Intake Assessment—Santa Fe Psychology

KILA HILLMAN-SENA, MA, LPCC with Santa Fe Psychology

NEW CLIENT INTAKE
Clinician Providing Assessment:

WELCOME
Your psychotherapist is Kila Hillman-Sena, MA, LPCC, a Professional Clinical Mental Health Counselor, NM License #CCMH0185581, and independent contractor with Santa Fe Psychology. She provides in person sessions from her personal office space or teletherapy via Zoom.

The confidential information gathered in this form is to help Kila gain essential information about you, provide you with information about her practice, as well as, sign the necessary forms. Some common answers are pre-selected, for the purposes of expedience, which you may change if they do not apply to you.

COMMUNICATION
COMMUNICATION/SCHEDULING OPT IN'S (non-Hippa Compliant (encrypted but still with interception risk)):
TEXT
EMAIL
HOME PHONE VOICEMAILS
CELL PHONE VOICEMAILS
OFFICE PHONE VOICEMAILS
CLIENT SIGNATURE (child's if 14 or older)*

Clear
I agree to the communication opt in's I have selected.
Name:*

First NameLast Name
Date:

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

Clear
I agree to the communication preferences I have selected.
Name

First NameLast Name
Date

MonthDayYear
Date

BILLING
Photo of Driver's License or Identification Card
Driver's Licence or Identification Card*
Insurance Card Photo
Payment Responsibility:*

primary insurancesecondary insuranceself-payorout of network benefitsOther
Name on Card (primary insurance subscriber or self-payor):*

First NameMiddle NameLast Name
Date of Birth (primary subscriber or self-payor):*

MonthDayYear
Date
Payment Method (insurance carrier or self-payor CC type) :*
Payment Number (primary member ID or self-payor CC/EXP/CVV):*
Name on Card (dependent subscriber):

First NameMiddle NameLast Name
Date of Birth (dependent subscriber):

MonthDayYear
Date
Dependent Member ID Number:
Dependent Subscriber Relationship to Primary Subscriber:

selfdependent spousedependent childOther
Secondary Insurance Carrier:
Secondary Insurance Member ID Number:
Insurance Co-payment Method (CC type):
Insurance Co-payment Number (CC/EXP/CVV code):

CLINICIAN-PATIENT AGREEMENT
PDF Copy (print or download for your records)
CLIENT SIGNATURE (child's if 14 or older)*

Clear
I have read and agree to the Clinician-Patient Services Agreement
Name

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

Clear
I have read and agree to the Clinician-Patient Services Agreement
Name

First NameLast Name
Date

MonthDayYear
Date

NEW MEXICO PRIVACY NOTICE
PDF Copy (print or download for your records)
CLIENT SIGNATURE (child's if 14 or older)*

Clear
I have read and agree to the New Mexico Notice Form
Name

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

Clear
I have read and agree to the New Mexico Notice Form.
Name

First NameLast Name
Date

MonthDayYear
Date

TELEHEALTH CONSENT
PDF Copy (print or download for your records)
CLIENT SIGNATURE (child's if 14 or older)*

Clear
I have read and agree to the Telehealth Consent for Treatment.
Name

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

Clear
I have read and agree to the Telehealth Consent for Treatment.
Name

First NameLast Name
Date

MonthDayYear
Date

AI NOTE TAKING SYSTEM CONSENT
PDF Copy (print or download for your records)
CLIENT SIGNATURE (child's if 14 or older)*

Clear
I have read and agree to the Telehealth Consent for Treatment.
Name

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

Clear
I have read and agree to the Telehealth Consent for Treatment.
Name

First NameLast Name
Date

MonthDayYear
Date

SELF-SCHEDULING SYSTEM CONSENT
PDF Copy (print or download for your records)
I understand and agree that choosing to OPT IN to self-schedule my own appointments could inadvertently expose my name, email or phone number during electronic transmission, and acknowledge that if I choose to OPT OUT of self-scheduling my own appointments, then I need to contact my provider directly to schedule my appointments for me.
CLIENT SIGNATURE (child's if 14 or older)*

Clear
I have read and agree to the Telehealth Consent for Treatment.
Name

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

Clear
I have read and agree to the Telehealth Consent for Treatment.
Name

First NameLast Name
Date

MonthDayYear
Date

COORDINATION OF CARE
OPTIONAL BEHAVIORAL CARE AND PRIMARY CARE PHYSICIAN (PCP) COORDINATION OF CARE FORM
YOU HAVE THE OPTION of releasing and exchanging your confidential behavioral health and medical information between Santa Fe Psychology, your primary care physician, and/or other healthcare practitioner's to promote the continuity and coordination of your behavioral health care and general medical care. This consent is automatically renewable each year and the confidential information that is exchanged will be kept by the recipient until such time as state law allows destruction of my patient record. This authorization may be revoked, in writing, at any time, except to the extent that any action has been taken in reliance thereon, and you legal representative is entitled to a copy of this form.
I have read and understand the Behavioral Care and Primary Care Physician (PCP) Coordination of Care Option (do not fill out Coordination of Care Form in next section in you OPT OUT):

COORDINATION OF CARE - opt in form
INSTRUCTIONS: don't fill out this form unless you are opting to consent to Coordination of Care between Santa Feyour Primary Care Physician and/or other providers wherby your mental health records, or a portion of your records, will be exchanged with them.
CONSENT FOR BEHAVIORAL CARE AND PRIMARY CARE PHYSICIAN (PCP) COORDINATION OF CARE FORM
CONFIDENTIAL PROTECTED HEALTH INFORMATION ENCLOSED. Protected Health Information (PHI) is personal and sensitive information related to a person's healthcare. It is being delivered to you after appropriate authorization from the patient/member or under circumstances that do not require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without additional patient/member consent or as permitted by law is prohibited. Unauthorized re-disclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law. We are sending via:

MailFaxOther
From:

Kila Hillman-Sena, MA, LPCC

Santa Fe Psychology
1225 S. St Francis, Bld B
Santa Fe, NM 87505

Work Cell: (505) 919-8037
Phone: (505) 795-5566
Fax: (505) 930-5204

Email: kila@kilahillman.net

Dear Primary Care Physician/or other Healthcare Practitioner:

I have seen the client named below for outpatient behavioral health treatment.
Client Assessment is Included
Number of sessions and dates attended:
The client's behavioral health diagnosis is:
Client Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Date of Birth:

MonthDayYear
Date
Social Security Number:
Primary Care Physician (PCP)/or other Healthcare Provider (to exchange confidential medical information with):

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:

Area CodePhone Number
Office Phone:

Area CodePhone Number
Fax:

Area CodePhone Number
Additional Healthcare Provider (to exchange confidential information with):

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:

Area CodePhone Number
Office Phone:

Area CodePhone Number
Fax:

Area CodePhone Number
Release the following to my primary care physician/or other healthcare practitioner:

Number of Sessions AttendedDiagnosisAssessmentOther
CLIENT SIGNATURE (child's if older than 14)

Clear
I authorize the release of confidential information between Kila Hillman-Sena, MA, LPCC/Santa Fe Psychology and my primary care physician/or other healthcare practitioner.
Name

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

Clear
I authorize the release of confidential information between Kila Hillman-Sena, MA, LPCC/Santa Fe Psychology and my primary care physician/or other healthcare practitioner.
Name

First NameLast Name
Date

MonthDayYear
Date

UPLOAD DOCUMENTS
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SUBMIT FORM
I have read and agree to the Schedulista Privacy Policy, understand that Kila Hillman-Sena, MA, LPCC with Santa Fe Psychology utilizes this scheduling system, and a PDF download was provided for your records.
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