Intake Assessment—Santa Fe Psychology

KILA HILLMAN, 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
Preferences for Contact:

allcell phoneemailhome phoneself-schedulertextwork phone
SELF-SCHEDULER not HIPPA COMPLIANT - use with provider an interception risk:
TEXT not HIPPA COMPLIANT - use with provider an interception risk:
EMAIL not HIPPA COMPLIANT - use with provider an interception risk:
PROVIDER MAY LEAVE ME VOICEMAILS - not HIPPA COMPLIANT
CLIENT SIGNATURE (child's if 14 or older)*

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

First NameLast Name
Date:

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

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

First NameLast Name
Date

MonthDayYear
Date

BILLING
Insurance Card Photo (optionally clinician can take photo first session):
Payment Responsibility:*

insuranceself paybill to third party
Primary Subscriber:*

First NameMiddle NameLast Name
Primary Subscriber Date of Birth:*

MonthDayYear
Date
Primary Insurance Carrier:*
Primary Subscriber ID:*
Dependent Subscriber:

First NameMiddle NameLast Name
Dependent Subscriber Date of Birth:

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

selfdependent spousedependent child
Secondary Insurance Carrier:
Secondary Insurance Subscriber ID:
Photo of Driver's Licence or Identification Card (optionally clinician can take photo first session)
Driver's Licence or Identification Card*

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

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

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

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

First NameLast Name
Date

MonthDayYear
Date

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

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

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

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

First NameLast Name
Date

MonthDayYear
Date

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

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

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

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

First NameLast Name
Date

MonthDayYear
Date

COORDINATION OF CARE
PAUSE AUTO SCROLLING WHEN FINISHED READING
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)
CLIENT SIGNATURE (child's if 14 or older)*

Clear
Name*

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

Clear
Name

First NameLast Name
Date

MonthDayYear
Date

COORDINATION OF CARE - opt in form
INSTRUCTIONS: don't fill out this form unless you are opting to consent to Coordination of Care between Kila Hillman, MA, LPCC and your 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:

MailFax
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 AttendedDiagnosisAssessment
CLIENT SIGNATURE (child's if older than 14)

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. Clear
Name

First NameLast Name
Date

MonthDayYear
Date
PARENT/GUARDIAN SIGNATURE

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. Clear
Name

First NameLast Name
Date

MonthDayYear
Date

UPLOAD DOCUMENTS
Upload Pertinent Medical Documents:

Upload

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INSTRUCTIONS
New Client Instructions-PDF

SUBMIT FORM
First Name
Middle Name
Last Name
Should be Empty: