Intake Form for Mental Health Providers

ESA/PSD Evaluation Form

The following questionnaire will take approximately 5 minutes to complete. Please be sure to complete the entire questionnaire AND then hit submit.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Order Number
Order Number Begins with Letters ADA
E-mail
Phone Number*

Area CodePhone Number
Birth Date*

MonthDayYear
Gender*
Name of Pet & Breed
Pet Type

DogCatOther
Type of ESA/PSD Plan Purchased

Psychiatric Service Dog Housing/TravelPsychiatric Service Dog TravelPsychiatric Service Dog HousingEmotional Support Animal Housing
Occupation
Marital Status
Spouse's Name
Spouse's Occupation
Spouse's Employer
Number of Children
Children's Names, Ages

History of the Present Problem
Purpose of this appointment:*
Have you ever had the same or a similar problem?

YesNo
If yes, please describe:

ESA/PSD Evaluation Form
Social History
Do you do any of the following? (Please check all that apply)

ExerciseUse tobacco productsConsume caffeineSleep well at nightDrink alcoholTake vitamin supplements
If you checked any of the options above, please detail below:
What are your hobbies?

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The Therapy Process

Working with you to identify presenting issues and develop a plan of care is the goal. However, it is your commitment to identifying personal goals towards which you desire to move and obstacles which may prevent that movement which will, in large part, determine the success of the therapy. If you have a crisis situation develop after hours, call the suicide prevention hotline at (800) 784-2433 or go to your local emergency room.

The privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require ethical and legal commitment to the confidentiality of your Personal Health Information.

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Legal Responsibility

Under the laws of the United States your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.

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Use and Disclosure of Your Personal Health Information (PHI)

Your PHI will not be used or disclosed for any purpose not listed below, without your specific written authorization. You must give written authorization to disclose your health information to anyone for any reason you want. Any specific written authorization you provide may be revoked at any time by your written request.

· Health Care Provider - PHI may be used and disclosed to your therapist who is also treating you.

· As Law Requires - Your PHI may be used and disclosed to any person required by federal, state, or local laws to have lawful access to your treatment program.

· Appointment Reminders - You may be contacted by phone or email for an appointment reminder. If contact is by phone, a recorded message may be left on your answering machine.

· Therapist Cancellation – If for some reason an appointment must be cancelled, you will be contacted by phone or email. If contact is by phone, a recorded message may be left on your answering machine/voicemail.

· Event of an Emergency - Your PHI may be disclosed to a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, you will be given an opportunity to object. If you object or are not present or are incapable of responding, your PHI will be used or disclosed in your best interest at that time. In so doing, only the aspects of your PHI that are necessary for response to the emergency will be used or disclosed.

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Patient Rights

· With limited exceptions, you can make a written request to inspect your PHI that is maintained by us for our use. Your PHI includes basic information about your diagnosis, treatment dates, treatment plans, intake and termination summaries. Psychotherapy notes may be exempt from this ruling.

· You must make a written request to have your PHI communicated with you by alternative means at an alternative location. (An example would be if your primary language is not spoken and a child for whom you have lawful custody is being treated.) Your written request must specify the alternative means and location.

· You can make a written request that restrictions be placed on other ways we use or disclose your health information. Any or all of your requested restrictions may be denied. If these restrictions are agreed to, they will be abided by in all situations except those in which professional judgment constitutes an emergency.

· You can make a written request that your PHI be amended. If approved, your records will be changed accordingly. Notification will also be made to anyone else who may have received this information and anyone else of your choosing. If denied, you can place a written statement in your records disagreeing with the denial of your request.

Contact Information
I understand that I may be contacted 12-24 hours in advance to confirm a scheduled appointment. I have indicated my preferred means of contact for this notification below.
Select one:*
Phone Number*

Area CodePhone Number
E-mail*
Best Time Frame To Reach You

:HourMinutesAM/PM Option
I understand that a scheduled appointment may need to be cancelled. I have indicated my preferred means of contact for this notification below.
Select one:*
Phone Number*

Area CodePhone Number
E-mail*

This section will require initials at the time of your first appointment.
Signature and Submission
Please type your name below to indicate consent to treatment and acknowledgement of Informed Consent & Privacy Policy. In addition you indemnify and hold harmless USASDR of all damages to property or person caused by your service dog or emotional support animal. You agree to indemnify, defend and hold harmless the company, its affiliates, and their respective officers, directors, employees, agents, contractors, therapists and representatives from and against any and all liability and costs (including, without limitation, attorneys’ fees) incurred by them in connection with any claim, threatened claim, damages, or other loss arising out of your breach of these terms of use or the representations, warranties and covenants contained herein or a claim by a third party that is based on your use of this site and/or your use of the material in violation of these terms or for infringement of any intellectual property rights.
Patient's Signature*
Date*

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

MonthDayYear
Should be Empty:

ESA/PSD Evaluation Form

Personal History

History of the Present Problem

ESA/PSD Evaluation Form

Social History

Family History

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Contact Information

Signature and Submission