Therapist Private Practice Intake Paperwork Form

Name of the Form
Which therapists are you going to be working with?
Therapists Name
NWC North Address Line 1
NWC North Address Line 2
NWC Address Line 1
NWC Address line 2
NWC Grandview address line 1
NWC Grandview address line 2

Demographic Information
Patient/Client Name*

First NameMiddle NameLast Name
Preferred Prounouns
What "Other" Pronoun/Pronouns do they prefer?
Date of Birth

MonthDayYear
Date
Age
SS Number*
In format: ######### (no dashes)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell phone provider (for appointment reminders from Therabill)
Email address
example@example.com
YesNo
YesNo
Responsible Party's Name

First NameLast Name
Responsible Party's DOB

MonthDayYear
Date
Responsible party's SS#
######### (No dashes)
Responsible party's relationship to client
Responsible party's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Responsible Party's Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell phone provider (for appointment reminders from Therabill), if different from above
YesNo
YesNo
Insured's Name

First NameMiddle NameLast Name
Insured's DOB

MonthDayYear
Date
Insured's SS#
###-##-####
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured's Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Insured's Employer
Insured's Cell Carrier
Insurance Company
Insured's Insurance ID #
Insured's Group ID #
Insurance card photos
Picture of the front of your card

Cancelof
Picture of the back of your card

Cancelof
Secondarily Responsible Party's Name

First NameMiddle NameLast Name
Secondarily Responsible Party's DOB

MonthDayYear
Date
Secondarily Responsible Party's SS#
In format: ######### (no dashes)
Secondarily Responsible Party's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondarily Responsible Party's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondarily Responsible's Cell Phone Carrier

Notice of Privacy Practices
This notice is being sent to you, to inform you that we are H.I.P.A.A. compliant, and to describe to you an "overview" of your privacy rights.

The H.I.P.A.A. law was created for companies who now transfer your personal and medical information electronically (via the Internet, email, etc As stated previously, we do not transfer any personal and/or medical documents electronically without your consent at this time and are not foreseeing doing this in the future.

Our Statement to You: We acknowledge your right to your privacy and will abide by both the H.I.P.A.A. and Privacy Act laws and regulations, we understand the meaning of the word "confidential" and we respect your rights to your privacy.

If you have any questions or you would like to exercise any of your rights described in this brochure, you must submit your request in writing to our H.I.P.A.A. manager; or you may call and leave a detailed message and our H.I.P.A.A. manager will get back to you as soon as possible.

A full copy of the H.I.P.A.A. Law and regulations is located at our place of business for your review, or you can visit these Government web sites for further information: www.CMS.hhs.gov/hipaa www.hhs.gov/ocr/hipaa www.hhs.gov/ocr/hipaa/privacy.html
Notice:
Our office transfers "Personal Health Information" electronically; we are H.I.P.A.A. compliant and we are regulated by the Federal Privacy Act.
Our Responsibility
The confidentiality of your personal health information is very important to us. All information kept in your file is confidential and will not be released unless we obtain written consent to do so and/or it is stated by the law that we may release this information without your consent.

What we are allowed to do without your Consent:

Under federal and Ohio law, we are permitted to use and disclose personal health information without authorization for treatment, payment, and health care operations. [However, the American Psychiatric Association's Principles of Medical Ethics or state law may require us to obtain your express consent before we make certain disclosures of your personal health information.] [If relevant: Participants in this organized health care arrangement also share health information with each other, as necessary to carry out treatment, payment, or health care operations relating to the organized health care arrangement.]

Asking a nurse to assist with taking your temperature and to document the results. Supplying your insurance company with a diagnosis or other related health information that will assist payment for services rendered. Supplying the billing department with demographic and diagnostic information, etc.

Under Federal and Ohio State law, we are permitted to use and disclose personal health information without authorization, for treatment, payment, and health care operations. Note: If you are available, we will provide you an are unavailable because, for example, you are opportunity to object before disclosing any such information. If YOU incapacitated or because of some other emergency circumstance, we will use our professional judgment to determine what is in your best interest regarding any such disclosure. Instances where your consent is not needed. (examples)
- Abuse, neglect, or domestic violence
- Appointment reminders and other health related services (this would include leaving messages on answering machines, unless directed not to)
- Business Associates such as a Billing Company
- Communicable Disease Control
- Communications with family, only if they are the responsible party for your care and/or payment
- Coroners, Medical Examiners, and Funeral Directors
- Disaster relief or to assist in disaster relief efforts
- Food and Drug Administration (FDA)
- Judicial or Administrative Proceedings
- Law Enforcement
There are other instances where your PMI (Personal Medical Information) may be given out. But our office policy is to always try to get permission from you first before we disclose any such information.

In general our practice will only release actual medical information, such as a diagnosis, medications you have been prescribed. Length of treatment, etc.

Session notes that document diagnoses, medications prescribed and the content of our sessions will only be released upon your signing of a specific release of information allowing me to share that information with those you designate. This is mostly done via fax. Please advise if this is not acceptable.
Your Health Information Rights:
Under the law, you have certain rights regarding the health information that we collect and maintain about you. This includes the right to: (examples)
- Request that we restrict certain uses and disclosures of your health information. We are not, however, required to agree to a requested restriction.
- Request to review, or to receive a copy of, the health information about you that is maintained in our files and the files of our business associates (if applicable If we are unable to satisfy your request, we will tell you in the reason for the denial and your right, if any, to request a review of the decision.
- Request that we amend or update the health information about you that is maintained in our files. This does not include therapy notes however.
- Request a list of whom we sent your health information to.
Acknowledgment of Receipt of Notice of Privacy Practices
I acknowledge and understand that my therapist is abiding by the H.I.P.A.A., Ohio state and federal privacy act law(s) and regulations; and I hereby acknowledge that I have reviewed and/or received a copy of the Notice of Privacy Practices
Responsible Party
Relationship to Client (if applicable)
Signature of Responsible Party (On Privacy Practices)*

Clear
Date of Signature

MonthDayYear
Date

Practice Policies
Your Therapist: Sessions with therapists are by appointment only. The best way to contact your therapist is by calling his/her direct phone number or sending an e- mail to the email provided by him or her. Voice mail will be checked throughout the day and at least once in the evenings and on the weekends. They will return your phone call as soon as possible. In the event of an emergency, please contact Riverside Hospital Behavioral Health Emergency Services at (614) 566-5056, NetCare Access at (614) 276-CARE or 911.

Appointments: Appointments are typically 50-60 minutes long. Missed appointments are not covered by insurance and may be paid out of pocket. There is a $60 no show fee if there is not 24 hours notice of a cancelation

Payments & Insurance: Co-payments are due at the time of the appointment. Payments can be given to the therapist , or you can use your card on file. If you are unsure about your balance or have any questions regarding billing, please contact yout therapist

Confidentiality: Everything that takes place in psychotherapy is confidential and may not be released without your expressed written permission. There are two exceptions to this: if you or your child becomes a danger to self or others; and if you or your child is involved in child abuse. In these situations I am legally bound to break confidentiality in order to protect all involved. Confidentiality for children and adolescents in situations other than those listed above will be discussed with you during the evaluation phase of treatment.

By signing. this document, I understand and agree with the policies described above. I also understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. If my account is more than 90 days in arrears, I authorize that pertinent billing information can move released to a professional service for the purpose of collection of the outstanding balances.
Signature of the Client or Responsible Party (if applicable) for the Practice Policies*

Clear
Date of Signature of the client for the Practice Policies*

MonthDayYear
Date

Consent for Psychotherapy/Treatment
General Information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and # 4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

By Signing below I am agreeing that I have read, understood, and agree to the items contained in this document.
Client name (Consent for Psychotherapy/Treatment)*

First NameMiddle NameLast Name
Client or Responsible Party (If applicable) Signature (Consent for Psychotherapy/Treatment)*

Clear
Date of Signature (Consent for Psychotherapy/Treatment)

MonthDayYear
Date
Parent or Guardian Name (if applicable) (Consent for Psychotherapy/Treatment)

First NameMiddle NameLast Name
Just scroll/click "next" through the next sections and complete the releases you were asked to complete, or that would make sense for you to complete depending upon your particular situation.

Release of Information
I hereby authorize
or designate) to exchange with/obtain from:
(Name of person or organization)
Information specified below regarding the care of:
Name of Client (Release of Information)

First NameMiddle NameLast Name
DOB of Client (Release of Information)

MonthDayYear
Date
EvaluationProgress/Therapy NotesTesting Results (Including Lab work)Other
Coordination of CareTransfer of CareOther
I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules.

I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to receive a copy of this authorization. I understand that I have a right to refuse to sign this authorization.

If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.
Signature for Release of Information

Clear
Date of Signature on Release of Information

MonthDayYear
Date
Relationship to the Client (If applicable) on the Release of Information
PROHIBITION ON REDISCLOSURE: THIS INFORMATION HAS BEEN DISCLOSED TO YOU FROM RECORDS WHOSE CONFIDENTIALITY IS PROTECTED BY FEDERAL LAW. FEDERAL REGULATIONS (42 CFR PART 2) PROHIBIT YOU FROM MAKING ANY FURTHER DISCLOSURE OF THIS INFORMATION EXCEPT WITH THE SPECIFIC WRITTEN CONSENT OF THE PERSON TO WHOM IT PERTAINS. A GENERAL AUTHORIZATION FOR THE RELEASE OF MEDICAL OR OTHER INFORMATION IF HELD BY ANOTHER PARTY IS NOT SUFFICIENT FOR THIS PURPOSE. FEDERAL REGULATIONS STATE THAT ANY PERSON WHO VIOLATES ANY PROVISION OF THIS LAW SHALL BE SUBJECT TO PROSECUTION UNDER FEDERAL LAW. THE FEDERAL RULES RESTRICT ANY USE OF THIS INFORMATION TO CRIMINALLY INVESTIGATE OR PROSECUTE ANY ALCOHOL

OR DRUG ABUSE PATIENT [52 FR 2 1809, June 9, 1987; 52 FR 4 1997, Nov. 2, 1987]

Consent for Telehealth Consultation
1. I understand that my health care provider wishes me to engage in a telehealth consultation.
2. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
By signing this form, I certify:
That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
Name of Client (for consent for Telehealth Consultation)

First NameMiddle NameLast Name
Client Signature (for consent for Telehealth Consultation)

Clear
Date of signature (for consent for Telehealth Consultation)

MonthDayYear
Date
Minor Client Name (if applicable) (for consent for Telehealth Consultation)

First NameMiddle NameLast Name
Parent or Guardian Name (if applicable) (for consent for Telehealth Consultation)

First NameMiddle NameLast Name
Parent/Guardian Signature (if applicable) (for consent for Telehealth Consultation)

Clear
Date of Parent/Guardian signature (if applicable) (for consent for Telehealth Consultation)

MonthDayYear
Date

Rows	Never	Some	Often	Very Often
A. Fail to give close attention to details, make careless mistakes
B. Have difficulty keeping your attention on tasks or play (trouble remaining focused on conversations, lectures, or lengthy reading)
C. Don't seem to listen, even when spoken to directly (mind seems elsewhere, even in the absence of any obvious distraction)
D. Don't follow through. Schoolwork, chores, or workplace tasks, once started, don't get done
E. Can't seem to get organized with tasks or activities (e.g., difficulty managing sequential tasks; difficulty keeping materials or belongings together; messy, disorganized work, poor time management; fail to meet deadlines.)
F. You avoid, dislike, or are reluctant to engage in tasks that require sustained mental effort (schoolwork or homework; preparing reports, completing forms, reviewing lengthy papers)
G. Lose things necessary for tasks, school or play (school material, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile phones)
H. Easily distracted by the smallest noise or object in the periphery (this may include unrelated thoughts)
I. Forgetful (doing chores, running errands; returning calls, paying bills, keeping appointments)
J. Fidgets or taps hands or feet: squirms in seat
K. Leave your seat in class, or other places that sitting in one place is expected
L. Run about or climb in places where you know you should not (in adults or adolescents may simply be a feeling of restlessness often.)
M. Can't seem to play or do much of anything quietly
N. Seem to be "on the go"' or "driven by a motor (unable to be or uncomfortable being still for extended times. May be experienced by others as being restless or difficult to keep up with)
0. Talks excessively
P. Blurt out answers even before the question is completed
Q. Can't seem to wait your turn
R. Interrupt or intrudes in to other people's space, conversations, games or activities. Use other people's things without asking; intrude or take over what others may be doing)

Rows	Never	Some	Often	Very Often
A. Are negative, hostile, and defiant in behavior
B. Lose temper
C. Argue with adults
D. Actively defy, or refuse to abide by, adults' requests or rules
E. Deliberately annoy people
F. Blame others for your mistakes or "bad" behavior
G. Are touchy or easily annoyed by others
H. Are angry and resentful
I. Are spiteful and unforgiving

Rows	Never	Some	Often	Very Often
A. You have developed a pattern where the basic rights of others or society's rules are violated
B. Bully, threaten, or intimidates others
C. Initiate physical fights
D. Have used a weapon toward someone (bat, brick, broken bottle, knife, gun)
E. Are physically cruel to people
F. Are physically cruel to animals
G. Have stolen by mugging, purse snatching, armed robbery or other means of direct confrontation
H. Have forced someone into sexual activity
I. Have started a fire with the intent of causing serious damage
J. Have destroyed someone's property on purpose (other than by fire setting)
K. Have broken into someone's house, building or car
L. You "Con" or lie to obtain favors, goods or to avoid obligations
M. Have stolen items of value not gum or candy etc without confronting a victim shoplifting, forgery etc
N. Stay out at night, despite being told not to. (Must begin before age 13)
0. Have run away from home for a significant period of time
P. Skip school (Must begin before age 13)

Rows	Never	Some	Often	Very Often
A. Are there periods where your mood seems down OR irritable most of the day nearly every day
B. Have you had a significant decrease in interest or pleasure in things
C. Has there been weight loss (or failure to make expected weight gains) when not dieting
D. Are you sleeping less because you can't fall asleep or stay asleep
E. Do you feel, or have others said that you appear, slowed down OR restless
F. Do you have feelings worthless or feeling excessively "guilty" about something
G. Having a hard time making decisions; can't seem to think or remember
H. Are you thinking of suicide or death

Rows	Never	Some	Often	Very Often
A. Are there periods (lasting at least several hours) where your mood is abnormally irritable, elevated or uninhibited
B. During these periods do you feel inflated in your self-esteem or do you feel extra special
C. During these periods do you seem to need much less sleep appears rested after only 3 hours etc
D. During these periods are you much more talkative and does your speech seem "pressured" to get words out
E. During these periods do their thoughts seem to come from "nowhere"; difficult to follow or understand
F. Are you much more distractible during these periods
G. Do you have much more energy to complete tasks, achieve conquests or gain accomplishments
H. Have you been physically aggressive during these specific periods
I. Do you become involved in pleasurable activities that have a high potential for painful consequences

Rows	Never	Some	Often	Very Ofte
A. Do you have fears that seem excessive or unreasonable
B. Do these fears come about when they think about or come in contact with a certain object or situation
C. The fears described above involve animals, getting a shot, airplanes, storms or any other specific object or situation
D. Exposure to that object or situation causes you to "freeze", have tantrums or be clingy
E. You avoid the object or situation or you endure it with intense anxiety or distress
F. You recognize that the fear is excessive, extreme or unreasonable
G. The avoidance of (or distress from) the object or situation causes loss of esteem or problems at school or home

Rows	Never	Some	Often	Very Ofte
H. Do you have unusual or uncomfortable thoughts, images or impulses that enter into your mind and cause distress (Note: These are not simply excessive worries about real-life problems)
I. Do you attempt to ignore or suppress the thoughts/images by doing rituals or repeated "magical" acts or thoughts
J. Do you realize that the thoughts/images are a product of your mind
K. Are these worries or thoughts seen as excessive, extreme or unreasonable
M. The acts or images cause marked distress, or are very time consuming/interfere with normal life

Rows	Never	Some	Often	Very Often
A. Do you refuse to maintain body weight at or above a "normal" body weight for your age and height?
B. Is there an intense fear of gaining weight or becoming fat, even though underweight?
C. Do you not see yourself as underweight, or do you deny the seriousness of your low body weight, or place undue
D. In girls, has there been an absence of at least 3 menstrual cycles?
E. Are there recurrent episodes of binge eating and a sense of lack of control over the eating during that episode?
F. Are there recurrent episodes of behavior in an attempt to prevent weight gain such as vomiting, misuse of laxatives, fasting or excessive exercise?

Demographic Information

Insurance card photos

Notice of Privacy Practices

Notice:

Our Responsibility

Your Health Information Rights:

Acknowledgment of Receipt of Notice of Privacy Practices

Practice Policies

Consent for Psychotherapy/Treatment

Release of Information

Consent for Telehealth Consultation