INTAKE PACKAGE FOR ADULTS

INTAKE PACKAGE (ADULTS)
I. Sociodemographic Information:
Client name:
Age:
Date of Birth:

MonthDayYear
Date
Education:
Gender:

FM
Status:

MarriedDivorceSeparatedSingle Occupation:
Occupation:
Contact Person / Telephone
Home Address:
Telephone:
Language (s) used at home: Primary and Secondary
Email
Reason for referral: Why do you seek mental health services? What's your main concerns and who referred you?
How did you hear about us?
Person filling out form & relationship with patient ( if different)
II. Family History:
Family Member full Name:
Age:
Home address (if different from client):
Occupation:
Preferred language:
Home phone:
E mail address:
example@example.com
Business phone:
Cell phone:
RELATIONSHIP: Husband/friend/significant other/girlfriend/boyfriend/Guardian/OTHER
(2) Other family member/s full
Name:
Age:
Home address (if different from patient's)
Occupation:
Preferred language:
Home phone:
E mail address:
example@example.com
Business phone:
Cell phone:
Parents name. If parents are deceased, please explain here:
Family Composition (biological and/ or incidental):
Name / Age / Relationship
III Family history of medical conditions:

Condition / Family Member
Psychosis (hallucinations, schizophrenia, distortion)
Suicide / Family Member
Depression / Family Member
Anxiety / Family Member
Mental Deficiency / Family Member
Hyperactivity / Family Member
Learning Problems / Family Member
Epilepsy and / or convulsion / Family Member
Conduct problems / Family Member
Neurological and/ or neurodevelopmental problems / Any Family Member had them?
Alcoholism / Family Member
Drug abuse / dependency / Family Member
Cancer history / Family Member
Cardiovascular / Family Member
Diabetes / Family Member
Hypoglycemic / Family Member
Thyroid / Family Member
Violence induced trauma/ Family Member
Explain any Other
IV. Development History
(any important remarks):
Sleep habits

Does the patient get up many times in the night?SometimesSleep all night
Current conditions/ Age at time of diagnosis / Doctor
Current Medication / Dosage / Physician / Purpose
Do any of these medications affect your behavior? Explain the effects.
Other medical or physical problems

Diagnoses Yes or No / Description
Gastrointestinal problems
Allergies
Ear infections
Sinus Infections
Headaches
Other
Communication Skills
How do you usually communicate your needs? ( check all that apply)
What in home activities do you like? ( physical, sports, art, music, food, series, movies etc.).
Do you have a support system?
Religion or spiritual believes?
Do you smoke

YesNo
If yes, how often:
Do you drink alcohol:

YesNo
Explain, if yes:
Any illegal drugs use

YesNo
Explain if yes:
Any Fears

YesNo
Explain, if yes
Nail biting

YesNo
Explain, if yes
Pulling or stripping of hair (head, eyebrows)

YesNo
Explain, if yes
Self-inflicted injurious (hits, cuts, bites)

YesNo
Explain, if yes
(hits, cuts, bites)
Other

YesNo
Explain, if yes
How do you manage stress? ( last episode frequency)
How do you deal with sadness? How often do you feel sad?
How do you manage anger? How often do you feel angry?
V. Psychological and psychiatric history
Have you ever had a psychological and /or psychiatric intervention? (reason, date, name of the professional, agency, institution, or hospital. If you have an existing psychiatric, psychological, psychometric, and/or neurological testing, please include.
VI. Social-Legal information:
Do you have any legal issues right now?

YesNo
Any pending criminal case:

YesNo
ADA assign:
Criminal #
Next court date
Any civil case: Case number:

YesNo
Case number:
Next court date

MonthDayYear
Date
Lawyer's Name (if apply)
Court
Assigned Judge
VII. Sexual History
Have you been sexually active, had previous relations, sexual developmental issues or trauma?
VIII. Trauma History
IX. Medical History

Patient History / Interview
History of medical conditions, hospitalizations, dates, professional.
Surgery history, dates, complications, use of anesthesia.
Accidents, fractures, when, how it happened, what part of the body was affected, results.
Food or medication allergies, reaction, management.
Substance use (tobacco, alcohol, drugs), past and present experiences.
Do you go to the bathroom regularly (gastric movements) , consistency, frequency, pain, what makes it better.
Nutritional habits (how much water, fruits, vegetables intake)
Name of person filling form and relation to patient
DATE OF COMPLETITION:

MonthDayYear
Date
Dr. Carmen C. Capella PY10124 DATE OF COMPLETITION:
Office Hours: M-F, 9:00am-6pm
PSYCHOLOGICAL SERVICES AGREEMENT (ADULTS)
Client name:
I, _______(clients name / or legal guardian or representative)
I am giving my consent to receive services at Behavioral Mind & Wellness (BMW). I certified that have been oriented about the followings aspects:
Date of birth

MonthDayYear
Date
1. (initial) My information, conditions and treatment are confidential, unless my emotional/ physical safety or another person is at risk.*
Please initial
2.(initial) I voluntarily consent to receive services / treatment, understanding I may retract my consent at any moment without penalty. If I decide to do so , it must be done in writing. *
Please initial
3. (initial) Individual therapy will last 45 minutes, couple therapy an hour, family therapy 50 minutes and group therapy two hours. Psychological and psychometric assessment services duration will be decided by the professional.*
Please initial
4. (initial) There will be no social meetings or interaction between the psychologist and me. I understand the interaction between the psychologist and me is strictly and exclusively professional.*
Please initial
5. (initial) Clinicians are not allow to accept gifts from patients. The best & only gift we can get is your personal improvement. *
Please initial
6. (initial) I understand I must be on time to every scheduled appointments or my appointment will be re-schedule. Cancelations must be informed 24 hours prior to appointment.*
Please initial
Client's Name
I hereby certify my clinician and BMW have explained in simple language, the benefits and risks of taking or not taking mental health services/treatment, including the material risks, benefits and other alternatives. PLEASE SIGN THIS BOX SO THIS DOCUMENT CAN BE SUCCESSFULLY SUBMITTED.
Clients Signature*

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Date

MonthDayYear
Date
Office Hours: M-F, 9:00am-6pm
Consent to Release Information
Client name:
I authorize Behavioral Mind Wellness: Evaluation, Prevention & Treatment, LLC.415 W Vine St. Kissimmee, FL 34741
Date of Birth:

MonthDayYear
Date
Agency/Contact:
To Exchange confidential information concerning the above-named client with the following:
Mailing address:
City, State, Zip:
Phone/Fax:
Email:
example@example.com
I authorize:

□ Informal communication regarding all client information between both parties.
AND/OR
(Check which documents are authorized to be released)

□ Copies of the following documents to be mailed/faxed to the agency listed above.□ Limited verbal communication (no copies) related only to the following records.
Psychosocial Evaluation

□ Bio□ Psychiatric Evaluation□ Report Cards / Transcripts□ Diagnosis□ Medication Management□ Behavioral Programs□ Treatment Plan/Reviews□ Medical History & Physical□ Individual Education Plan□ Progress Summary□ Immunization Records□ Discharge Review□ Lab Results□ Other:
Purpose of Release:
* I understand I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment from Behavioral Mind Wellness. * I understand that if am court-ordered into treatment and refuse to allow BMW to share information with those responsible for monitoring my compliance, this may result in negative consequences imposed by the court. * I understand that I may revoke this authorization in writing at any time; however, I cannot revoke authorization for actions already taken. * A copy of this release shall be as valid as the original.

□ Assessment□ Treatment Coordination□ Other, specify:□ Notification of compliance with court-ordered treatment (e.g. DCF, DJJ)
THIS CONSENT EXPIRES 1 YEAR FROM DATE SIGNED UNLESS OTHERWISE SPECIFIED.
Client/Legal Guardian Signature. PLEASE SIGN THIS BOX SO THIS DOCUMENT CAN BE SUCCESSFULLY SUBMITTED.*

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Date

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Date
Office Hours: M-F, 9:00am-6pm
Intake Consent & Orientation
Client name:
Date of birth:

MonthDayYear
Date
(initial) HEALTH & SAFETY: I received a copy of the Health & Safety pamphlet, which content was explained to me.*
(initial) CLIENT'S RIGHTS: I have received a copy of the Client's Rights pamphlet, which content was explained to me*
(initial) CONFIDENTIALITY/PRIVACY: I understand all client's information is private, and it will not be shared without my consent, except if one of the following happens: - BMW must report any suspicion of abuse or negligence toward a child/elderly/incapacitated adult. - BMW must provide information in case of an abuse/negligence investigation. - BMW may warn potential victims when a professional understands their life might be in danger. BMW must provide copy of your record and testify in court when requested by authorities through a Subpoena *
Even, if I give this consent, BMW only will share the information that is necessary for an assessment, coordinated treatment, notify the person responsible, if it is a mandatory treatment or other purposes as specify on the notification and Release of information consent.
(initial) AUTHORIZATION OF CONSENT: I certify I have the legal authorization to consent to a mental health treatment, divulge information and/or any legal situation related to the client. If my status as legal guardian (in case of a minor or incapacitated client) changes, I will immediately notify BMW the name, address and phone number of the new legal guardian appointed. *
(initial) CONSENT FOR TREATMENT: I give my consent for the client mentioned above to get Behavioral health assessment and treatment at BMW, including sharing relevant confidential information with other professionals working at the same case: □ School personnel (professors, counselors, behavioral specialists, principals, etc. and other professionals. □ Other family members. (spouses, step parents, siblings, grandparents, foster parents, etc. ) □ Other professionals: *
(initial) FUNDING AUTHORIZATION: I authorized BMW to share confidential information with the insurance panels with the purpose of: complying with reclaim process, obtaining compensation and to abide with audits required by them as SOP. *
(initial) PROFESSIONAL EXECUTOR: If your therapist dies or is disable, the assigned professional executor will be in charge of files and contacting patients. *
** I understand that I am responsible for any charges my health insurance will not cover, including any services provided after a denied claim. I understand, I can revoke this consent at any moment, but cannot revoke consent for actions already taken. A copy of this release is as valid as the original.
THIS CONSENT EXPIRES A YEAR AFTER IT WAS SIGNED.
Client signature/Legal guardian. PLEASE SIGN THIS BOX SO THIS DOCUMENT CAN BE SUCCESSFULLY SUBMITTED.*

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Date

MonthDayYear
Office Hours: M-F, 9:00am-6pm
HEALTH & SAFETY
Behavioral Health & Safety Policies:
1. Abuse & neglect: All Behavioral Health staff are legally required to report allegations or suspicion of abuse or neglect of children (age 0-17), elderly, or disabled adults.

2. Danger to self or others: If a Behavioral Health clinician determines that a client or family member is likely to seriously harm him/herself or someone else, the clinician has a responsibility to protect that person and others from harm. In this case, more secure placement, such as hospitalization may be required on an emergency basis.

3. Tobacco: The use of tobacco products is not allowed in our office or office building. Use of tobacco is permitted in designated areas away from the building entrance. Our staff are not allowed to use tobacco products in the presence of clients or their families.

4. Drugs/alcohol: The use of recreational drugs or alcohol prior to or during sessions is not allowed. If a Behavioral Health clinician determines that a client or other person present for the session is under the influence of alcohol or drugs, he/she may decide to cancel the session.

5. Prescription medication: If a legally prescribed medication taken prior to or during a session impairs the ability of a client or other session participant to benefit from treatment, the Behavioral Health clinician may decide to cancel the session.

6. Weapons: Weapons of any kind are not permitted in a Behavioral Health office. During in-home sessions, all firearms must be maintained in a securely locked area.
Behavioral Health Emergency Procedures:
1. Violent or threatening situations: If a client or other person present for a session becomes violent or threatening, your clinician will try to verbally de-escalate him/her. If he/she is unsuccessful and the person continues to present a clear danger, 911 will be called. Our staff is not allowed to restrain clients or anyone else.
2. Medical emergencies: If a medical emergency occurs during a session, your clinician will call 911.
3. Natural disasters: If you or your clinician are aware of an incoming natural disaster (e.g., hurricane, tornado, flood), check the
4. National Weather Service and follow their instructions. When conditions are unsafe to drive, you may need to cancel and reschedule your session. If you are at our office, your clinician will stay at the office with you until it is safe to leave. For home calls, your clinician may need to remain at your home until the weather clears and it is safe to drive again.
5. Power outage: If the electricity in the office goes out for more than 15 minutes, your session will be cancelled and
6. Evacuation: An evacuation diagram with instructions is posted on or beside the exit door. If an evacuation of the office is required, your clinician will guide you out of the building to a safe area.
7. Fire extinguishers & first aid kits
8. necessary for safety (e.g., fire), your clinician will guide you out of the office and to the meeting area (next to the entrance of the parking : There is a fire extinguisher and a first aid kit in each office. Your clinician will know where
Office Hours: M-F, 9:00am-6pm
This document is to inform you about basic ways of staying safe. It also includes information about Behavioral Health safety policies and emergency procedures.

If you have any questions or would like more information please ask your assigned clinician:
Name:
Phone #: (321) 888-6965
If you are in crisis and your clinician is not available, you can call the crisis hotline: (407) 425-2624. In the event of an emergency (danger to self or others), call 911. If you have a question that cannot be answered by your assigned clinician, please contact the Office Manager Astrid A. Martquez for your location: Executive Director: Dra. Carmen C. Capella
Client signature/Legal guardian. PLEASE SIGN THIS BOX SO THIS DOCUMENT CAN BE SUCCESSFULLY SUBMITTED.*

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Date

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CLIENT RIGHTS
This document will let you know what to expect from services you and/or your child will be receiving from Behavioral Mind Wellness, your rights and what to do to make your treatment a success.

If you have any questions, you can contact your Primary Clinician:
Name:
Phone number: (321)888-6965
Complaints/Grievances:
If you have a concern which cannot be resolved by speaking with the staff directly, please contact the Office Manager for your location. The Office Manager will respond to your concern within 2 business days.

If your concern is not resolved by the Manager, you may file a grievance in writing by sending a letter or email to the Executive Director. The Director will contact you by email or phone within 2 business. The matter will be investigated, and resolution reached within 1 week.

Grievances should be sent to Dr. Carmen C. Capella, Executive Director at the address below.
Treatment Philosophy
Client-centered: Together with the clinician, you will determine the goals of therapy and have input into interventions. Building a positive, trusting team between the client/family and the clinician is one of the most important aspects of effective treatment.

Ecological: In addition to helping the individual client learn strategies to resolve his/her situation, we work with your environment to promote healing, growth, and interpersonal relationships. The client’s support system is seen as the key to making the client’s treatment gains last after services end and this is the reason why we recommend they be part of the treatment.

Empowering: Therapy teaches clients and their families valuable skills, which become powewfull tools to keep the autohealing process going.

Evidence-based/Outcome-oriented: We only use treatment approaches that have been proven effective through research. Clinicians continuously evaluate interventions effectiveness and switch strategies as needed to get results.

Efficient:We strive to achieve goals while using the elast amount of resources as possible. This includes minimizing cost to the funder and family for services, as well as designintg interventions that are both cost efficient and energy-efficient (least effort) for the patient/family.
What to Expect:
1. Sessions are scheduled based on your particular needs.
2. Treatment takes usually a year, depending on your motivation and progress.
3. Within the first 2-3 visits, you and your family will work with your clinician to develop a treatment plan, which will list your goals for treatment and ways to reach those goals.
4. Every 3 or 6 months, you, your family, and your clinician will discuss your progress in a Treatment Plan Review, which you (and your parents, if under 18) will sign.
5. At treatment's end you should feel better and should have met the goals set at the beginning of treatment.
6. At the final session, your clinician will make sure you get any services you will need after our treatment ends.
7. Several months after treatment ends, you may be contacted as a follow up.
Your Rights:
1. Respect: You and your family will be treated with respect by all Behavioral Mind Wellness staff.
2. Anti-Discrimination: Your religious and cultural beliefs will be respected. You will not be treated differently based on your age, disability, race, sex, or ethnic group.
3. Freedom of Choice: You have the right to change providers, refuse referrals for other services, or stop services at any time without penalty.
4. Confidentiality/Privacy: You have the right to decide when and with whom to share your private information. Information are exceptions to this rule, including suspected abuse, neglect, or exploitation, if we believe someone’s life is in danger, or if a judge orders it. Information shared in an individual session with a child may have to be shared with a parent, but the clinician will only share information if it is necessary for treatment.
5. Access to Records: You have the right to read and have copies of your chart information in a timely manner.
6. Grievances: If you make a complaint or file a grievance, your services will not be terminated or affected in any way.
7. Freedom from Harm: We are required by law to report any suspected abuse, neglect, or exploitation. If you need to report abuse, neglect, or exploitation, call the Abuse Hotline: 1-800-96-ABUSE (800-962-2873
Your Responsibilities:
1. Attendance: You and/or your family will keep appointments made with the clinician. If you cannot keep an appointment, call your clinician 24 hours in advance to reschedule.
2. Participation: You and/or your family will participate in treatment and will follow through with the strategies agreed upon during treatment sessions. Family sessions are required if school is part of the treatment.
3. Notification: You will inform the clinician of any changes to your address or phone number so we can contact you.
4. Payment: You are responsible for any services, co-payments or deductibles not paid by your insurance.
BMW Rights & Responsibilities:
1. All BMW staff will behave in a trustworthy, considerate, polite, discrete and professional manner.
2. We will provide consistent, high quality treatment. Clinician will notify in advance when running late for an appointment or when session must be cancelled.
3. We will keep an accurate written record of the treatment we provide.
4. We have the right to terminate services if you fail to follow through on your responsibilities (listed above) or if we believe that maximum benefit has been reached.
Client signature/Legal guardian. PLEASE SIGN THIS BOX SO THIS DOCUMENT CAN BE SUCCESSFULLY SUBMITTED.*

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Office Hours: M-F, 9:00am-6pm
No Show/Cancellation Policy
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Regular attendance at scheduled appointments is important. Our services will not be effective in helping you if appointments are not kept. Irregular attendance, especially a “no show”, is also inconvenient and costly to your treatment plan. It is therefore your responsibility to attend all scheduled appointments.

CANCELLATION POLICY: In order to cancel an appointment you should call, at least, 24 hour in advance.
- You will be charged a $95.00 no show fee.
- After the first cancellation, the staff will call you to reschedule.
- After two cancellations, BMW will send you a letter explaining you must call if you wish to continue services.
- After the third cancellation, services will be terminated.
NO SHOW POLICY: If you do not call to cancel, at least 24 hours before the scheduled appointment time, it is considered a no show.
- You will be charged a $95.00 no show fee.
- After the first “No Show”, the staff will call to reschedule the appointment.
- After the second “No Show”, the Administrator will send you a letter notifying services have been suspended and that you are required to pay the fees for both missed sessions to reinstate services.
- After the third “No Show”, your case will be closed.
Court-ordered services, the person responsible for monitoring compliance with the mandate (e.g. dependency case manager, probation officer) will be notified of repeated cancellations/no-shows and suspension or termination of services.

I understand BMW No Show/Cancellation policy and understand that regular attendance is necessary for the treatment to be effective. Therefore, I agree to attend all scheduled sessions. If I cannot keep an appointment, I will call the staff 24 hours in advance to reschedule. If I have an emergency that prevents me from attending, I will call in an hour in advance and cancel the appointment.
Signature. PLEASE SIGN THIS BOX SO THIS DOCUMENT CAN BE SUCCESSFULLY SUBMITTED.*

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Date
Primary Care Physician (PCP) Notification
Client name:
DOB:
The primary care physician for this client is:

□ No PCP
PCP name:
Phone/Fax
Mailing address:
City, State, Zip:
Email:
example@example.com
Purpose of Release:
FOR NOTIFICATION PURPOSES ONLY.
This document serves as notification to the Primary Care Physician that counseling and/or assessment services are being provided by Behavioral Mind Wellness: Evaluation, Prevention and Treatment LLC (BMW):
Treatment or assessment purpose:
Start date:

MonthDayYear
Date
Clinician name:
PHONE NUMBER (321)888-6965
Acknowledgement:
By signing below, I authorize BMW to exchange confidential information with my PCP for the purpose of treatment coordination.

BMW Contact information:

415 W Vine St, Kissimmee, Florida T (321)888-6965 - Bmindwellness@gmail.com

* I understand I may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment from BMW.

*I understand I may revoke this authorization in writing at any time; however, I cannot revoke authorization for actions already taken. * A copy of this release shall be as valid as the original.

THIS CONSENT EXPIRES 1 YEAR AFTER THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.
Client/Legal Guardian Signature. PLEASE SIGN THIS BOX SO THIS DOCUMENT CAN BE SUCCESSFULLY SUBMITTED.*

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Date:

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Date
Office Hours: M-F, 9:00am-6pm
Consent to Interview another person as part of my treatment

I give authorization to my BMW's clinician, as part of my treatment to interview:
Clients name:
Name of person I authorize to interview:
Client Name:
Client/Guardian Signature*

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Professional Signature

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Professional Name
Office Hours: M-F, 9:00am-6pm
HIPAA AUTHORIZATION FORM BEHAVIORAL MIND WELLNESS

This authorization is for the disclosure of protected health information required by the Health Insurance Portability Act, 45 C.F.R. Parts 160 and 164.
I. AUTHORIZATION:

I authorize Behavioral Mind Wellness to use and disclose the protected health information describe below to:
Primary Care Physician information:
II. EFFECTIVE PERIOD:
This authorization for release information covers the period of healthcare from:
All past, present and future.
III. EXTENDED OF AUTHORIZATION:
Type a question

I authorize to release my complete helath record ( including records relating to mental health care, infectious diseases, HIV or AIDS, and alccohol or drug abuse treatment). ORI authorize to release of my complete health care record except for the fdollowing information:Mental Helath CareCommunicable diseases ( including HIV or AIDSAlcohol or drug abuse treatmentOther
IV. The medical information:

may be use by the person I authorize to receive this information for medical treatment or consultation, billing or claims payments, or other purposes as I may direct.
V. This information shall be in force and effect until
( date or event ) at which time this authorization expires).
VI. I understand that I have the rights to revoke this authorization, in writing, at any time. I understand that a revocation is not sufficient the extent that any person or entity has already acted in reliance on my authorization or if they obtained my permission as a condition of receiving insurances coverage. The insurer has a legal right to contest a claim.
VII. I understand that my treatment, payment, enrollment or eligibility for benefits will is not conditioning on whether I sign this authorization.
VIII. I understand that the information used or disclosed according to this authorization may be informed by the recipient and may no longer be protected by federal or state law.
Signature of patient or personal representative. *

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Printed name of the person or personal representative, and his relationship with patient.
Date

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Date
TELEHEALTH SERVICES CONSENT
I
(patient or guardian name)
hereby consent to Tele-health Services, Psychotherapy and or Medication Management with BEHAVIORAL MIND WELLNESS as part of my treatment. I understand “Tele-health” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. Tele-health also involves sharing my medical/mental information, both orally and visually, with other health care practitioners located in Florida.

I understand I have the following rights:

1. I may withhold or withdraw consent at any time without affecting my right to future care or treatment.

2. Laws protecting confidentiality of my medical information also apply to Tele-health. Information disclosed during my treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elderly, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and when my mental or emotional state is an issue in a legal proceeding. The dissemination of any personally identifiable images or information from a Tele-health interaction to researchers or other entities shall not occur without my written consent.

3. There are risks and consequences from Tele-health, including, but not limited to, the possibility, despite reasonable efforts on the part of my treatment, that: the transmission of my medical information could be disrupted or distorted by technical failures; or the transmission could be interrupted by unauthorized persons; and or the electronic storage of my medical information could be accessed by unauthorized persons.

4. I understand Tele-health-based services and care may not be as complete as face-to-face services. If my provider believes I would be better benefit from another form of services (e.g., face-to-face services), I will be referred to a provider who can provide such services.

5. There are potential risks and benefits associated with any form of psychiatric or psychotherapy services, and that despite my efforts and the efforts of my provider, my condition may not improve, and in some cases, may even get worse. I understand I may benefit from Tele-health, but that results cannot be guaranteed or assured.

6. I understand I have a right to access my medical information and copies of medical records in accordance with Florida state law. I have read and understood the information provided above. I have discussed it with my provider, and all my questions have been answered to my satisfaction. My signature below indicates my informed and willful consent to treatment.
THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.
Client Parents Name
Signature*

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Behavioral Mind Wellness: Evaluation, Prevention, & Treatment, LLC
GOOD FAITH ESTIMATE (based on the No Surprise Act)

Provider Name: Dr. Carmen C. Capella License Number: PY10124 Provider Address: 417 W Vine Street, Kissimmee, Florida
34741 Provider Phone Number: (321) 888-6965 Provider Tax ID Number: 84-3694317 Provider NPI Number: 1013088681

Effective January 1, 2022, a ruling went into effect called the "No Surprise Act, which requires doctors to provide a Good Faith Estimate (GFE). You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychologist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, the frequency, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. Good Faith Estimate This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depend on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

The one-time fee for an initial diagnostic assessment is $180 (CPT code 90791). Beyond this, the fee for a traditional 45-minute psychotherapy visit with Dr. Carmen C. Capella (in person or via telehealth) is $150.00 for individual therapy (CPT code: 90837). Couple Therapy is $150.00 each. No show - cancellation less than 24 hours charge is $95.00 as of March 31, 2022
Most clients will attend two psychotherapies visits per month, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, or every other week, once a month, depending upon your needs. Based on a fee of $150.00 per visit, the following are expected charges of psychotherapy services: Dr. Carmen C. Capella at Behavioral Mind Wellness: Evaluation, Prevention, & Treatment, LLC recognizes every client's therapy journey is unique. How long you need to engage in therapy anyhow often you attend sessions will be influenced by many factors including * Your schedule and life circumstances * Therapist availability * Ongoing life challenges * The nature of your specific challenges and how you address them * Personal Finances You and Dr. Carmen C. Capella will continually assess the appropriate frequency of therapy and will work together when you have met your goals and are ready for discharge and or a new good faith estimate. As related, you may request a new GFE at any time in writing during your treatment. Total estimated charges for 1 session per month: 1 Week of Service: $150/ 13 Weeks of Service (Approx. 3 Months): $450/ 26 Weeks of Service (Approx. 6 months): $900 /Total estimated charges for 2 sessions
per month 1 Week of Service: $300 13 Weeks of Service (Approx. 3 Months): $900/ 26 Weeks of Service (Approx. 6 months): $1,800/ Good Faith Estimate Disclaimer You have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate. To do this, please contact health care at bmindwellness@gmail.com. If this is not resolved satisfactorily, you can start a dispute resolution with the U.S. Department of Health & Human Services (HHS). You must start this process within 120 calendar days of the date of the original bill. There is a $25 fee to use the HHS dispute process. If the agency agrees with you, you will pay the amount on this estimate. If the agency disagrees with you, you will pay the higher billed amount to the health care provider. To learn more or start the process, go to: www.cms.gov/nosurprises. Thanks! Important: You may not require to sign this form; however, if you do not sign, the provider
and/or practice may not treat you. You have the right to choose to get care from a provider and/or practice that is within your health plan's network.

The Good Faith Act may or may not apply to you depending on if you are using your health insurance for the services. If you are using your insurance and the insurance does not pay for the services, you are responsible for the payment of the services provided
to you.
Name

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Address

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Patient Diagnosis (If known/ applicable): A formal diagnostic assessment has been completed. Your psychologist will discuss, as relevant, diagnosis (es) as applicable to treatment. It is within your rights to decline a formal diagnosis:
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INTAKE PACKAGE (ADULTS)

I. Sociodemographic Information:

II. Family History:

Family Composition (biological and/ or incidental):

III Family history of medical conditions:

IV. Development History

Other medical or physical problems

Communication Skills

V. Psychological and psychiatric history

VI. Social-Legal information:

VII. Sexual History

IX. Medical History

Office Hours: M-F, 9:00am-6pm

PSYCHOLOGICAL SERVICES AGREEMENT (ADULTS)

Office Hours: M-F, 9:00am-6pm

Consent to Release Information

AND/OR

Purpose of Release:

Office Hours: M-F, 9:00am-6pm

Intake Consent & Orientation

Office Hours: M-F, 9:00am-6pm

HEALTH & SAFETY

Behavioral Health & Safety Policies:

Behavioral Health Emergency Procedures:

Office Hours: M-F, 9:00am-6pm

Phone #: (321) 888-6965

CLIENT RIGHTS

Complaints/Grievances:

Treatment Philosophy

What to Expect:

Your Rights:

Your Responsibilities:

BMW Rights & Responsibilities:

Office Hours: M-F, 9:00am-6pm

No Show/Cancellation Policy

Primary Care Physician (PCP) Notification

FOR NOTIFICATION PURPOSES ONLY.

Acknowledgement:

Office Hours: M-F, 9:00am-6pm

Office Hours: M-F, 9:00am-6pm

HIPAA AUTHORIZATION FORM BEHAVIORAL MIND WELLNESS

I. AUTHORIZATION:

II. EFFECTIVE PERIOD:

III. EXTENDED OF AUTHORIZATION:

IV. The medical information:

VII. I understand that my treatment, payment, enrollment or eligibility for benefits will is not conditioning on whether I sign this authorization.

VIII. I understand that the information used or disclosed according to this authorization may be informed by the recipient and may no longer be protected by federal or state law.

TELEHEALTH SERVICES CONSENT

THIS CONSENT EXPIRES 1 YEAR FROM THE DATE SIGNED UNLESS OTHERWISE SPECIFIED.