New Patient Intake-FINAL (Updated & Has previous Submissions)

New Patient Intake Form

James R Álvarez PhD | www.jamesralvarez.com
Personal Information
Full Name*

PrefixFirst NameMiddle NameSurnameSuffix
Preferred Name

First NameLast Name
Date of Birth*

DayMonthYear
Mobile Phone*
Preferred Email*
example@example.com
Skype/Other Name(s)
Gender*
If other please complete below.
Other
Please specify your gender and pronouns
Home Address*

Street Address

Street Address Line 2

CityCounty/State

Postal/Zip CodeCountry
Occupation*
Marital Status
Spouse's Information
Spouse's Name
Spouse's Age
Spouse's Occupation
In Case of Emergency (ICE) Contact
ICE Contact Name*
ICE Mobile Phone Number*
Other Phone Number*
Emergency Contact Email*
ICE Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
GP Details

Though not mandatory, it is best practice to keep your GP informed about your care. If you have been referred by a doctor who asks for feedback on your progress, we may need to charge for time spent writing letters and reports but only with your prior consent.
GP Name
GP Practice
GP Phone Number
GP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you give Dr Álvarez permission to communicate with your GP about your case if necessary?*

YesNo
Financial Information
How I plan to pay for treatment:*

I will use my credit cardI will pay by cashI will use my insurance benefitsOther - Please complete below
Other payment method
Insurance Information
Primary Insurance Company name
If other please complete below.
Other insurance company
Policy / Registration / Membership No.
Authorisation / Claim / Case ID No.
Number of sessions authorised 1
Secondary Insurance Company Name
Policy / Registration / Membership No.
Authorisation / Claim / Case ID No.
Number of sessions authorised 2
Sponsor's Name
Person other than you that carries the insurance
Sponsor's Date of birth
Person who carries the insurance
Sponsor's Phone Number
Person who carries the insurance
Sponsor's complete home address
Person who carries the insurance
Insurance company telephone #
Attach any relevant insurance documents if necessary

Browse Files
PDF, DOC, TIFF, JPEG Files only. Cancelof

Data Protection
James R Álvarez PhD is registered with the Information Commissioner’s Office (ICO) which monitors data protection. He is professionally and legally required to hold sensitive and identifiable data about you. Sensitive information such as session notes will usually only refer to you by your initials. Your data is archived in secure cloud storage and will be retained for six years after termination of therapy. This is to ensure adherence to the appropriate professional requirements. If you want your records to be permanently destroyed after termination of therapy, please be aware that this may mean that Dr Álvarez will have no evidence of your attendance, which may create difficulties in the future you require this information for legal or insurance reasons.

Please read below and select Yes or No for the following options about the retention of your information.

I agree that James R Álvarez PhD can:
1. Hold identifiable and/or sensitive information (on paper or electronically) about me, including, but not limited to: My name, address, date of birth, GP contact details, next of kin and/employers, for the duration of my therapy, my personal health, family and mental health history, my current circumstances and the discussions I have with my Psychologist for the duration of my therapy*

YesNo
2. Hold identifiable and/or sensitive information (on paper or electronically) about me for up to six years after I have stopped using James R Álvarez PhD’s services to comply with the appropriate professional guidelines on the retention of records.*

YesNo
Agreement, Signature and Submission
My signature below signifies that I have read and understood this document, that all the information I provided is true to the best of my knowledge, that I agree to comply with its terms and conditions and that I agree to proceed with my initial appointment after which my clinician and I will agree upon an appropriate treatment plan if necessary.
Patient's Signature*

Clear
Date of signature*

DayMonthYear
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Patient/Guardian Signature

Clear
Date of signature*

DayMonthYear
Please verify that you are human*
Should be Empty:

New Patient Intake Form

Personal Information

Spouse's Information

In Case of Emergency (ICE) Contact

GP Details

Financial Information

Insurance Information

Data Protection

Agreement, Signature and Submission