjuncts in the child’s treatment. While the parents can expect benefits from this treatment for the child, they fully understand that no particular outcome can be guaranteed. The parents understand that they are free to discontinue treatment of the child at any time but that it would be best to discuss with the psychotherapist any plans to end therapy before doing so. The parents have fully discussed with the psychotherapist what is involved in psychotherapy and understand and agree to the policies about scheduling, fees and missed appointments. The discussion about therapy has included the psychotherapist’s evaluation and diagnostic formulation of the child’s problems, the method of treatment, goals and length of treatment, and information about record-keeping. The parents have been informed about and understand the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment. The parents understand that therapy can sometimes cause upsetting feelings to emerge, and that the child’s problems may worsen temporarily before improving. The parents understand that the psychotherapist cannot provide emergency services. The psychotherapist has told the parents whom to call if an emergency arises and the psychotherapist is unavailable. The parents understand that information about psychotherapy is almost always kept confidential by the psychotherapist and not revealed to others besides the parents unless a parent authorizes such release. There are few exceptions as follows: 1. 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. 2. If a child tells the psychotherapist that he or she 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 the child threatens to harm him or herself, or a child’s life or health is in any immediate danger, the psychotherapist will try to protect the child, including, as necessary, by telling the police or other health care providers, who may be able to assist in protecting the child. 3. If a child is involved in certain court proceedings the psychotherapist may be required by law to reveal information about the child’s 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. 4. If the parents’ and child’s health insurance or managed care plan will be reimbursing me or paying the psychotherapist directly, they will require that confidentiality be waived and that the psychotherapist give them information about the child’s treatment. 5. The psychotherapist may consult with other healthcare professionals about the child’s treatment, but in doing so will not reveal the child’s name or other information that might identify the child, unless specific consent to do so is obtained from the parent. Further, when the psychotherapist is away or unavailable, another psychotherapist might answer calls and so will need to have some information about the child’s treatment. 6. If an account with the psychotherapist becomes overdue and responsible parties do not work out a payment plan, the psychotherapist will reveal a limited amount of information about a patient’s treatment in taking legal measures to be paid. This would include the child’s and parents’ names, social security number, address, dates and type of treatment and the amount due. In all of the situations described above the psychotherapist will try to discuss the situation with a parent before any confidential information is revealed, and will reveal only the least amount of information that is necessary. The parents, as legal guardians of the child, have rights to general information about what takes place in the child’s therapy, to information about the child’s progress in therapy, to information about any dangers the child might present to self or others, and, upon request, to obtain copies of the child’s treatment record (with certain qualifications and exceptions). The parents understand that it is usually best not to ask for specific information about what was said in therapy sessions because this might break the trust between the child and the psychotherapist, especially for children over the age of 12. The parents agree that in the event custody of, or visitation with, the child is contested in a legal proceeding, neither the parents nor their attorneys will require the psychotherapist to testify at any proceedings, because to do so would hurt the child’s treatment, because the psychotherapist’s role is a therapeutic and not evaluative one, and because other forensic professionals would be better able and more appropriate to conduct any necessary evaluation. Because of these limitations, the psychotherapist also will not be able to give any opinion regarding custody, visitation or any other legal issue. If such a proceeding does occur, the parents agree that the psychotherapist’s role will be limited to providing to a mental health professional appointed to perform such an evaluation, and/or to the attorneys, law guardian, if any, and the judge involved in the legal proceeding, written information regarding, and/or the record of, the child’ treatment; the psychotherapist will provide these either as required by law or upon the authorization of either parent. The psychotherapist has explained to the parents that children with two parents have the best chance to benefit from therapy if both parents are involved and cooperate with each other and the psychotherapist. If both of a child’s parents are consenting to therapy: *Each of us agrees that he or she will not end the child’s therapy without the agreement of the other parent, and that if we disagree about the child’s continuing in therapy, we will try to come to an agreement, by counseling if necessary, before ending the child’s therapy. *We each agree to cooperate with the treatment plan of the psychotherapist for the child and understand that without mutual cooperation, the psychotherapist may not be able to act in the child’s best interests and may have to end therapy. *We agree that each of us has and shall continue to have the right to information about the child’s treatment and the treatment records of the psychotherapist regarding the child, and agree that the psychotherapist may release information or records to either of us without any additional authorization of the other. If the parents and child are participating in a managed care plan, the parents have discussed with the psychotherapist their financial responsibility of co-payments, and the plan’s limits on the number of therapy sessions. If the parents are not participating in a managed care program, they understand that they are fully responsible for treatment, including any portion of fees not reimbursed by health insurance. The psychotherapist has also discussed options for continuation of treatment when managed care or health insurance benefits end. The parents understand that I 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 the parents are indicating that they have read and understood this agreement, that they give consent to the psychotherapist’s treatment of the child, and that they have the proper legal status to give consent to therapy for the child. *

Please Initial

Signature *

Date / Time *

Date

Time

Have you ever experienced any of the following?

Occupational Information

Educational Information

Religious / Spiritual Information

Marital Information

Family Composition

Other Information

Consent For Communication

No Show, Late Cancellation and Co-payment Policy

Health Insurance Claim Form

Self Pay Agreement:

INFORMED CONSENT TO INDIVIDUAL PSYCHOTHERAPY

Contact

Call: 631-503-1539

4109 Sunrise Highway Bohemia, New York 11716