New Client Information – Erin Fish, APRN-BC, or Kelly Culmore DNP Date* MM slash DD slash YYYY Who referred you to our practice? Patient Name* First Middle Last Sex* M F Date of Birth* MM slash DD slash YYYY Social Security Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone 1*Phone 1* Home Work Cell Phone 2Phone 2 Home Work Cell Patient's Employer Primary Care Physician or Psychiatrist* Address or Phone* Accounts must be kept current or statements will be mailed and calls will be made. In the event that we need to contact you may we:Leave a voicemail at the numbers above?* Yes No Send mail to home?* Yes No Leave our name and number with another person at the numbers above?* Yes No FOR MINOR CHILDREN OR PATIENTS WITH GUARDIANS (The parent/guardian who is bringing the child to the appointments will be listed as the responsible party. Please list that party’s name first)Parent/Guardian #1 Relationship Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Contact #1 Contact #2 Parent/Guardian #2 Relationship Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact #1 Contact #2 Emergency ContactEmergency Contact Name* Relationship* Phone*Primary Insurance Company* Name of Policy Holder* Sex Select All M F Relationship to Patient Date of Birth MM slash DD slash YYYY Social Security Contract/Member ID* Group #* Employer Secondary Insurance Company Sex M F Name of Policy Holder Relationship to Patient Date of Birth MM slash DD slash YYYY Social Security Contract/Member ID Group # Employer All Copays and Deductibles are Due at Time of Service INSURANCE RELEASE: I authorize the release of any information my clinician may feel is necessary to process my insurance claims. This may include information about my mental health. I authorize participating insurance payments directly to my provider. I fully understand that I will be responsible for any amounts due following a response from my insurance, including deductible and non-covered services. I understand that if I have an insurance the Psychology Associates does not participate with that I am responsible for payment in full at the time of service and a courtesy claim will be billed on my behalf and any reimbursement will be sent directly to me from my insurance company.Electronic Signature of Patient/Parent/Guardian* Date* MM slash DD slash YYYY Psychology Associates Mid Towne POLICY INFORMATION Thank you for choosing Psychology Associates Mid Towne. We are committed to providing you with the highest quality, professional and ethical treatment. Please understand that payment of your bill is considered part of your treatment. PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECKS, OR VISA / MASTERCARD I DISCOVER / AMERICAN EXPRESS. The following is Psychology Associate’s policy information, which we require you to read, Initial by checking the box next to each item, and electronically sign prior to any treatment. If you do not understand, or if you have any questions, please ask. Confidentiality*All information disclosed within sessions is confidential and may not be revealed to anyone without your expressed, written consent. There are exceptions to confidentiality. specifically IN CASES WHERE THE THERAPIST IS MANDATED BY LAW TO REPORT TO THE APPROPRIATE AUTHORITIES (i.e. WHERE THERE IS REASONABLE SUSPICION OF ABUSE OF CHILDREN. ELDERLY OR DISABLED PERSONS; WHERE THE CLIENT IS LIKELY TO HARM HIM/HERSELF OR OTHERS UNLESS PROTECTIVE MEASURES ARE TAKEN). If you have any questions about confidentiality, especially as it relates to children and adolescents, please ask your therapist. Please note that if you use insurance to help pay for your sessions, your signature on the bottom of our intake sheet grants the insurance company permission to request information about you from us. Initial Insurance*We participate with several Insurance companies. Participation means that we will accept what your insurance company approves. You are responsible for any copays, deductibles or non-covered services at the time of service. If we do not participate with your insurance company you are responsible for the full fee at the time of service. We will tum in a courtesy claim for you to your insurance so that they can reimburse you directly, apply the visit to your deductible. etc. Initial Payment for Services*Payment is expected at the time of the scheduled session unless you request other arrangements. If you are having diffiCUlty paying your bill please talk with us regarding payment arrangements. If we receive payment other than expected from your insurance company, the remaining balance will be transferred to your account. Any outstanding balance must be paid in full within 30 days. We will mail a statement to all clients who have a balance due on their account. If payment is not received within the calendar month, a $10 statement fee will be assessed. If an account remains unpaid, we will pursue collection of this past due account. Initial Minor Patients*The adult accompanying a minor and/or the parents/guardians of the minor are responsible for full payment. For unaccompanied minors treatment will be denied unless charges have been pre-authorized to an approved credit card or payment is made by cash or check at time of service. unless prior arrangements have been made. Initial Building Policies*Psychology Associates Mid Towne, located in the Women’s Health Center of West Michigan, has parking available in the attached Ellis parking structure. Please bring your parking ticket with you to your appointment and you will be given a parking voucher. You will need both the ticket and the voucher to exit the lot. Please note that this voucher will provide 1.5 hours free parking for your time spent in our office. Without this voucher, you will be required to use credit card payment to exit the ramp. There are fire alarm pull stations throughout the building. If a pull station is activated to create a false or nuisance alarm the fire department may assess a$1000 fine to the responsible party. Women’s Health Center of West Michigan is a smoke·free campus. This includes the building, the parking structure, and its surrounding property. Please dispose of your cigarettes, etc. before leaving your vehicle. Initial Cancellations / Missed Appointments*We request that appointment cancellations be made 48 hours in advance. Cancellations made less than 24 hours prior to the appointment or no show appointments may result in a charge that may total the full fee of your appointment. Initial Client Acknowledgement and Agreement *I have read and understood the above information. * I have had the opportunity to ask questions and have any questions answered. * I agree to pay the fee for each visit for services rendered.Electronic Signature of Patient or Responsible Party* Date* MM slash DD slash YYYY Electronic Signature Co-Responsible Party Date MM slash DD slash YYYY Psychiatric Addendum Policy Information The following is an addendum to Psychology Associate’s policy information, which we require you to read and initial prior to any treatment.Medication Refills*Medication refills will be addressed during scheduled appointments. A $20 charge will be applied for refills needed outside of scheduled appointment times. Initial Promptness*Please arrive on time for your appointment. If you arrive more than 10 minutes late for a med check appointment, the visit will have to be rescheduled. A late fee may be charged. Initial Additional Psychotherapy Charge*An additional psychotherapy charge may be added when psychotherapy is provided as part of the medication management visit. The amount of charge will vary with length of visit time. Initial Cancellations / Missed Appointments*Scheduled appointments must be kept, or cancelled / rescheduled with at least 24-hour notice. Cancellations made less than 24 hours prior to the appointment will result in a $65 charge. Broken appointments without notice will be billed the full fee of $110. Initial Practice Model*Patients must be actively involved in psychotherapy while receiving medication management services. This model supports the research that a combination of psychotherapy and medications is most effective in managing mental health problems. When therapy is terminated by the patient or therapist, patients will be referred to other community providers for long-term medication management (ex. PCP, Pine Rest, Forest View, or their insurance company for other suggestions.) Initial Notice of Privacy Practices Acknowledgement of Receipt I acknowledge that I have been offered the Psychology Associates of Grand Rapids and Affiliated Therapists and Psychiatrists Notice of Privacy Practices.Print Patient Name* Patient or Patient Representative Electronic Signature* Date* MM slash DD slash YYYY INFORMED CONSENT FOR TELEPSYCHOLOGY This Informed Consent for Telepsychology contains important information focusing on doing psychotherapy using the phone or the Internet. Please read this carefully and let me know if you have any questions. When you sign this document, it will represent an agreement between us. Benefits and Risks of Telepsychology Telepsychology refers to providing psychotherapy services remotely using video conferencing. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Te1epsychology, however, requires technical competence on both our parts to be helpful. Although there are benefits of telepsychology, there are some differences between in-person psychotherapy and telepsychology, as well as some risks. For example: Risks to confidentiality. Because telepsychology sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. Issues related to technology. There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session. Crisis management and intervention. In the event of a life-threatening emergency please call the office and speak with a support staff or follow the after-hours prompts for contacting our answering service. Efficacy. Most research shows that telepsychology is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand nonverbal information when working remotely. Electronic Communications We will be using the telecommunication service. You will need a cell phone, tablet or computer with a camera and microphone to use telepsychology services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telepsychology. Confidentiality I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our telepsychology. Our system is HIPAA compliant and does not store session content. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. You should also take reasonable steps to ensure the security of our communications (for example, having passwords to protect the device you use for telepsychology). Technical Concerns If the session is interrupted, disconnect from the session and I will wait two (2) minutes and then re-contact me via the telepsychology platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, then I will contact you via phone. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. Fees The same fee rates will apply for telepsychology as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in telepsychology sessions in order to determine whether these sessions will be covered. Records The telepsychology sessions shall not be recorded in any way. I will maintain a record of our session in the same way I maintain records of in-person sessions in accordance with my policies. Informed Consent This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together and does not amend any of the terms of that agreement. Your signature below indicates agreement with its terms and conditions. Client Signature* Date* MM slash DD slash YYYY CLIENT AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION VIA ELECTRONIC COMMUNICATIONClient Name* Birth Date* MM slash DD slash YYYY Purpose of Request: I authorize the Practice and my Provider,named below, to disclose Protected Health Information (as described below) directly to me at the e-mail address and/or text number I have indicated. I understand that it is my responsibility to notify the Practice and my Provider of any changes in my e-mail address and that any disclosure made to the e-mail address, indicated by me, is subject to the redisclosure statement within this authorization.Client E-Mail Address Client Text Phone Number I authorize the Practice and my Provider to disclose the following Protected Health Information about me to the e-mail address I have indicated (please provide a written description of the information to be disclosed): Appointment Scheduling Only Clinical Updates Other: Describe below DescriptionPurpose of Disclosure: I am authorizing the disclosure of my Protected Health Information to the specified e-mail address as a means of enhancing communication with my healthcare Provider and the Practice. Expirations or Termination of Authorization: This authorization will expire one year from the date it was initiated unless I specify an earlier termination. I understand that I must submit a new authorization after the expiration date to continue the authorization. I also understand that I have the right to terminate this authorization at any time. Desired Date MM slash DD slash YYYY Right to Revoke or Terminate: As stated in the Practice’s Notice of Privacy Practices, I have the right to revoke or terminate this authorization by submitting a written request to the Practice’s Privacy Manager. This may be presented in person, or by mailing a request to the Practice, Attn: Privacy Manager. Re-Disclosure: I understand that the Practice has no control regarding persons who may have access to the email address I have listed to receive my Protected Health Information. Therefore, I understand that my Protected Health Information disclosed under this authorization will no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of this Practice. Use of Electronic Communication: I understand that electronic communication is not intended to be used for therapy. I also understand that it is not to be used for clinical emergencies or urgencies. I acknowledge that there may be a fee associated with the exchange of electronic communications, and the clinical review of and response to that communication. I understand that any fee charged will not be billed to my insurance carrier and I hereby agree to pay any fee assessed. Fees will be charged at the clinical hourly rate unless otherwise identified below. Provider's Name* New Patient InformationLegal Name* Preferred Name* Biological Sex* Preferred Gender Pronoun* Gender Identity Birthdate* Age*Questions or concerns you'd like addressedWrite down any questions or concerns about treatment you'd like us to address:*Mental Health History None Have you received counseling in the past?* Yes No If yes, when, with whom, and for what reason?Substance Abuse HistoryAlcohol* None Past Present Alcohol frequency/amount Drugs* None Past Present Drugs frequency/amount Nicotine* None Past Present Nicotine frequency/amount Caffeine* None Past Present Caffeine frequency/amount Have you received treatment for any of the above substances?* Yes No If yes, when, for what substance, and how long? Family/Social/Personal HistoryDo you have any family members with substance abuse or mental health problems?* Yes No If yes, list relationship and the problem. Describe your current family relationships and living arrangements.*Is there any history of verbal, physical, or sexual abuse or assault in your past?* Yes No If yes, please describe.Have there been other very difficult or stressful things in your past?* Yes No For example, serious accident; life-threatening or serious illness or injury; a sudden, violent or unexpected death of someone close to you, other significant losses such as a partner, child, parent, petIf yes, please describe.Relationship HistoryRelationship Status* Single Married Separated Divorced Living together Name of spouse/partner: If married, number of years: Date of separation: Date of divorce: Number of years living together: If in a relationship, how would you describe the quality/satisfaction of your present relationship?How many children do you have and what are their ages?Educational/Employment HistoryWhat is the highest grade you completed in school?* GED?* Yes No Other education/training? Occupation/Vocation:* Current Employer:* How long at current employer?* Legal HistoryNumber of arrests:* Nature of arrest(s): Other legal concerns: Religious/Spiritual BackgroundList any formal religious affiliation: Cultural/Racial Identity: White/Caucasian African American Asian Hispanic American Indian Middle Eastern Muslim Hindu/Buddhist Recent SymptomsHow many days have you felt well in the past week (mentally and physically)?*0-7Any sleep problems in the past week?* Select All Falling asleep Staying sleep Waking too early Rate how you've felt over the past week:Depression, including lack of pleasure/motivation* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Inactive, withdrawing or not doing much* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Trouble making decisions, concentrating, planning or organizing* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Thoughts that you would be better off dead, or of hurting yourself* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Anxiety, fear, or nervousness* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Irritable, impatient, or argumentative* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Energized, agitated, restless, wired; or still active despite few hours of sleep* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) More hyper, driven, active, or doing a lot more than normal for you* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Doing things that others might think are risky, impulsive or excessive* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Rapid thoughts that move so fast it's hard to follow them* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Difficulty sustaining attention (e.g. reading, lectures, conversation, TV)* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Distracted by noises around you or by your own thoughts* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Procrastinating, avoiding tasks, or not finishing them* None Mild (infrequent or rarely causes a problem) Moderate (often or causes some problems) Severe (constant or causes many problems) Choose ANY recent symptoms (regardless of their cause)Mental: emotional numbing paranoid sensations panic attacks hearing voices or seeing things tired memory problems If panic attacks, how many per week: Sleep: needing > 10 hrs sleep needing < 4 hrs sleep vivid dreams sleep-walking snoring Neurologic: inner tension or restlessness muscle stiffness slowing or weakness in muscles unwanted muscle movements (besides tremor) imbalance dizziness fainting or falling tremor sensory changes taste changes headaches teeth grinding General: flu-like feelings sexual difficulties physical pain If physical pain, rate 1-10, 10 = worst: Eyes: blurry vision visual changes double vision Stomach: increased appetite binging or purging appetite loss stomach pain nausea diarrhea constipation dry mouth excess thirst excess salvation Skin: rash acne excess sweating itch easily sunburned unusual bruising hair loss Heart: palpitations Urinary: frequent urination difficulty urinating Female: menstrual changes breast changes Caffeine – how many cups per day?* Nicotine – how many packs per day?* Alcohol – how many drinks per day?* Other drugs: Sleep meds – how many per week?* If taking any meds as-needed for anxiety, how many do you use? per day/week/monthCurrent weight:*Current height:*Allergies to medications?* Yes No If yes, which one(s)? Current medications (including over-the-counter and vitamins)Include name, dose, and when you started it.Have you ever had any of the following:Diabetes* Yes No High blood pressure* Yes No High cholesterol or lipids* Yes No Heart disease* Yes No Thyroid illness* Yes No Head injury* Yes No Seizure* Yes No Migraines* Yes No Multiple sclerosis* Yes No Stroke* Yes No Psoriasis* Yes No Family history of diabetes* Yes No Arthritis* Yes No Chronic pain* Yes No Sexually transmitted diseases* Yes No Renal/kidney disease* Yes No Restless leg syndrome* Yes No Sleep apnea* Yes No Glaucoma* Yes No Liver disease/hepatitis* Yes No Heartburn/reflux* Yes No Asthma* Yes No Complications in your birth or first few months of life* Yes No Other: Handedness* Right Left Ambidextrous (equally right/left) For women, are you currently pregnant, breast-feeding or considering pregnancy? Yes No For women, is your menstrual cycle active? Yes No Are you in treatment with anyone else (primary care doctor, therapist, etc.)?List name, city, and phone numberPast TreatmentsHave you ever been admitted to a hospital for mental health?* Yes No Yes to ER but not admitted Which psychiatric medications have your tried?*List medication name, start/stop dates or year/duration, and how you responded to it.
