Adult New Client Forms - ahpdelaware.com · Describes how we will work together. Client Concerns Checklist and Questionnaire to let us know about your concerns. Client Survey Survey

Adult New Client Forms

This packet includes the forms listed below.

Please bring these completed forms with you to your first appointment at Associates in Health Psychology (AHP). Since your therapist may want some additional information, please arrive 5 minutes early. There will not be a receptionist so you do not need to check-in with anyone. Any additional forms for you to complete will be on a clipboard marked with your therapist's name and time of your appointment.

Welcome

Information about beginning therapy.

Intake Asks for contact information, some medical and personal background, and family history.

Office Policies Provides you with an overview of our general office policies and procedures.

Privacy Policies Gives you information about how the privacy of your health information is maintained. These pages are for you to keep.

Acknowledgment of Receipt of Privacy Policies

Only this page of the Privacy Policies needs to be signed and returned.

Consent for Therapy/Evaluation

Describes how we will work together.

Client Concerns

Checklist and Questionnaire to let us know about your concerns.

Client Survey

Survey about your goals for treatment.

Insurance Assignment,

Health Insurance Managed Care Release

and Insurance Information

Complete ONLY if our office staff has determined that we participate with your insurance plan. Please be sure to bring your insurance card and a photo ID for your therapist to copy at your initial appointment. At the time of each visit, our office will accept cash, check, or credit card (Visa, Discover or MasterCard) payments for your co-pays and deductibles. Also included is an explanation of your

your co-pay, co-insurance and deductible obligations.

Authorization to Release Information

The first Authorization form allows your therapist and AHP to coordinate care with your primary care provider. The second Authorization form may be filled out to allow us to communicate with the person who referred you, a specialist involved in your care, or anyone else you would like to keep informed of your treatment with AHP. Please complete a separate form for each contact person, providing the name, address, telephone, and fax number for that person.

If you bring the completed forms with you to your first appointment, do not

complete an extra set in the office. Please check the clipboard in case your

therapist left any additional forms for you to complete.

Forms19/Intake/FormsListAdultWebJul19

J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803

(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com

Welcome to Associates in Health Psychology. We look forward to helping you find meaningful solutions to the challenges you face. Beginning the important work of therapy is often a difficult decision. Even once your initial appointment has been made, you may feel both eager to begin as well as somewhat uncomfortable about coming in for your first meeting with your therapist. We understand. Many people find the thought of beginning therapy unsettling until they actually start the process. Then they feel more comfortable. Now that you’ve taken the first step toward working on some of the areas of concern in your life, try not to let some initial discomfort keep you from pursuing what you know will be in your best interest. Before your first meeting, you might think about what you hope to gain from therapy and what is most important to you. Then you can discuss these thoughts with your therapist. Some clients have found that jotting down notes about what they want to discuss helps them feel more comfortable. If you have any questions prior to your appointment, please call our office or email us. You may leave a message for our office staff or our therapists 24 hours a day, 7 days a week at 302-428-0205. Our email is: [email protected]. For directions to our locations, see: www.AHPDelaware.com/locations.htm. Location information is also available on our telephone system. Cordially yours, The Therapists at Associates in Health Psychology

Forms19\Intake\WelcomeIntroAdultWebJun19.doc

http://healthymindsdelaware.com/locations.htm

Associates in Health Psychology, LLC adult intake

(302) 428-0205 Wilmington & Newark

Name _______________________________________________________ Date__________________ First Middle Last

Address ________________________________________ Home Phone _______________________

City ________________________________________ Cell Phone _______________________

State, ZIP _______________________________________ Work Phone _______________________ Date of Birth _______________ Age _____ Sex ____ Email ______________________________

Relationship Status ❏Married ❏Never Married ❏Domestic Partnership/Civil Union

❏Partnered ❏Separated from spouse/partner ❏Divorced/permanently separated from

spouse/partner ❏Other: _________________________________________________

Employer ____________________________________ Occupation _______________________________

Highest Grade Completed _______ Educational/Vocational Specialization _________________ Notify in Emergency _______________________________________ Phone ______________________ Name / Relationship

When did symptoms first appear? _______________ Similar symptoms in past? _____________ Referred by ____________________________________________________________________________ Primary Care Doctor and Other Medical Specialist(s) Seen for Ongoing Health Conditions

Health Care Provider’s First & Last Name Specialty Area City & State

List all Health Conditions and Allergies (If you need more space for this or any other item, please attach an additional sheet.) _________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________ Current Use of: Caffeine_____ Cigarettes/Tobacco_____ Alcohol_____ Drugs_____ Past Use of: Caffeine_____ Cigarettes/Tobacco_____ Alcohol_____ Drugs_____

FOR OFFICE USE: HA SB MD CE SE JF SBJ HLS SX AR KTH CW _____

DSM-5: ________________________________________________________________________________ ICD10: _____________

DSM-5: ________________________________________________________________________________ ICD10: _____________

IntakeAdultJun19 page 1 of 3

AHP, LLC Name ________________________________________________________________ PAGE 2 First Middle Last

List all current medication, condition for which you take the medication and dosage:

Medications /Supplements/Vitamins Condition Treated by whom? Dosage

Previous Treatment History

Psychological/Psychiatric: Have you ever received outpatient or inpatient psychological or psychiatric services, drug/alcohol treatment, counseling services, or psychiatric medications prescribed by a provider other than a psychiatrist or psychiatric nurse practitioner? No Yes. If yes, please describe:

When (approx. dates)?

For what (diagnosis)?

What kind of treatment?

Where or from whom?

With what result?

Other Significant Medical Treatments (Hospitalizations, Major Injuries, Surgeries): List hospitalizations, head injuries, concussions, important accidents & injuries, surgeries, and other medical conditions not previously listed.

Condition Age Treated by whom Results

IntakeAdultJun19 page 2 of 3

AHP, LLC Name _______________________________________________________________________ PAGE 3 First Middle Last

Family: Spouse/Partner _____________________________ ______ ___________________________ Name Age Occupation

Children Name Sex Age Residence (City & State)

Client Birthplace ________________________ Childhood Residence _________________________

Father's Occupation _____________________ Mother's Occupation _________________________

Brothers & Sisters Name Sex Age Residence (City & State)

Are you currently involved in a lawsuit, custody case or accident, short term disability (STD), long term disability (LTD), FMLA, social security disability application, injury or workman’s comp case? Yes No If yes, please explain:

__________________________________________________________________________________________________

__________________________________________________________________________________________________ Please indicate important or stressful life events that have impacted you, such as deaths of people close to you, job loss, abuse or other victimization, etc.

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________ What else would you like me to know about you or your family, including religious, ethnic, or cultural background or hobbies, skills, talent or interests?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Forms2019/ IntakeAdultJun19 page 3 of 3

Associates in Health Psychology, LLC

Wilmington & Newark

OFFICE POLICIES

OfficePoliciesJun19 page 1 of 2

In order to prevent misunderstandings about office policies, please read the following:

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to

those sessions are confidential and may not be revealed to anyone without your written permission, except

where disclosure is required by law or by court order. The law requires disclosure where there is a

reasonable suspicion of child abuse (past or present), elder abuse or neglect; where a client presents a

danger to self, to others, or to property; is gravely disabled; or is significantly impaired from drug and/or

alcohol use. In these emergency situations, therapists will do whatever they can, within the limits of the

law, to prevent clients from injuring self or others and to ensure that clients receive the proper care.

Disclosure is also required by law when there is reasonable suspicion of a licensed medical practitioner or

other licensed healthcare provider who is guilty of unprofessional conduct or appears to be unfit to

practice. Within AHP, therapists share on-call responsibilities. All AHP therapists are legally bound to

keep disclosed information confidential. However, we can’t guarantee confidentiality if you exchange

emails, cell phone calls or texts with anyone from AHP. We will maintain client case files for 7 years

from the last session date, or until the client reaches age 21, whichever is later.

TELEPHONE & EMERGENCY PROCEDURES: If you need to reach your (or your child’s) therapist

between appointments, you may leave a message 24 hours a day, 7 days a week, on his/her voice mail at

(302) 428-0205. If your call is urgent, call (302) 428-0205 and dial extension 9. Inform the office staff

or our answering service that your call is urgent. If it is during office hours and your therapist is available,

he/she will call you back. After hours, the on-call therapist will call you back as soon as possible. If your

call is urgent and a therapist does not call you back immediately, please call the Rockford Center Needs

Assessment (302) 996-5480, Psych Crisis Team at Christiana Hospital (302) 320-2118, Psych Crisis

Team at Wilmington Hospital (302) 428-2118, Crisis Intervention Services (302) 577-2484 or (800) 652-

2929, or MeadowWood Hospital at (302) 213-3568. If your call is a life-threatening emergency, you

should go immediately to the closest hospital or call 911.

PAYMENTS: At each session, payment is expected for any fees due. Missed appointments will be

charged to you at your therapist’s usual and customary rate, unless you cancel 24 hours before the

scheduled appointment. Monday appointments must be canceled by the previous Friday. Telephone

conversations, site visits, report writing and/or form completion, consultation with other professionals,

reading records, longer sessions, and/or travel time will be charged at the therapist’s standard, non-

contractual rate. Requests to release your records will be subject to an administrative charge.

INSURANCE REIMBURSEMENT: If you have a health insurance policy, it will usually provide some

coverage for mental health treatment. AHP will provide you with assistance in helping you receive the

benefits to which you are entitled; however, you (not your insurance company) are responsible for full

payment of my fees. It is important that you find out exactly what mental health services your insurance

policy covers. Due to the rising costs of health care, insurance benefits have increasingly become more

complex. It is sometimes difficult to determine exactly how much mental health coverage is available.

These plans are often limited to short-term treatment approaches designed to work out specific problems

that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more

therapy after a certain number of sessions. Though a lot can be accomplished in short-term therapy, some

patients feel that they need more services after insurance benefits end. (Some managed-care plans will

not allow me to provide services to you once your benefits end. If this is the case, I will try to assist you

in finding another provider who will help you continue your psychotherapy.)

Associates in Health Psychology, LLC OFFICE POLICIES, page 2

Forms2019/Intake/OfficePoliciesJun19 page 2 of 2

You should also be aware that most insurance companies require that I provide them with your clinical

diagnosis. Sometimes I have to provide additional clinical information, such as treatment plans, progress

notes or summaries, or copies of the entire record (in rare cases). This information will become part of

the insurance company files. Though all insurance companies claim to keep such information

confidential, I have no control over what they do with it once it is in their hands. In some cases, they may

share the information with a national medical information databank. By using your insurance, you

authorize me to release such information to your insurance company. I will try to keep that information

limited to the minimum necessary.

It is important to remember that you always have the right to pay for my services yourself to avoid the

problems described above (unless prohibited by the insurance contract).

LITIGATION LIMITATION: Due to the nature of the therapeutic process, which often involves

making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that

should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, or

lawsuits), neither you nor your attorneys, nor anyone else acting on your behalf, will call on you (or your

child’s) therapist to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy

records be requested. If you become involved in legal proceedings that require my participation, you will

be expected to pay for any professional time I spend on your legal matter, even if the request comes from

another party. (Because of the difficulty of legal involvement, I charge three times my hourly private pay

therapy fees for professional services which involve preparation and attendance at any legal proceedings

I am asked or required to perform in relation to your legal matter.)

RECORDING: Video or audio recording of any part of a session by either the therapist or client requires

the written consent of both.

TERMINATION: After the first one or two meetings, your therapist will assess if he/she can be of benefit

to you (or your child). Our therapists accept clients only if, in their opinion, they have the particular skills

and experience necessary for treatment. If at any point the therapist assesses that he/she is not effective

in helping you reach your therapeutic goals, your therapist will discuss it with you. If appropriate,

treatment will end and you will be given referrals to other treatment providers. You also have the right to

terminate services at any time. If you wish to do so, please inform your therapist directly so the necessary

steps may be taken to discharge you from care and close your file. If you do not show up for two scheduled

appointments without notice, or you miss an appointment and your therapist does not receive a message

from you during the next 4 weeks, your therapist will assume that you are terminating services, discharge

you from care, and close your file.

WEBSITE: Associates in Health Psychology has a website that you are welcome to access:

https://ahpdelaware.com. It provides information to others about our practice as well as provides

resources to promote emotional well-being. You are invited to review the information on the website and,

if you have questions about any of the information, please discuss this during your therapy sessions.

I have read the Office Policies. I understand them and agree to abide by them.

___________________________________________________________________________________

Signature of Client (or if minor, Date Client Name (Print)

Parent/Guardian’ Signature) Reviewed at initial meeting: _________

https://ahpdelaware.com/

Forms05\HIPPAtx\AHPPrivNoticeSep13


Notice of Privacy Policies & Practices

Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

I. Uses and Disclosures for Treatment, Payment, and Healthcare Operations

We may use and disclose your protected health information (PHI) for treatment, payment, and healthcare operations with

your consent. To help clarify these terms, here are some definitions.

A. “PHI” refers to information in your health record that could identify you.

B. “Treatment, Payment and Health Care Operations”

– Treatment is providing, coordinating or managing your health care and other services related to your health

care. For example, we may use PHI to provide counseling to you. Or, we may disclose your PHI to other health care providers involved in your treatment, such as your family physician or another psychologist.

– Payment is obtaining reimbursement for your healthcare. For example, we will disclose your PHI to your

health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. – Health Care Operations are activities that relate to the performance and operation of our practice. Examples

of health care operations are quality assessment and improvement activities, business-related matters such as audits

and administrative services, and case management and care coordination.

C. “Use” applies only to activities within Associates in Health Psychology such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

D. “Disclosure” applies to activities outside of our practice, such as releasing, transferring, or providing access to

information about you to other parties.

II. Uses and Disclosures Requiring Your Authorization

AHP may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your

appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that

permits only specific disclosures.

A. Psychotherapy Notes: Notes recorded by your therapist documenting the contents of a counseling session with you

("Psychotherapy Notes") will be used only by your therapist and will not otherwise be used or disclosed without your

written authorization. Psychotherapy Notes are given a greater degree of protection than PHI.

B. Other Uses and Disclosures: Uses and disclosures other than those described in Section I. above will only be made

with your authorization. For example, you will need to sign an authorization form before AHP can send PHI to your life

insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.

You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in

writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the

authorization was obtained as a condition of obtaining insurance coverage; the law provides the insurer the right to contest

the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

Your therapist may use or disclose PHI without your consent or authorization when required or permitted to do so by

law. The most common such disclosures are listed below.

A. Child Abuse: If a therapist knows or in good faith suspects child abuse or neglect, the therapist is required to report

such knowledge or suspicion to the appropriate authority.

B. Adult and Domestic Abuse: If a therapist has reasonable cause to believe that an adult person is infirm or incapacitated and in need of protective services, the therapist must report such information to the Delaware Department

of Health and Social Services.

C. Health Oversight Activities: If the Division of Professional Regulation is investigating our practice, we must

comply with any subpoenas issued by the Division.

D. Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for

information about your diagnosis and treatment and the records thereof, such information is privileged under state law,

and AHP will not release information without the written authorization of you or your legally appointed representative or


a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is

court ordered. You will be informed in advance if this is the case.

E. Serious Threat to Health or Safety: If you communicate to your therapist an explicit and imminent threat to kill or

seriously injure a clearly identified victim or victims, or to commit a specific violent act or to destroy property under

circumstances which could easily lead to serious personal injury or death, and you have an apparent intent and ability to

carry out the threat, the therapist may disclose information in order to provide protection for the identified victim. If your therapist believes that there is an imminent risk that you will inflict serious physical harm on yourself, the therapist may

disclose information in order to protect you.

F. Privacy Rule Exceptions: When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law. This includes certain narrowly-

defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of

health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and

intelligence.

IV. Your Rights

A. Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket. You have the right to restrict

certain disclosures of PHI to a health plan when you pay out-of-pocket in full for AHP services.

B. Right to Request Other Restrictions: You have the right to request other restrictions on certain uses and disclosures of protected health information. However, AHP is not required to agree to your request.

C Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have

the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing a therapist.) On your request, we will

send your bills to another address.

D. Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in the AHP mental

health and billing records used to make decisions about you for as long as the PHI is maintained in the record. AHP may

deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. If you are

a parent or legal guardian of a minor, please note that certain portions of the minor's medical record will not be accessible to you. On your request, the AHP Privacy Officer will discuss with you the details of the request and denial process.

E. Right to Request Amendment: You have the right to request an amendment of PHI for as long as the PHI is

maintained in the record. Your request must be in writing, and it must explain why the information should be amended. AHP may deny your request under certain circumstances.

F. Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for purposes

other than treatment, payment or health care operations, excluding disclosures made to you or disclosures otherwise

authorized by you. On your request, the AHP Privacy Officer will discuss with you the details of the accounting process.

G. Right to Be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a

breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not

been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

H. Right to a Paper Copy: You have the right to obtain a paper copy of the AHP Privacy Notice upon request to your

therapist or the office staff at any time.

I. Questions and Complaints: You may contact the AHP Privacy Officer at Associates in Health Psychology, LLC;

1521 Concord Pike, Suite 103, Wilmington, DE 19803 with questions or complaints. You may also file written

complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. AHP will

not retaliate against you if you file a complaint.

V. Effective Date and Changes to this Notice

A. Effective Date: The original version was effective on April 14, 2003. This Notice was revised February 8, 2010, and

revised again under the “Final Rule” effective September 23, 2013.

B. Changes to this Notice: AHP may change the terms of this Notice and the changes will apply retroactively to all

PHI we maintain. The revised notice will be available upon request, in our office and on our web site.



ACKNOWLEDGMENT OF RECEIPT OF

NOTICE OF PRIVACY POLICIES & PRACTICES

By my signature below I, , acknowledge that I received a copy of the

Notice of Privacy Policies & Practices for Associates in Health Psychology, LLC.

Signature of client (or personal representative) Date

If this acknowledgment is signed by a personal representative on behalf of the client, complete the following:

Personal Representative’s Name:

Relationship to Client:

For Office Use Only

I attempted to obtain written acknowledgment of receipt of our Notice of Privacy Policies & Practices, but

acknowledgment could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgment

An emergency situation prevented us from obtaining acknowledgment

Other (Please Specify)

This form will be retained in your medical record.



CONSENT FOR THERAPY/EVALUATION

THE PROCESS OF THERAPY/EVALUATION Psychotherapy is not easily described in general statements.

It varies depending on the personalities of the therapist and client and the particular problems you bring

forward. There are many different methods that therapists at AHP may use to deal with the problems you hope

to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part.

In order for therapy to be most successful, you will have to work on things talked about in our sessions.

Psychotherapy can have benefits and risks. Since therapy sometimes involves discussing unpleasant aspects of

your life, you may at times experience uncomfortable feelings such as sadness, guilt, anger, frustration,

loneliness, and helplessness. At the same time, psychotherapy has been shown to have many positive benefits

for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and

significant reductions in feelings of distress. There are no guarantees of what you will experience, however.

Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal

relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions

about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a

decision that is positive for one family member is viewed quite negatively by another family member.

Sometimes change will be easy and swift, but it can also be slow and even frustrating.

The first one or two meetings will involve a discussion of your concerns and other important aspects of your

life. These meetings allow the therapist to get to know you and to have a context in which to understand your

goals. By the end of the evaluation, your therapist will be able to assess if he/she can be of benefit to you. If so,

your therapist will give you an initial plan of what your work together will include. During the course of

working together, your therapist may ask you for your feedback and views on your therapy, its progress or

about other aspects of the therapy. You are encouraged to respond openly and honestly. It is always

appropriate for you to ask questions about your therapy and your therapist’s view of your progress. All of the

therapists at AHP do their best to create an atmosphere in which you feel safe to disclose your true thoughts and

feelings.

We look forward to working with you to help you successfully face the challenges in your life. Your signature

below indicates that you have read this Consent and understand it.

________________________________________ _________________________________________

Client's Signature Client's Name (please print)

________________________________________ _________________________________________

Parent/Guardian's Signature if client is a minor Date

Forms19\Intake\ConsentTherapy&EvalApr14.doc

Associates in Health Psychology, LLC Newark & Wilmington __________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

Adapted from The Paper Office Forms19/Intake/tConcernsFeb19

Concerns Your honest responses to the questions below will help me get to know you better.

Name: _____________________________________________________________ Date: _____________________

For each item on this list, please use the 0-to-3 rating to indicate how much it has concerned you during the past month. Draw a circle around the most appropriate number, using these definitions:

0 = Not at all 1 = A little concern 2 = More than a little 3 = A lot of concern

Aggression, violence 0 1 2 3

Alcohol use 0 1 2 3

Anger, hostility, arguing, irritability 0 1 2 3

Anxiety, nervousness, worry 0 1 2 3

Attention, distractibility, can’t concentrate 0 1 2 3

Career concerns, goals, and choices 0 1 2 3

Childhood issues (your own childhood) 0 1 2 3

Children, child management, child care, parenting/guardianship

0 1 2 3

Codependent, dysfunctional relationships 0 1 2 3

Conflicts with others 0 1 2 3

Confusion, disorganized thoughts 0 1 2 3

Decision making, indecision, mixed feelings, putting off decisions

0 1 2 3

Delusions (false ideas) 0 1 2 3

Dependence 0 1 2 3

Depression, low mood, sadness, crying 0 1 2 3

Divorce, separation, child custody 0 1 2 3

Drug use: prescription medications, over-the-counter medications, street drugs

0 1 2 3

Eating problems – overeating, under-eating, appetite issues, vomiting

0 1 2 3

Failure 0 1 2 3

Fatigue, tiredness, low energy 0 1 2 3

Fears, phobias 0 1 2 3

Financial or money troubles, debt, impulsive spending, low income

0 1 2 3

Friendships, lack of social support 0 1 2 3

Gambling 0 1 2 3

Grieving, death, other losses 0 1 2 3

Guilt, feeling guilty 0 1 2 3

Health, illness, medical concerns, physical problems, pain, nausea

0 1 2 3

Hopelessness 0 1 2 3

Inferiority feelings, lack of confidence 0 1 2 3

Impulsiveness, loss of control, outbursts 0 1 2 3

Irresponsibility, judgment problems, taking unnecessary risks

0 1 2 3

Jealousy, feeling jealous 0 1 2 3

Legal matters, charges, lawsuits 0 1 2 3

Loneliness, emptiness 0 1 2 3

Marital conflict, distance/coldness, infidelity/affairs, remarriage

0 1 2 3

Memory problems 0 1 2 3

Menstrual problems, PMS, menopause 0 1 2 3

Mood swings 0 1 2 3

Motivation, feeling lazy, lack of interest 0 1 2 3

Nervousness, restlessness, fidgeting 0 1 2 3

Obsessions and/or compulsions (thoughts or actions that repeat themselves)

0 1 2 3

Oversensitivity to rejection or criticism 0 1 2 3

Panic or anxiety attacks 0 1 2 3

Perfectionism 0 1 2 3

Pessimism 0 1 2 3

Relationship problems 0 1 2 3

School problems 0 1 2 3

Self-cutting, self-mutilation 0 1 2 3

Self-neglect, difficulty with self-care 0 1 2 3

Sexual issues, sexual orientation, gender identity issues

0 1 2 3

Shyness 0 1 2 3

Sleep problems – too much, too little, insomnia, nightmares

0 1 2 3

Stress, stress management, stress disorders, tension

0 1 2 3

Suicidal thoughts 0 1 2 3

Suspiciousness, problems trusting people 0 1 2 3

Temper problems, self-control, low frustration tolerance

0 1 2 3

Thoughts of death or dying 0 1 2 3

Threats, fear of being harmed 0 1 2 3

Traumatic experiences, re-living trauma 0 1 2 3

Urges to beat, injure, or harm someone 0 1 2 3

Urges to break or smash things 0 1 2 3

Weight and diet issues 0 1 2 3

Withdrawal, self-isolation 0 1 2 3

Work problems, employment, trouble keeping a job, workaholic/overworking

0 1 2 3

Other concerns:

0 1 2 3

Other concerns:

0 1 2 3


Forms2019/PHQ9&GAD7 Jun19

Client Name: _________________________________________________ Date: __________________

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

Over the past 2 weeks, how often have you been bothered by the following problems?

Not at all sure

Several days

Over half the days

Nearly every day

1. Feeling nervous, anxious, or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless it’s hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful might happen 0 1 2 3

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

© 1999 Pfizer Inc. Depression Screening; Spitzer RL, et.al., Arch Intern. Med. 2006;166:1092-1097, A brief measure for assessing anxiety.

FOR OFFICE USE: PHQ-9: __________ GAD-7: _________ Administration number: _____

Over the past 2 weeks, how often have you been bothered by any of the following problems?

Not at All

Several Days

More than Half the Days

Nearly Every Day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed or hopeless 0 1 2 3

3. Trouble falling asleep, staying asleep, or sleeping too much 0 1

2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself--or that you're a failure or have let yourself or your family down

0 1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television

0 1 2 3

8. Moving or speaking so slowly that other people could have noticed being so fidgety or restless that you have been moving around a lot more than usual

0 1 2 3

9. Thoughts that you would be better off dead or of hurting yourself in some way

0 1 2 3

Over the past 2 weeks, how often have you been bothered by any of the following problems?

Not at All

Several Days

More than Half the Days

Nearly Every Day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed or hopeless 0 1 2 3

3. Trouble falling asleep, staying asleep, or sleeping too much 0 1

2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

Associates in Health Psychology, LLC Newark & Wilmington ______________________________________________________________________________________________________________________________________________________________________________________________

Forms19/Intake/ClientSurveyApr12

Client Survey Name: ________________________________ Date: _______________

Part 1: We are interested in the goals you have for therapy. For each potential goal on

the list, please circle Yes or No to indicate whether this is one of your goals, and if it is, whether or not you are making progress toward this goal.

Therapy Goals Is this one of your goals?

Are you making progress toward this goal?

1. Improve relationships Yes No Yes No N/A

2. Increase self-esteem Yes No Yes No N/A

3. Decrease depression Yes No Yes No N/A

4. Improve school/work functioning Yes No Yes No N/A

5. Cope with anger/frustration Yes No Yes No N/A

6. Decrease stress/anxiety Yes No Yes No N/A

7. Improve family functioning Yes No Yes No N/A

8. Increase satisfaction in friendships Yes No Yes No N/A

9. Take better care of myself Yes No Yes No N/A

10. Change addictive behavior ___ Alcohol ___ Eating Disorder

___ Other:

Yes No Yes No N/A

11. Reduce self-destructive behavior Yes No Yes No N/A

12. Other:

Yes No Yes No N/A

What are the concerns or goals that you most want help with? _________________

___________________________________________________________________

___________________________________________________________________

Part 2: Please answer these questions about any current alcohol or drug use.

1. Have you ever felt you should cut down your drinking or drug use? Yes No

2. Have people annoyed you by criticizing your drinking or drug use? Yes No

3. Have you ever felt bad or guilty about your drinking or drug use? Yes No

4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

Yes No



ASSIGNMENT OF INSURANCE BENEFITS

You must complete and sign this form in order for us to bill your insurance

company. We will also need to copy your insurance card and photo ID at your initial

meeting and any time there are changes to your policy. Please note that your

insurance will not cover missed sessions and you will be responsible for the fee.

It is the policy of Associates in Health Psychology to require 24 hours notice for a

missed session. You may leave a message for your therapist 24 hours a day, 7 days a

week.

I authorize release of all information necessary to process my insurance claims for services received from Associates in Health Psychology, LLC. I assign all medical

and/or mental health benefits to which I am entitled for these services to Associates in Health Psychology, LLC. This assignment will remain in effect until revoked by me in

writing. A photocopy of this assignment is to be considered as valid as the original.

I understand that I am responsible for knowing what my insurance policy covers, and

I am financially responsible for paying co-pays, deductibles, and any other balances not paid by my insurance, such as those listed in the AHP Office Policies. I have read this information and understand it.

Please print all responses:

Insurance Company covering client:

Insurance ID# for policy covering client:

Name of POLICY HOLDER (if not client):

POLICY HOLDER’S Date of Birth:

POLICY HOLDER’S relationship to Client: POLICY HOLDER’S Place of Employment:

Financially Responsible Party (if not Client): Include First Name, Middle Initial, and Last Name

___________________________________ ____________________________

Client’s Name (please print) Client’s Date of Birth

___________________________________ ____________________________

Signature of Financially Responsible Party Date

Forms19\Intake\InsurAssignmentApril19.doc



Health Insurance and Managed Care Release

I have agreed to see you under the terms set by the health insurance/managed care company which oversees your

mental health benefits. Managed care means that an outside company selects approved therapists and determines

both the need for treatment and the length of time treatment will be provided. The following paragraphs outline

some of the general aspects of managed care contracts you should know about.

1) The managed care company may require regular and somewhat detailed reports regarding your symptoms,

diagnosis and treatment. There are no restrictions on the type or amount of information they may require. I will be

glad to discuss the content of these reports with you. Although my experience is that the information provided has

been treated with an appropriate degree of confidentiality, I cannot be responsible in any way for the health

insurance/managed care company's use or re-disclosure of the information provided to them.

2) In some instances, the managed care company must approve all sessions in advance. Each company has its own

criteria regarding what it considers as a "medical need" for therapy, which may differ from your and my assessment

of your need for therapy. I will take responsibility for the timely filing of requests for additional sessions, and I will

notify you of the outcome of these requests. However, provided I have met my responsibilities as stated above, you

will be financially responsible for direct payment of any charges which are not paid by your insurance.

3) At times, the managed care company may provide us with information concerning your previous mental health

history. This may include information on symptoms, diagnosis, and/or treatment. If you have ever had any

treatment that included substance abuse issues, provide the name(s) of the treatment facility and/or provider(s)

and the dates of treatment. Your initials below give me permission to obtain more information about your prior

substance abuse issues and/or related treatment from your managed care company, which in turn will help me to

support you more fully. Not applicable _____

Prior Treatment Facility & or Provider Name(s) and Address:____________________________________________

______________________________Dates of Treatment: Client Initials: ____________

Prior Treatment Facility & or Provider Name(s) and Address:____________________________________________

______________________________Dates of Treatment: Client Initials: ____________

4) As explained in our Office Policies, it is our practice to charge for all canceled sessions if at least 24-hours notice

is not provided. Monday appointments must be canceled by the previous Friday. Please note that you can leave a

message for me 24 hours a day, 7 days a week. Insurance companies will not pay for missed sessions. Therefore,

you will be responsible for the full fee. You are also responsible for any co-payments and deductibles not covered

by your insurance. You may find out what these are by asking your insurance company or I will have information

available by your next appointment.

I will be glad to answer any questions you may have. Please sign this form indicating that you have read this

information and authorize release of information to your managed care company. This release will expire 3 months

beyond the period of time that you are in treatment with a behavioral health therapist at Associates in Health

Psychology, LLC.

_______________________________________________ _____________________

Client Signature Date

____________________________________

Parent/Guardian Signature if client is a minor forms19\intake\ins managcare release jun13.doc



CO-PAYS, CO-INSURANCES, and DEDUCTIBLES

Due to policy provisions in your contract with your insurance carrier, at each visit we are obligated to collect your co-pay, co-insurance, and/or deductible. Payment is expected at the time of the visit. If your insurance policy has provisions such as deductibles, co-insurances, or co-payments, please note that these provisions have been agreed to between you and your carrier. We cannot legally discount fees submitted for services submitted for insurance reimbursement. If our office had verified that your therapist has contracted with your mental health insurance plan, we have additional contractual obligations to collect the balances as outlined by your insurance company. Your out-of-pocket maximum will not be calculated correctly if we do not collect what your insurance company expects us to collect. Furthermore, Associates in Health Psychology’s contract with your carrier will be jeopardized if we do not collect your co-insurance, co-payment, and/or deductible. Additionally, for those Medicare clients who receive services eligible under Medicare, the terms of the anti-kickback laws obligate us to collect the co-insurance, co-payment, and/or deductible. We sincerely regret any inconvenience which might be caused by these regulatory or contractual provisions, but we must be bound by all provisions of insurance policy and federal law. Associates in Health Psychology will be happy to assist you in resolving any issues or concerns regarding your insurance. Please feel free to contact us with any questions you may have.

forms19\intake\co-pays deductibles Jun19.doc



AUTHORIZATION to RELEASE INFORMATION to

PRIMARY CARE PROVIDER

This form, when completed and signed by you, authorizes AHP to release and obtain protected information from your clinical record to the person you designate below.

I, ___________________________________________________________, authorize _____________________________,

a therapist at Associates in Health Psychology (AHP), LLC, and/or their office staff, to release and/or obtain information in

medical records for myself (DOB: ______/______/_________) OR

for a minor child (Child’s name: ___________________________________________ DOB: ______/______/_________).

This release of information pertains to only the following person (circle and provide contact information):

Primary Care Provider Psychiatrist Medical Specialist Therapist Teacher Other: _____________________

Name: ________________________________________________ Phone: ___________________

Address: _________________________________________________ Fax: ___________________

The purpose of this release is (circle one): Coordination of Care Evaluation Results Background Information

At the request of the Client/Parent/Guardian Other: _____________________________________

This information may include diagnoses, treatment information and other notations; substance abuse information; and

information on AIDS/HIV status.

You have the right to revoke this authorization, in writing, at any time by sending such written notification to the AHP

office address. However, your revocation will not be effective to the extent that AHP has taken action in reliance on the

authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal

right to contest a claim. This consent, if not withdrawn, will be valid for the duration of treatment and billing requirements.

I am aware of my right to confidential communications under psychologist-patient privilege.

I understand that the information used or disclosed pursuant to the Authorization may be subject to redisclosure by the

recipient and no longer protected by HIPAA Privacy Rule. However, any disclosure of information that pertains to the

treatment or diagnosis of drug abuse or alcohol abuse or a referral for such treatment or diagnosis, and which would

identify a patient as an alcohol or drug abuser, permitted hereunder shall be accompanied by the following written

statement: “This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR

part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is

expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A

general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules

restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.”

I understand that my signing this authorization is not required for obtaining psychological services unless these services are

being provided for the purpose of creating health information for a third party.

Any facsimile, copy, or photocopy of this Authorization shall have the same effect as the original.

___I do not have a PCP ___I do not want information sent to my PCP

_____________________________________________ _________________________

Signature of Client or Parent/Guardian Date

Forms19\Release\PCPReleaseJul19

http://www.ahpdelaware.com/



AUTHORIZATION TO RELEASE INFORMATION

This form when completed and signed by you, authorizes me to release and obtain protected information from your clinical record to the person you designate below.

I, ___________________________________, authorize __________________________________, a therapist at

Associates in Health Psychology, LLC, to release and/or obtain protected information in medical records for myself

(DOB: ___/___/_____) OR

for a minor child (Child’s name: ______________________________ DOB: ___/___/______).

This release of information pertains to only the following person (circle and provide contact information):

Primary Care Provider Psychiatrist Medical Specialist Therapist Teacher Other: __________________

Name: ________________________________________________ Phone: __________________

Address: _________________________________________________ Fax: __________________

The purpose of this release is (circle one): Coordination of care Evaluation Results Background Information

At the request of the client/parent/guardian Other: ____________________________________________

This information may include diagnoses, treatment information and other notations; substance abuse information; and

information on AIDS/HIV status.

You have the right to revoke this authorization, in writing, at any time by sending such written notification to the AHP

office address. However, your revocation will not be effective to the extent that AHP has taken action in reliance on the

authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a

legal right to contest a claim. This consent, if not withdrawn, will be valid for the duration of treatment and billing

requirements.

I am aware of my right to confidential communications under psychologist-patient privilege.

I understand that the information used or disclosed pursuant to the Authorization may be subject to redisclosure by the

recipient and no longer protected by HIPAA Privacy Rule. However, any disclosure of information that pertains to the

treatment or diagnosis of drug abuse or alcohol abuse or a referral for such treatment or diagnosis, and which would

identify a patient as an alcohol or drug abuser, permitted hereunder shall be accompanied by the following written

statement: “This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR

part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure

is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part

2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal

rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.”

I understand that my therapist generally may not condition psychological services upon my signing an authorization

unless the services are provided for the purpose of creating health information for a third party.

Any facsimile, copy, or photocopy of this Authorization shall have the same effect as the original.

_______________________________________________ ______________________

Signature of Client or Parent/Guardian Date

Release\ReleaseOct16.doc

Documents

Adult New Client Forms - ahpdelaware.com · Describes how we will work together. Client Concerns Checklist and Questionnaire to let us know about your concerns. Client Survey Survey