Adult Intake Form - Rock Landing Psychological Group

Name

Date

Marital Status

Date Of Birth

Sex

Female

Male

Ethnicity

Address

City, State, ZIP

Preferred Contact Method: (Cell/Home)

Secondary Contact Method: (Cell/Home)

Occupation

SSN

Emergency Contact Person

Phone

IF DIFFERENT THAN ABOVE, GUARANTOR INFORMATION (RESPONSIBLE PARTY)

Relationship to Client

Spouse

Parent

Guardian

Name

Address

Date of birth

Gender

Female

Male

SSN

Employer

Occupation

Home Phone

Work / other phone

INSURANCE INFORMATION

Primary Insurance

Subscriber Date of Birth

Subscriber Name

Subscriber SSN

Policy ID #

Group #

Subscriber’s Employer

Work Phone

Secondary Insurance

Subscriber Date Of Birth

Subscriber Name

Subscriber SSN

Policy ID #

Group #

Subscriber’s Employer

Work Phone

Treatment Contract

Insurance and Financial Policy Statement

Thank you for choosing Rock Landing Psychological Group for counseling. As part of providing high quality services, we need to clarify our financial policies. Should you have any questions regarding the practice policies, please ask a member of the staff for clarification.

If you are using your health insurance benefits, we will bill your insurance company. To do so, we need you to provide us with accurate and timely information regarding your insurance. All co-pays, deductibles, and denied payments are your responsibility. Your health insurance company may require you to make a co-payment and/or satisfy a deductible. The co-payment is determined by your health insurance company and is due at the time of service. If you have a deductible which has not been met, then the full fee is due until the deductible has been met.

I authorized a release of information to my health insurance company and I assign all benefits to Rock Landing Psychological Group.

Late Cancellation/No Show Fee

Rock Landing Psychological Group requires 24 hour notice for routine cancellations. Late cancellations and no shows will incur a $65.00 charge for a missed appointment with your therapist and a $75.00 charge for missed appointment with your psychiatrist to be paid at your next scheduled session. Please note that your health insurance company will not cover this fee. The practice has a 24 hour voice mail system to take your cancellations. Please call (757) 873-1736 and speak to a staff member or if it is after hours leave a message for he scheduling staff on the voice mail system. At the time of check out you are given a card with the date of your next scheduled appointment. Our office will make every effort to remind you of your scheduled appointment. However, it is your responsibility to be aware of your appointment. Repeated cancellations and/or missed appointments may result in being disengaged from this practice.

Late Cancellation/No Show Fee for Psychological Testing

The psychologist requires 72 hours for cancellation for testing. Late cancellations and no shows will incur a $65.00 charge for each hour the individual was scheduled for testing. Please note the health insurance company will not cover this fee. Please be aware it will be at the discretion of the examiner as to whether or not the individual will be rescheduled for testing.

Signature

Clear

Date

Consent to Treatment

I do hereby seek and consent to take part in the treatment provided by Rock Landing Psychological Group.

I understand that developing a treatment plan with my provider(s) and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process.

I understand that no promises have been made to me as to the results of treatment or of any procedures rendered by my provider(s).

I am aware that I may stop treatment with my provider(s) at any time. I will still be responsible for payment of services I have already received.

Signature

Clear

Date

Coordination of Treatment

If I am referred to any other clinician or physician at Rock Landing Psychological Group, I give my consent for those clinicians to obtain and release pertinent information to each other for the purpose of coordinating my care.

Signature

Clear

Date

I give permission to the following to schedule and/or speak with the office about my appointment.

Agreement

I hereby attest that all information contained in these pages is current and correct. I understand that I am responsible for informing Rock Landing Psychological Group of any changes. Failure to do so may delay processing of insurance claims, in which case I will incur responsibility for those unpaid claims. Falsification of this information is punishable under Federal Law. I have received a copy of the Notice of Privacy Information Practices (HIPAA) pertaining to this practice.

Client Signature

Clear

Date

Responsible Party Signature

Clear

Date

Referral Information

Who referred you to this practice?

May we have permission to thank them for your referral?

Yes

Have you been seen here before?

Yes

If yes please give approximate date and reason for seeking counseling

Additional Information

Are you and/or your child currently involved in the legal system?

Name of spouse/partner

Age

Please list names and ages of children

Your Education & Training

Pre-School to High School

High School Diploma/GED

Vocational/Technical School

College

Graduate/Professional School

Client Signature

Clear

Date

Health Information

Prescription medications your child takes.

List medication, dosage, and what it's taken for

List all diseases, illnesses, significant accidents and injuries, surgeries, hospitalizations, periods of loss of consciousness, seizures, and any other medical conditions you have or have had.

Are you now being treated for any medical condition?

Yes

When was your last medical exam?

Your health is:

Excellent

Good

Fair

Poor

Describe any allergies you have by allergy, reaction and medications taken.

Health Habits

Do you use any tobacco products?

Yes

If yes, number of packs per day

Do you wish to quit?

Yes

Do you drink alcohol?

Yes

Drinks per day

Drinks per week

Has your drinking ever been a problem?

Yes

Previous Treatment?

Do you use street drugs?

Yes

If yes, which ones?

Has your drug use ever posed a problem?

Yes

Treatment?

Yes

How many cups of caffeinated beverages do you drink each day (coffee, tea, cola)?

None

1-3

4 or more

Do you frequently take over-the-counter medications?

Yes

Is so, which ones?

Do you take vitamins/food supplements?

Yes

If so, which ones?

How often do you exercise?

Are you aware of the physical and mental health benefits of regular exercise?

Yes

What do you do to manage stress?

Mental Health History

Have you ever had a psychiatric hospitalization?

Yes

If yes, please enter date, facility and the reason

Was it helpful?

Yes

Have you ever had mental health/family/marriage counseling?

Yes

If yes, enter date and counselor

Was it helpful?

Yes

Have you ever been under the care of a psychiatrist?

Yes

If yes, enter date and counselor

Was it helpful?

Yes

Have you ever thought a lot about trying to harm or kill yourself?

Yes

If so, when and where?

Please mark all of the items below that apply

Name

Date

Problems with thinking

Attention, concentration, distractibility

Decision making, indecision, mixed feelings, putting off decisions

Obsessions, compulsions (thoughts or actions that repeat)

Delusions (false ideas)

Memory problems

Confusion

Abuse

Physical

Neglect (of child or elderly)

Sexual

Emotional

Employment/Career Problems

Additional concerns or issues:

Please look back over the concerns you have checked off and choose the one which you most want help with. It is:

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