CPAC Intake Paperwork

CONWAY PSYCHOLOGICAL ASSESSMENT CENTER
REGISTRATION FORM & INTAKE PAPERWORK
CLIENT INFORMATION
Today’s Date

MonthDayYear
Date
PCP
PCP Clinic
Client’s Last Name*
First Name*
Middle Initial
Is this client's legal name?*

YesNo
Legal Name if applicable
Client’s Date of Birth*

MonthDayYear
Date
Client’s Age*
Client’s Sex*

MaleFemaleNonbinaryPrefer not to answer
Street Address*
P.O. Box
City*
State*
Zip Code*
Cell #*
Please enter a valid phone number.
Home #
Please enter a valid phone number.
Email*
example@example.com
Occupation
Employer
Work Phone Number:
School (if applicable)
Chose clinic because/referred to clinic by (Please check one box)*

Dr.FamilyFriendInsurance PlanHospitalClose to home/workInternetOther
GUARDIAN INFORMATION

Please complete if client is under 18 or under legal guardianship
Guardian’s Name
Date of Birth

MonthDayYear
Date
Relationship to Client
Who has custody?
Does the client live with the guardian?

YesNo
Guardian Email
example@example.com
How do you prefer to be contacted:*

CellHomeWorkEmail
INSURANCE INFORMATION
Please upload the front copy of your driver's license and the front and back of your insurance card(s).*

Cancelof
Person responsible for bill*
Relationship to Client*
Address of this person (if different)
Is Client covered by Insurance?*

YesNo
Insured's Phone number*
Please enter a valid phone number.
Please indicate PRIMARY insurance*

AR Blue CrossAnthem Blue CrossBlue Cross Out of StateUnitedQualchoiceHealth AdvantageUMRAetnaMunicipalWebTPAFederal BCBSTrustmark/LuminareCigna HealthAmbetterSelf-payOther
Subscriber’s Name
Subscriber’s Date of Birth

MonthDayYear
Date
Member ID# (If self-pay, write None)*
Group Number (If self-pay, write None)*
Relationship to Client

SelfSpouseParent/GuardianOther
Is there a SECONDARY insurance?*

YesNo
If so, which company?
Subscriber’s Name
Subscriber’s Date of Birth

MonthDayYear
Date
Member ID#
Group Number
Relationship to Client

SelfSpouseParent/GuardianOther
Signature*

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Date*

MonthDayYear
Date
4555 Prince Street, Conway, Arkansas 72034

(501) 932-0255

www.conwaypsychtesting.com
CLIENTS RIGHTS & RESPONSIBILITIES
CLIENT’S NAME*
CLIENT’S RIGHTS
The client has the right to expect appropriate psychological care regardless of race, disability, color, religion, national origin, the client’s source of payment, sexual orientation, or religious and spiritual beliefs.

The client has the right to be treated with respect, addressed by proper name without undo familiarity, listened to when requesting information and to receive an appropriate and timely response.

The client has the right to privacy and confidentiality in all aspects of care. The client’s records will be treated as confidential. The client is entitled to privacy when examined – to have the door closed, to have observers identified, and to be informed of the role they play in client care. The client may ask any individual to leave the room, and has the right to restrict visitors during the assessment or consultation.

The client has the right to an explanation of all charges.

The client has the right to know the name of the clinician responsible for their service, to talk with that clinician and to obtain information necessary for an understanding of their problems.

The client has the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for care) concerning treatment with the expectation that the clinic will honor the intent of that directive to the extent permitted by law and policy.

The client has the right to be informed of the course of the assessment and to receive an explanation of any planned procedures. If an interpreter is required, one will be obtained for the client.

The client has the right to be advised when the clinician is considering the client as part of a clinical research program, and the client must give informed consent prior to actual participation in such a program. After the details of the program have been explained, the client may refuse to participate and may cancel participation at any time. This decision will not change the right of the client to receive treatment.

The client has the right to express any grievance orally or in writing, without fear of reprisal. The client has the right to discuss their concerns with their doctor or therapist or they may bring their concerns to the C-PAC Clinical Director at 501-932-0255.

The client has the right to obtain a personal advocate at any time.
CLIENT RESPONSIBILITIES
The client has the responsibility to provide, to the best of their knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to psychiatric health.

The client has the responsibility to report unexpected changes in their condition to the responsible practitioner.

The client is responsible for reporting whether they comprehend a contemplated course of action and what is expected of them.

The client is responsible for following the treatment plan recommended by the practitioner primarily responsible for their care. This may include following the instructions of nurses and allied health personnel as they carry out the coordinated plan of care, and implement the responsible practitioner’s orders.

The client is responsible for their actions if they refuse treatment or does not follow the practitioner’s instructions.

The client is responsible for keeping appointments, and when the client is unable to do so for any reason, is responsible for notifying the responsible practitioner.

The client is responsible for assuring that the financial obligations of their health care are fulfilled as promptly as possible.

The client is responsible for following C-PAC rules and regulations affecting client care and conduct.

The client is responsible for being considerate of the rights of other clients and C-PAC personnel and for assisting in the control of noise and by not smoking or vaping. The client is responsible for being respectful of the property of other persons and C

*The term client includes, when appropriate, the family, guardian or primary caregiver.

I have read this statement of rights and responsibilities and/or it has been read to me. I have had an opportunity to ask questions and have them answered. I understand what my rights and responsibilities are, and I have been given a copy of this statement.
Print Name*
Client/Guardian’s Signature*

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Relationship of Signer
Date*

MonthDayYear
Date
AGREEMENT TO CARE
You are requesting an evaluation and/or therapy/treatment from a Conway Psychological Assessment Center. You understand that testing and/or therapy at CPAC is voluntary and that you may discontinue treatment at any time.
CONFIDENTIALITY
All information between you and the provider is strictly confidential unless you specifically authorize release in writing or in compliance with certain legal requirements. The purpose of an evaluation is to compile as much information about the client as possible in order to provide a differential diagnosis. Therefore, the information collected will be included in the report unless specifically stated. CPAC is required to inform others to take protective measures if a client presents a physical danger to self or others, or if client or elder abuse is suspected. Please discuss any concerns with the client’s therapist or doctor.
MISSED APPOINTMENTS
CPAC makes every effort to give an appointment in a timely manner. When you fail to make your scheduled appointment time and we are not notified, we are unable to schedule someone else in your place. This makes it more difficult for us to see all clients requesting appointments, raises the cost of doing business, and impacts the insurance rates you are charged. We are unable to bill your insurance carrier for missed appointments. You are personally responsible for a $50 fee for missed appointments.

TO AVOID BEING CHARGED FOR THE FULL COST OF MISSED APPOINTMENTS, PLEASE CANCEL APPOINTMENTS AT LEAST 24 HOURS IN ADVANCE.
RELEASE OF INFORMATION
I authorize the release of information regarding my care or the care of my child, including release of my mental health records, to my health plan or insurance company for the payment of claims, certifications/case management decisions, quality improvement activities, and other purposes related to the administration of benefits for my health plan or insurance coverage.
RESPONSIBILITY FOR PAYMENT
I agree to pay any fees I incur for services rendered by Conway Psychological Assessment Center for the client, regardless of insurance coverage.
I UNDERSTAND THAT ALL FEES AND COPAYMENTS ARE DUE AND PAYABLE AT THE TIME OF
WE ACCEPT CASH, VISA, MASTERCARD OR DISCOVER FOR PAYMENT. WE ARE UNABLE TO ACCEPT CHECKS OR AMERICAN EXPRESS.
Client or Guardian Signature*

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Relationship to the Signer*
Date*

MonthDayYear
Date
CONWAY PSYCHOLOGICAL ASSESSMENT CENTER
AUTHORIZATION/CONSENT FOR RELEASE OF MEDICAL/EDUCATIONAL INFORMATION

Please fill out this form to authorize the release of your health and/or educational information
Patient’s Full Name*
Date of Birth*

MonthDayYear
Date
I authorize Conway Psychological Assessment Center to disclose to and/or obtain medical and/or educational records from the following organizations/persons:

(Only include organizations that would have previous or current treatment records relevant to your care at CPAC)
Name of Person/Organization to Release Information To or From
Name of Person/Organization to Release Information To or From
Name of Person/Organization to Release Information To or From
Name of Person/Organization to Release Information To or From
Name of Person/Organization to Release Information To or From
Description of Information to be Disclosed (patient should check each item to be disclosed):
Description of Information to be Disclosed (patient should check each item to be disclosed:

Psychological EvaluationsPsychotherapy Notes or Treatment SummaryPsychiatric EvaluationsMedication Management InformationDischarge/Transfer Summary from Inpatient StaysEducational History (Grades, Discipline RecordsTRIAND Records (Standardized Test Results/Benchmarks)Speech/OT/PT/Developmental AssessmentsSpecial Education Records (SPED classification, IEP summaries)Other
I also authorize release of information regarding (only if giving consent or applicable):

Alcohol and/or Substance Abuse HistoryHIV/AIDS or other communicable disease
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal Rule prohibits you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
Relationship to the patient*
Name of patient or guardian signing the form and their relationship to the patient*

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Date*

MonthDayYear
Date
CONWAY PSYCHOLOGICAL ASSESSMENT CENTER
INTAKE PAPERWORK

(Please complete as comprehensively as possible)
Client’s Name*
Please list the problem(s) for which you are seeking help (example ADHD, Autism, Bipolar Disorder, etc.)*
Purpose of the visit:*

Individual therapyPsychological testingBariatric Surgery EvaluationSpinal Stimulator EvaluationEducational/Dyslexia AssessmentQualify for waiver or disability services
Please use this space to describe/explain the purpose of this visit*

0/100
Current Symptoms for the Client*

Depressed moodExcessive WorryImpulsivitySleep pattern disturbanceAvoidanceHallucinationsMood swingsDifficulty transitioningThoughts of suicideRestricted interestsPoor social awarenessCounting or checking as a ritualAvoiding huge public placesAbnormal body movementsExtremely bothered by texturesTalking excessivelyPoor social skillsDifficulty finding or keeping a jobSensory sensitivities to light/soundEyes water or hurt while readingSocial anxietyExcessive video game playingDisorganizedSuicidal thoughts or behaviors (including cutting)Racing thoughtsDifficulty making or keeping friendsAnxiety/panic attacksIncreased risky behaviorAggression toward othersConcentration problems/forgetfulnessSuspiciousnessExcessive energyIncreased irritabilityCrying spellsFear of contaminationPoor personal hygieneHoarding objectsWashing hands repeatedlyDelusionsInterrupting othersAcademic difficultiesRefuses to complete choresNeeds assistance to complete ADLsMath difficultiesStruggles with reading comprehensionFixates on topicsSchool discipline problemsHearing voices no one else can hear
MEDICAL HISTORY
What is the client's overall physical health?*

Usually good health/physically fitHas a health condition that does not require medicationHas a health condition that requires medication
Have you noticed any recent changes in appetite or weight in the client?*

YesNo
Client's current medical problems (If none, type NA):*
Client’s past medical problems, including birth historycomplications, nonpsychiatric hospitalization, or surgeries*

List any non-psychiatric medications the client is currently prescribed and the reason for the prescription:

	Medication Name	Reason for the Prescription	Prescribing doctor
Medication #1
Medication #2
Medication #3
Medication #4

How many hours does the client typically get each night (If client regularly naps, add to total)?*

Less than 6 hours7-8 hours9-10 hoursMore than 10 hoursNo set number of sleep hoursTakes frequent naps each day
Does the client have any allergies?*

YesNo
If yes, then list them:
Does the client wear glasses or contacts?*

YesNo
Does the client have hearing loss?*

YesNo
PSYCHIATRIC HISTORY
Has the client received outpatient treatment (therapy)?*

YesNo

If yes, complete the following:

	Clinic Name	Therapist	Dates of Treatment	Check if it was helpful?
Clinic #1
Clinic #2
Clinic #3
Clinic #4

Check any of the following diagnoses the client has been given:*

AnxietyDepressionADHDBipolar DisorderPosttraumatic Stress DisorderSchizophreniaAutism Spectrum DisorderBorderline Personality DisorderDisruptive Mood Dysregulation DisorderOppositional Defiant DisorderSubstance AbuseAlcohol AbuseObsessive-Compulsive DisorderNoneOther

If you endorsed any of the symptoms above, please complete this table:

	Year Diagnosed	Family History of It	Which Family Member has been diagnosed with it?
Anxiety
Depression
ADHD
Bipolar Disorder
Posttraumatic Stress Disorder
Schizophrenia
Autism Spectrum Disorder
Borderline Personality Disorder
Disruptive Mood Dysregulation Disorder
Oppositional Defiant Disorder
Substance Abuse
Alcohol Abuse
Obsessive Compulsive Disorder
Other

Has the client ever been hospitalized for psychiatric reasons?*

YesNo

Has the client ever been hospitalized for psychiatric reasons?

	Dates of Hospitalization	Hospital	Reason for Hospitalization
Hospitalization #1
Hospitalization #2
Hospitalization #3
Hospitalization #4

Psychiatric Medications

List any psychiatric medication the client has been prescribed:

	Name	Purpose	Dates prescribed	Prescriber
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8

SUBSTANCE USE AND/OR ABUSE HISTORY
Check if the client has ever tried the following:*

AlcoholMarijuanaHeroinTranquilizer/sleeping pillsMethamphetamineNo history of substance useStimulants (not prescribed)EcstasyPain killers (not prescribed)CocaineLSD or HallucinogensMethadoneNo use of substancesOther
Explain length of time used and if any of them are currently being used
Has the client been in a treatment program for substances?*

YesNo
If yes, explain the type of program and the outcome
FAMILY BACKGROUND & CHILDHOOD HISTORY
Was the client adopted?*

YesNo
If yes, describe how the client came to live with their adoptive parents, the condition of the client when entered care, and any challenges that evolved during that transition
List any complications that occurred during the pregnancy of the client (including prenatal exposure to illicit drugs or alcohol. If none, type None*
How much did the client weigh at birth (approximate if necessary)?*
Mother's age at client's birth:
Father's age at client's birth:
Describe any developmental delays (walking, talking, toilet training, etc). If none, type None*
Has the client received developmental therapies (Speech, Occupational, Physical, & Developmental)?*

YesNo

If so, please complete the following:

	Type of Therapy	Location of Therapy	Dates of Therapy	Length of Therapy
Therapy #1
Therapy #2
Therapy #3
Therapy #4
Therapy #5

List the names and ages of the people living in the home with the client: *

	Name	Relationship	Age
Family Member #1
Family Member #2
Family Member #3
Family Member #4
Family Member #5
Family Member #6
Family Member #7

Other people actively involved in the client’s life
STRESSFUL EVENTS & FAMILY HISTORY
Check if the client has experienced any of the following:*

None reportedLegal problemsDivorceNew/Beginning schoolSeparation from family/friendsFamily violenceSexual Abuse as a ChildIllness (mental or physical)MarriageMultiple Family Moved/Recent MovesCustody IssuesSexual Abuse as an AdultPhysical Abuse as a ChildWitnessed ViolenceHomelessnessBirth/DeathPhysical Abuse as an AdultFamily Substance AbuseOther

Check any of the following the client has experienced:

	Experienced	By whom
Verbal Abuse
Physical Abuse
Sexual Harassment
Sexual Abuse
Rape
Sex Trafficking

SOCIAL HISTORY
How would you rate the client's current social support?*

Has a strong social support networkHas a few people in the family on which the client can countThe client’s support comes from people outside the familyThe client has almost no social supportThe client has no support at all
Describe the client's legal system involvement:*

The client is currently involved in the legal system and this treatment is court-orderedThe client is currently involved in the legal system, but treatment is voluntaryThe client has a past history of legal involvementThe client has no legal system involvement
Social/Peer Relations (Check all that apply)*

NormalIsolativeInteractiveAggressiveCooperativeControlling
Choose the words that best describe the client’s temperament (personality):(Check all that apply)*

AccommodatingActiveAffectionateArgumentativeCalmCaringConscientiousEmotionalHappyHyperactiveImpatientImpulsiveIndependentIntelligentObedientOutgoingReservedShySociableStubbornTrustingDemandingDeterminedMotivatedInsecureIrritableCreativeUnhappyDifficultBossy
Is the client currently:*

MarriedDivorcedWidowedPartneredSingleClient is a minor
Does the client have any children?*

YesNo
If yes, describe the relationship the client has with them
Describe the client's friendships/peer interactions & sibling interactions (include if the client prefers same age peer interactions or gravitates toward younger or older peers)*
How many hours does the client typically spend on screen time (video games, YouTube, computers, tablet, phone)?*

Less than 1 hour dailyBetween 2-3 hours daily4-5 hours daily6-7 hours dailyMore than 8 hours daily
Is the client’s screen time a source of conflict in the home or does it contribute to task avoidance?*

YesNo
Current Resources*

ClubsChurchIntramural SportsSportsFraternity/SororityROTC/MilitaryNone reported
EDUCATIONAL HISTORY
Client's highest grade completed:*
Has the client repeated a grade?*

YesNo
Describe the client's grade history:
Does/Did client receive special education?

YesNo
504 Plan?

YesNo
If yes for special education, under what category?

Specific Learning DisabilityOther Health ImpairmentDeaf-BlindnessVisual ImpairmentIntellectual DisabilitySpeech Language ImpairmentHearing ImpairmentMultiple DisabilitiesAutismEmotional DisturbanceTraumatic Brain Injury
Describe any behavior problems or academic problems for the client:*
I attest this information provided is accurate to the best of my knowledge.*

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Relationship to the Signer*
Date*

MonthDayYear
Date
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CONWAY PSYCHOLOGICAL ASSESSMENT CENTER

REGISTRATION FORM & INTAKE PAPERWORK

CLIENT INFORMATION

GUARDIAN INFORMATION

INSURANCE INFORMATION

CLIENTS RIGHTS & RESPONSIBILITIES

CLIENT’S RIGHTS

CLIENT RESPONSIBILITIES

AGREEMENT TO CARE

CONFIDENTIALITY

MISSED APPOINTMENTS

RELEASE OF INFORMATION

RESPONSIBILITY FOR PAYMENT

I UNDERSTAND THAT ALL FEES AND COPAYMENTS ARE DUE AND PAYABLE AT THE TIME OF

CONWAY PSYCHOLOGICAL ASSESSMENT CENTER

AUTHORIZATION/CONSENT FOR RELEASE OF MEDICAL/EDUCATIONAL INFORMATION

CONWAY PSYCHOLOGICAL ASSESSMENT CENTER

INTAKE PAPERWORK

MEDICAL HISTORY

PSYCHIATRIC HISTORY

Psychiatric Medications

SUBSTANCE USE AND/OR ABUSE HISTORY

FAMILY BACKGROUND & CHILDHOOD HISTORY

STRESSFUL EVENTS & FAMILY HISTORY

SOCIAL HISTORY

EDUCATIONAL HISTORY