• Client Information

  • Date Format: MM slash DD slash YYYY
  • Payment

  • Insurance Details

    Please fill out all of the following information – even if a copy of your insurance card is attached.
  • Date Format: MM slash DD slash YYYY
  • (if different from Client)
  • EAP

  • For Clinician Use Only:

  • Client History, Concerns & Goals

  • Date Format: MM slash DD slash YYYY
  • Please fill in the following information as completely as possible. All information is covered by our Confidentiality Policy (see attached Office Policies).
  • Please describe the condition, date and its treatment
  • Please describe the medication, its dosage, prescribing physician name and the started date
  • Please describe the medication, its dosage, prescribing physician name and the started date
  • 9) Please list other substances that you use. Include amount and frequency.
  • Office Policies

  • Legal and Ethical Policies: Without pressure or coercion, I, the client/guardian, consent to treatment for myself and/or my legal guardian. All information disclosed in sessions and the written records pertaining to those sessions are confidential and may not be  revealed to anyone without my, the client/guardian’s, written permission, except where disclosure is required by law.

    The reporting of information disclosed in session is required by law under the following circumstances:
    • If a client presents an imminent danger to self or others or is gravely disabled (severely disoriented or in danger due to a psychiatric condition) authorities must be notified.
    • If a client expresses a serious threat of harm to an identifiable person, that person must be warned and the police must be notified.
    • If there is reasonable suspicion of a child, dependent, or elder abuse or neglect, authorities must be notified.

    The reporting of information disclosed in session may be required:
    • If the client’s mental status is placed at issue in litigation initiated by me, the client/guardian.
    • In the event of a court order or subpoena, information, records, or testimony about the client may have to be produced.

    I, the client/guardian, have the right to review and/or receive a copy of the client’s protected health information. If the treating  clinician deems that releasing such information might be harmful in any way, the clinician will either deny my request or provide the  records to an appropriate and licensed mental health professional of the client/guardian’s choice.

    I, the client/guardian, may end treatment at any time by notifying the clinician in person or by telephone.

    Financial Responsibilities: I, the client/guardian, assume primary financial responsibility for all professional services rendered and understand that any balance due will be billed to me on a monthly basis. I, the client/guardian, am responsible for the standard fee of $___________ per session or insurance contracted rate per session. Payment is due at the time that services are provided. Insurance co-payment per session is $ ___________.

    Cancellation Policy: If the client misses an appointment or cancels an appointment without giving 24 hours notice I, the client/guardian, will be charged $ ____________ for the missed session. Please be advised that missed appointments and late cancellations are NOT covered by insurance.

    Services provided outside of the client’s usual scheduled session (i.e., telephone consultations, site visits, travel time, longer sessions, etc.) may be charged to me, the client/guardian, at the clinician’s standard fee, unless otherwise agreed upon.

    If payment of the client’s account is over 120 days late or if it goes to collection, all fees including collection and attorney fees will be my, the client/guardian’s, responsibility.

    Insurance Policies:

    I, the client/guardian, consent to have claims submitted to the client’s insurance company. Yes _____ No _____

    I,the client/guardian, consent to have PsychStrategies release the client’sprotected health information to the client’s insurance company in order toreceive payment for claims. I understand that the client’s protected healthinformation will include diagnostic information, dates of service, and otherinformation as requested by the client’s insurance company for payment. I, theclient/guardian, understand that PsychStrategies has no control over orknowledge of what insurance companies do with the submitted information or whohas access to this information after it is released.

    I understand that PsychStrategies has no control over or knowledge of what insurance companies do with the submitted information or information, dates of service, and other information as requested by the client’s insurance company for payment. I, the client/guardian, company in order to receive payment for claims. I understand that the client’s protected health information will include diagnostic I, the client/guardian, consent to have PsychStrategies release the client’s protected health information to the client’s insurance.

    It is my, the client/guardian’s, responsibility to verify the specifics of the client’s insurance coverage and be aware of and inform PsychStrategies of any changes that may occur to the client’s insurance coverage. It is my, the client/guardian’s, responsibility to be aware of the amount of the client’s insurance co-payment and any changes to the amount of the client’s copayment.

    General PsychStrategies Policies: I, the client/guardian, consent to release the client’s protected health information to all PsychStrategies clinicians who participate in the client’s treatment.

    EMERGENCY PROCEDURES:

    • Non-Emergency: To contact my clinician between sessions, I, the client/guardian, can leave a message on the voicemail number 
      provided. Clinicians check messages regularly during the week.
    • Emergency: If I, the client/guardian, think I or the client is having an emergency, I will call 911 or go to the nearest Emergency 
      Room with the client.

    Satisfaction Survey: I agree to allow PsychStrategies to mail a Satisfaction Survey to my mailing address. ¨ Yes  ¨  No The Satisfaction Survey will be mailed within one year of your first appointment.

    Grievances & Appeals: It is the policy of PsychStrategies that the client/guardian or other individual who voice concerns, complaints, or grievances have the right, within a responsible period of time, to file a grievance to be heard by an impartial staff member (General Manager). The General Manager of PsychStrategies will provide a written response to a grievance within twenty (20) working days from the  date a grievance is filed. If additional time is needed due to extenuating circumstances, the client/guardian will be given written notification.

    The following procedure will be observed when a grievance is to be filed with PsychStrategies.

    1. When a client/guardian expresses a concern, complaint, or grievance regarding past and/or present services, he/she must submit in writing and must be signed by the client or the individual submitting the grievance on the client’s behalf (must include the date, time, description and name(s) of the clinicians and/or staff member(s) involved) to:PsychStrategies, Inc.
      Attn: General Manager 
      1160 North Dutton Avenue
      Suite 230
      Santa Rosa, CA 95401
    2. If the griever is not satisfied with the General Manager’s response, he/she may submit the written grievance to the President of the Board of Directors, Robert Mosby, PhD. The President of the Board of Directors will provide a written response within fifteen (15) working days.
    3. If the griever still feels the grievance has not been resolved, he/she will be advised and referred to outside entities.
    4. The General Manager will keep a written record of all grievances received, this record will include a copy of the grievance, documentation reflecting process used and resolution/remedy of the grievance (if applicable, also any documentation of extenuating circumstances for extending the time period for resolving the grievance beyond twenty one (21) working days). The General Manager receiving and/or addressing a complaint will provide the necessary documentation and when appropriate, refer the person to a more appropriate resource. Records will be kept in a locked filing cabinet accessible only to the General Manager and President of the Board of Directors. Periodically, the General Manager will review the grievances for informational purposes that may be used in enhancing the clinical services PsychStrategies provides.

    If the client’s insurance company denies additional sessions, I, the client/guardian, may appeal for additional sessions. Appeals to decisions made by PsychStrategies may be made directly to the client’s insurance company. Appeals/Grievances regarding the client’s insurance company can be made to the Department of Managed Healthcare at (800) 400-0815.


  • If requested, a copy of this form was provided to the client/guardian.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Acknowledgment of Receipt of Notice of Privacy Practices

  • By signature of this form, you acknowledge receipt of the Notice of Privacy Practices that PsychStrategies has given you. The Notice of Privacy Practices provides information about how PsychStrategies may use and disclose your protected health information (PHI). You are encouraged to read it in full.

    The Notice of Privacy Practices is subject to change. If PsychStrategies changes its Notice of Privacy Practices, you may obtain a copy of the revised form from your clinician, from our website at www.psychstrategies.com or by contacting our main office at (707) 303-3200.

    Please discuss any questions about the Notice of Privacy Practices of PsychStrategies with your clinician.

    I acknowledge receipt of the Notice of Privacy Practices of PsychStrategies.



  • Date Format: MM slash DD slash YYYY
  • Inability to Obtain Acknowledgment of Receipt of Notice of Privacy Practices

  • (Describe good faith attempts)
  • (reason(s) why acknowledgment was not obtained) I was unable to obtain my client’s acknowledgment.
  • Date Format: MM slash DD slash YYYY