• Intake Form

  • We know your time is valuable, so we appreciate your taking the time to complete this intake form. It may seem lengthy, but our therapists will find it helpful for your treatment. Additionally, some information are required by the State and your insurance company. We appreciate your time.

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  • Personal Information

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  • Present Problem

  • Medical and Mental Health Information


  • Social Information


  • Family History


  • Wellness Survey

  • Over the last two weeks, how often have you been bothered by any of the following problems?

  • Informed Consent & Confidentiality Policy

  • 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 (877) 943-2052 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.

  • Legal Responsibility

    Under the laws of the United States and the State of Massachusetts 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.

  • 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 physician or other healthcare provider who is also treating you.

    · Payment - Your PHI may be used and disclosed to your health insurance plan or other third party for payment of services provided for you. If your contract with your insurance company requires that information relevant to the services provided be given before payment, providing them with a clinical diagnosis, as well as clinical information such as treatment plans or summaries and/or copies of any records maintained about your therapy sessions may be required.

    · Health Care Operations - Your PHI may be used and disclosed to staff members for the purpose of obtaining insurance eligibility, billing health insurance and inquiring about claim status.

    · 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.

    · Court Orders, Judicial and Administrative Proceedings, and Law Enforcement - Your PHI may be disclosed as part of a court proceeding, in response to a subpoena, or in other situations as required by law.

    · 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.

    · Victims of Abuse, Neglect, or Domestic Violence - Your PHI may be used or disclosed to authorized persons from state agencies in cases of disclosures required by applicable state laws governing abuse, neglect, criminal activities, threats to the health/safety of the client and others, domestic violence, etc. In the case of minor children, the law requires such information to be disclosed.

    · 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.

  • 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.

    · Requested copies of any PHI information will be provided at the cost of $.25 per page.

    · 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.

  • For Questions, Concerns, and Complaints

    We are committed to practice according to the ethics of our profession. You may contact the Massachusetts Division of Professional Licensure and/or the secretary of the United States Department of Health and Human Services with questions or to register complaints about any licensed mental health professional.

  • Agreement and Understanding

  • Appointment Confirmations: I understand that I may be contacted via text or phone 24-48 hours in advance to confirm a scheduled appointment.

  • Your insurance company may require us to consult with a client’s primary care physician or psychiatrist whenever symptoms of a mental health diagnosis are present. The purpose of such consultation is to determine if there may be a medical condition or medication that may be causing or contributing to the client’s symptoms. The client/parent/legal guardian may also choose to waive such consultation. The clinician may provide treatment or evaluation until such time that the medical consultation is obtained or waived.
  • Financial Agreement

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  • A valid credit or debit card is required to hold your appointment. Please upload your credit card information below. If you are unable to do so, please call our billing partner, Therapist Solutions, Monday - Friday between 9 am and 4 pm at 860-535-9922. Therapist Solutions is contracted by TCA to handle our billing and claims services. The information you provide them is strictly confidential.

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  • Signature

  • Please type and sign your name below to indicate consent to treatment and acknowledgement of Informed Consent, Privacy Policy and financial agreement.

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    If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.

     

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