Ackerman Institute's Intake Packet

Welcome to the Ackerman Institute for the Family! We know families come to Ackerman to find solutions for many kinds of challenges. Our goal is to always help you address your concerns. We are committed to a diverse, equitable, and inclusive community.

Therapy is provided by mental health professionals on the Ackerman faculty and by therapists in the postgraduate training program at Ackerman. Our faculty and therapists are people of diverse cultural backgrounds and identities, inclusive of race, gender, ethnicity, sexual orientation, countries of origin, and abilities.

Appointments
When you make an appointment with a therapist, that time is set aside for your family. Your therapist will make every effort to begin your appointment on time. Please observe the same courtesy and arrive on time or early. If you are arriving after your scheduled time please call us. If you need to cancel please call us no less than 24 hours in advance at 212-879-4900 x100.

Missing appointments without calling to cancel means your therapist cannot use that time to see another family. Therefore, if your appointment is not cancelled at least 24 hours in advance, you will be charged for the session. Please note some insurance companies will not reimburse you for missed sessions.

If your family is unable to schedule and keep three consecutive appointments, it suggests that treatment is not a good fit at this time, and treatment will end. We want to work with your family, so please come at or before your scheduled time. If you are arriving after your scheduled appointment time or need to cancel, notify us ahead of time.

If your therapist provides their email address or cell phone number, texting and emailing your therapist is used solely for scheduling purposes.

Treatment
We use a few different tools to ensure that families and couples are receiving the best service. Sessions are recorded so your therapist can review them in between appointments. This will be explained in more detail at your intake appointment, where you will be asked to sign a consent form. Your therapist will also review this information with you again. A one-way mirror is used for supervisory sessions. It allows for the therapist’s supervisor and their colleagues on the supervision team, who are behind the mirror, to provide feedback during the session.

Recording of therapy sessions and live supervision is required.

Clinic Hours
The clinic is open Mon-Fri: 9 AM to 9 PM and Sat: 9 AM to 5 PM. If there is an emergency after operating hours, call the Ackerman main number at 212-879-4900 and follow the prompts to reach our after-hours emergency service and your therapist. .

Payment Payment for therapy is due before each appointment and can be made with the receptionist. We accept credit cards (Visa, Master Card, and American Express), checks, and cash. Please have your payment ready when you arrive.

Please let us know immediately if your insurance changes. Without such notification payment for your sessions will become your responsibility.

Insurance For private insurance show your card during the first visit and inform the front desk if it changes. For state program insurances, bring your card at every visit.

Thank you for choosing the Ackerman Institute for the Family!

Payment
Payment for therapy is due before each appointment and can be made with the receptionist. We accept credit cards (Visa, Master Card, and American Express), checks, and cash. Please have your payment ready when you arrive.

Insurance
Please let us know immediately if your insurance changes. Without such notification payment for your sessions will become your responsibility.

For private insurance show your card during the first visit and inform the front desk if it changes. For state program insurances, bring your card at every visit.

Signature Section Collapse Hidden
Thank you for choosing the Ackerman Institute for the Family!

Each consenting adult must sign below that they have read the Ackerman Institute for the Family’s terms outlined above regarding appointments, treatment, clinic hours, payment, and insurance.

I agree and accept the terms of this letter.
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Each consenting adult must sign that they have read the terms. Do you need more signature space?

YesNo

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Please use the tabs at the top to navigate through this intake packet. All required fields must be completed before final submission.
HEALTH SCREENING REPORTS

Each participating member must fill out their own Health Screening Report. If there are members who are not of consenting age an adult may fill out the form on their behalf. Four Health Screening Reports have been provided, if you need more please connect with Intake. If at any point you need to stop you may click save at the bottom and return at a later point.

Health Screening Report 1
Legal Name:*
Age*
Birth Date*

MonthDayYear
Preferred Name:*
Preferred Pronoun*

sheheother, please write below
If selected other write your preferred pronoun here
Sex Assigned at Birth*

femalemaleintersex
Gender Identity*

girl / womanboy / mantransgenderother, please write below
If selected other write how you identify
Date of last physical exam:*

MonthDayYear
Allergies to any medications?*

NoYes, [If Yes, please describe below]
What medications are you allergic to?
Are you currently taking any medications - prescribed, over the counter or herbal?*

NoYes

Any physical symptoms such as change in appetite, change in energy level, rapid heartbeat, and sleep difficulties?*

NoYes
If Yes, to physical symptoms please describe
Do you exercise?*

NoYes
If Yes to the above question please describe how much, how often
Do you drink tea or coffee?*

NoYes
If Yes to the above question please describe how much, how often
Do you smoke cigarettes?*

NoYes
If Yes to the above question please describe how much, how often
Do you drink alcohol?*

NoYes
If Yes to the above question please describe how much, how often
Do you use any other substances*

NoYes
If Yes to the above question please describe how much, how often

Have you ever...*

	No	Yes
Thought you should cut down on drinking or drug use?
Become annoyed when people criticized your drinking or drug use?
Felt bad or guilty about your drinking or drug use?
Needed an eye-opener (drink or drugs first thing in the morning) to feel better?

Has smoking, drinking or drug use ever interfered with your relationships?*

NoYes
If Yes, please describe in what ways drinking or drugs have interfered
Medical History Health Screening Report Continued.

Please indicate below if you, or anyone in your family (parents, brothers, or sisters) have a history of any of the following

	Myself	Family Member (please indicate if parents, brothers or sisters)
Heart disease
High blood pressure
High cholesterol
Mental illness
Ulcers
Colitis
Allergies/Asthma/Hay Fever
Cancer/Tumor
Stroke
Diabetes
Arthritis
AIDS/HIV
Sexually transmitted disease
Seizures/Epilepsy
Anemia
Fainting Spells
Head injury
Migraine/Tension
Drug/Alcohol abuse
Accidents
Surgery
For Children: Developmental delays
For Children: Learning Disabilities

For any other applicable conditions type them here
Can be either yourself or a family member

MENTAL HEALTH SCREENING FORM
Currently, are you or any one of your family members who plan on participating in couple/family therapy receiving additional therapy? (i.e. individual, group, couple, family, AA/NA, anger management, art/play therapy, OT...)*

If none please check this boxYes, please explain below

If YES, use these rows to explain.*

	Family Member Name	Type of Treatment	Start Date	Provider Name	Private/ Agency	Provider Contact
1
2
3
4

Currently, do you or any of your family members who plan on participating in couple/family therapy, have a diagnosis or symptoms where medication has been suggested and/or prescribed?*

If none please check this boxYes, please explain below

If YES, use these rows to explain*

	Family Member Name	Diagnosis/Symptoms	Overseeing Provider	Provider Contact
1
2
3
4

Currently, what medications are being prescribed for the diagnosis/symptoms?*

	Family Member Name	Medications, Dosages	Side Effects, if Any
1
2
3
4

In the PAST, have you or any of your family members who plan on participating in couple/family therapy ever been in any type of therapy?*

If none please check this boxYes, please explain below

If YES, use the rows below to explain.*

	Family Member Name	Type of Treatment	Dates Attended
1
2
3
4

In the PAST, have you or any of your family members who plan on participating in couple/family therapy ever been psychiatrically hospitalized?*

If not please check this boxYes, please explain below

If YES, please describe in the rows below*

	Family Member Name	Date, Length of Stay	Reason for Hospitalization	Hospital Name	Discharge Plan
1
2
3
4

Is there anything important or significant from your current or past treatment experience(s) that you believe is relevant to your couple/family therapy here at Ackerman? Please use this space to complete this and any other responses.

Telepractice Consent Form
Telepractice involves the use of electronic communication to enable Ackerman Institute for the Family clinicians to provide Family and Couple sessions from a host location (936 Broadway, 2nd Fl. New York, NY 10010) or secure locations for the purpose of providing mental health services.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient information.

By signing this form, I understand the following:
1. I understand that the laws that protect privacy and the confidentiality of behavioral health information (42CFR) also apply to telepractice, and no information obtained in the use of telepractice which identifies me will be disclosed to other entities without my consent.
2. I understand telepractice is a means of service delivery for engaging with my provider for mental health counseling.
3. Ackerman Institute for the Family personnel has explained to me how the video conferencing technology will be used.
4. I understand that my behavioral health information may be shared with other personnel for scheduling and billing purposes.
5. I understand that Ackerman Institute for the Family is not responsible for managing or maintaining confidentiality of the participant’s location where they are receiving telepractice services.
6. I understand that it is my responsibility to inform my Ackerman therapist if there are any issues with my technology that may disrupt or interrupt services.
7. I have had telepractice explained to me. The possible risks of utilizing telepractice have been explained to me. These risks may include:
  1. In rare cases, information transmitted may not be sufficient (e.g. poor connection) to continue a session once started.
  2. Security protocols could fail, causing a breach of privacy of personal information.
  3. Receiver of services session may be interrupted because their location becomes non-confidential and a new location is required.
8. I understand that I have the right to withdraw my consent to the use of telepractice in the course of my care at any time, without affecting my right to future care or treatment.
I have read and understand the information provided above regarding telepractice, have discussed it with my therapist and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telepractice in my mental health counseling.
Signature*

Clear
Date*

MonthDayYear
Date
Name*
Signature

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Date

MonthDayYear
Date
Name*
Each consenting adult must sign that they have read the terms. Do you need more signature space?

YesNo

General Consent for Treatment, Recording and Use of Recorded Materials
The Ackerman Institute is a mental health clinic and teaching institution, which records each session as part of the teaching process. Recorded materials are used by therapists and supervisors to review treatment. Recorded materials are erased after their use and are not part of the medical record.

I (we) the undersigned consent to the treatment and video recording of sessions of myself (ourselves) and/or my (our) children.

I (we) understand to revoke this consent, I must by write a letter to the Medical Director of the Ackerman Institute.

Please have all participating family members sign below:
Family Name(s)
Signature*

Clear
Name*
Date*

MonthDayYear
Date
Signature

Clear
Name
Date

MonthDayYear
Date
Each consenting adult must sign that they have read the terms. Do you need more signature space?

YesNo

Notice of Privacy Practices
This is to verify that we were given a Notice of Privacy Practices at the Ackerman Institute for the Family. Distribution of this notice is a requirement of HIPPA, the Health Insurance Portability and Accountability Act. The Notice of Privacy Practices describes how medical information about us may be used and disclosed, and how we can get access to our medical information, if we so desire.

We also understand that if we desire our treatment record, that it is the Ackerman Institute for the Family’s policy that every adult member seen in treatment must sign a release of information. Without all signatures the record cannot be released.

If you have any questions about this Privacy Notice, you can call Dr. Adi Loebl, Privacy Officer at the Ackerman Institute for the Family, 212-879-4900, Extension 141.

You may download the below Notice of Privacy Practices to review before signing.
All consenting adults must sign below after reviewing the included Notice of Privacy Practices.
Family Name(s)
Signature*

Clear
Name*
Date*

MonthDayYear
Date
Signature

Clear
Name
Date

MonthDayYear
Date
Each consenting adult must sign that they have read the terms. Do you need more signature space?

YesNo

Insurance Payment Policy
Thank you for choosing the Ackerman Institute for the Family. We are committed to providing you with the best possible treatment. We would like to inform you of our insurance policy. We ask that you please read and sign this agreement.

Insurance: Our office will bill your insurance company for the services rendered. We cannot successfully bill your insurance company unless you give us the correct insurance information. Please understand that your medical insurance is a contract between you and your insurance company. We are not party to that contract and therefore, your bill is ultimately your responsibility whether your insurance company pays or not. If your insurance company has not paid your account in full within 30 business days, it will then become your responsibility to pay the balance.

Insurance Payments: In the event your insurance company pays you directly for the services your family received at the Ackerman Institute for the Family, you agree to return all such payments to the Ackerman Institute for the Family upon receipt. You also understand that by failing to forward such payments to the Ackerman Institute for the Family, you may be guilty of committing insurance fraud or violating other federal, state, or local laws.

Co-payments, deductibles and fees: All co-payments, insurance deductibles and fees for services not covered by your insurance policy are due at the time service is rendered. The co-pay cannot be waived, as it is a requirement placed on you by your insurance company.

Payment: We accept cash, credit cards and personal checks.

I understand the Ackerman Institute for the Family's insurance policy and by signing I agree to the terms. Clients who are not using insurance please sign as well.
If you are not using insurance please write "not using insurance" in the field below.
Signature*

Clear
Full Name*
Date*

MonthDayYear
Date

Should be Empty:

	Medication Name:	Dosage:	For what condition:	Side effects: (if any)
1
2
3
4

	Medication Name:	Dosage:	For what condition:	Side effects: (if any)
1
2
3
4

	Medication Name:	Dosage:	For what condition:	Side effects: (if any)
1
2
3
4

	Medication Name:	Dosage:	For what condition:	Side effects: (if any)
1
2
3
4

	Yes	No
Heroin
Methadone
Buprenorphine
Morphine
MS CONTIN
OxyContin
Oxycodone
Other opioid analgesics (Vicodine, Darvocetm etc)

HEALTH SCREENING REPORTS

Medical History Health Screening Report Continued.

Medical History Health Screening Report Continued.

Medical History Health Screening Report Continued.

Medical History Health Screening Report Continued.

MENTAL HEALTH SCREENING FORM

Rapid Opioid Dependence Screen (RODS)

Telepractice Consent Form

General Consent for Treatment, Recording and Use of Recorded Materials

Notice of Privacy Practices

Insurance Payment Policy