Client Information Form

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Submitted

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Client Account Number

Client Information

First Name*

Last Name*

Client Phone Number*

Sex

Male
Female

DOB*

May we correspond via email?

Yes
No

Email Address*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Marital Status

Client Social Security #

Person Completing Form, if not the Client

Telephone

Primary Care Physician

Telephone

Emergency Contact

Telephone

Payment

Cash Pay

Yes
No

Insurance Details

Please fill out all of the following information – even if a copy of your insurance card is attached.

Primary Insurance*

Telephone

Insurance Billing Address

Name of Policy Holder*

Date Of Birth*

Policy Holder ID #

SS #

Group #

Policy Holder Mailing Address

(if different from Client)

Policy Holder Telephone

Relationship to Client

Upload Insurance Card Front

Max. file size: 3 MB.

Upload Insurance Card Back

Max. file size: 3 MB.

EAP

Name of Employer

EAP Company

Auth #

# of Sessions Authorized

Date Range

Are you involved in any legal proceedings (e.g. Workers’ Compensation Claim, Child Custody Dispute, Etc.) which may involve your Clinician?

Yes
No

If yes, please describe:

How did you hear about PsychStrategies and who referred you to us?

I authorize my insurance carrier to pay PsychStrategies (please sign):*

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For Clinician Use Only:

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Clinician Name:

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#

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Dx:

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Copay/Session:

Client History, Concerns & Goals

Client Name:

Date:

Form Completed by:

Relationship:

Please fill in the following information as completely as possible. All information is covered by our Confidentiality Policy (see attached Office Policies).

1) Describe what has happened recently that led you to seek counseling now.

2) Describe current concerns and symptoms.

3) Check the response that best applies (please check only one):

a. My current concerns and symptoms are:

the continuation of a long-standing condition
a recent worsening of an on-going condition
the reoccurrence of a previous condition
significantly different from any previous condition
my first occurrence of any condition

b. My current symptoms developed:

suddenly (less than four weeks)
gradually (one to several months)
very gradually (one to several years)

4) Medical History: Please list major injuries, illnesses or surgeries:

Please describe the condition, date and its treatment

5) Are you currently on any medication?

Yes
No

If Yes, please specify

Please describe the medication, its dosage, prescribing physician name and the started date

Allergies/Sensitivities to any medications:

6) Any psychiatric medications you have taken in the past (and are NOT currently taking):

Yes
No

If Yes, please specify

Please describe the medication, its dosage, prescribing physician name and the started date

7) Name of Spouse/Significant Other:

Age:

Children - Name(s) and age(s):

Parents - Name(s) and ages(s):

Please describe your current family situation and relationship history:

8) Please indicate any significant prenatal events and developmental history:

9) Please list other substances that you use. Include amount and frequency.

Alcohol

Heroin

Marijuana

Psychedelics

Caffeine

Methamphetamine

Tobacco

Other

10) Have you been in psychotherapy or been hospitalized in a psychiatric facility?

Yes
No

If yes, please list names of past clinicians and hospitalizations, dates and reason for treatment:

11) Has anyone in your immediate or extended family had a psychiatric illness?

Yes
No

If yes, please list relationship and nature of illness:

12) Education:

13) Current employment and work history (summary):

14) Describe your relationship within your family of origin. Include parental substance abuse issues, as well as other relevant life events:

15) Briefly describe your current support system (family, friends, organizations, self):

16) Briefly describe your strengths and weaknesses:

17) Please describe your goals for therapy:

a.

b.

c.

18) Do you have thoughts about hurting yourself or others?

Yes
No

If yes, please describe:

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.

Electronic Communication Policy: In order to maintain clarity regarding our use of electronic modes of communication during your treatment, we have prepared the following policy. This is because the use of various types of electronic communications is common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. Many of these common modes of communication, however, put your privacy at risk and can be inconsistent with the law and with the standards of our profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law. If you have any questions about this policy, please feel free to discuss this with your therapist.

Email Communications: We use email communication and text messaging only with your permission and only for administrative purposes unless you have made another agreement with your therapist. That means that email exchanges and text messages with our office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email your therapist about clinical matters because email is not a secure way to contact your therapist. Please note if you do email your therapist about clinical matters that it is not a secure method of communication and therefore, may not be confidential. If you need to discuss a clinical matter with your therapist, please feel free to call him or her so you can discuss it on the phone or wait so you can discuss it during your therapy session. The telephone or face-to-face context simply is much more secure as a mode of communication.

Text Messaging: Text messaging is an unsecure mode of communication. However, there may be special circumstances where this is the preferred method of contact. If you have reasons for the use of text messaging as your preferred method of contact please discuss this with your therapist. Please be aware that if you do use text messaging to discuss clinical matters it is not a secure method and therefore it may not be confidential.

Social Media: We do not communicate with, or contact, our clients through social media platforms like Twitter and Facebook. In addition, if we discover that we have accidentally established an online relationship with you, we will cancel that relationship. This is because these types of casual social contacts can create significant security risks for you.

PsychStrategies participates in various social networks, but only in a professional capacity. If you have an online presence, there is a possibility that you may encounter your therapist’s personal social media by accident. If that occurs, you may want to discuss it with your therapistPsychStrategies participates in various social networks, but only in a professional capacity. If you have an online presence, there is a possibility that you may encounter your therapist’s personal social media by accident. If that occurs, you may want to discuss it with your therapist during your time together as we believe that any communications with clients online have a high potential to compromise the professional relationship.

Websites: We have a website that you are free to access. We use it for professional reasons to provide information and forms to others about our practice. You are welcome to access and review the information that we have on our website and, if you have questions about it, please discuss this during your therapy sessions.

Web Searches: It is not our policy to gather information about you without your permission. We believe that this violates your privacy rights. However, we understand that you might choose to gather information about us in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about us through web searches, or in any other fashion for that matter, you may want to discuss this with your therapist during your time together so that you can deal with it and its potential impact on your treatment.

It is not a regular part of our practice to search for clients using search engines. However, in extremely rare instances if your therapist suspects that you are in danger, there might be an instance where using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare.

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.

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
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.
If the griever still feels the grievance has not been resolved, he/she will be advised and referred to outside entities.
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.

I, the client/guardian, request a copy of this form.

Yes
No

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

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Date:

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Staff Initials:

Consent*

I hereby acknowledge that I have read and agree to all information contained in the Office Policies and Acknowledgment of Receipt of Notice of Privacy Practices sections following my signature(s).

Client/Legal Dependent Name (Signature)

Date

Print Name

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Clinician Name (Signature)

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Date

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Print Name

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.

Signature of Client/Guardian*

Date

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Inability to Obtain Acknowledgment of Receipt of Notice of Privacy Practices

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I have made good faith attempts to obtain my client’s acknowledgment of his/her receipt of the Notice of Privacy Practices of PsychStrategies, including

(Describe good faith attempts)

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However, because of

(reason(s) why acknowledgment was not obtained) I was unable to obtain my client’s acknowledgment.

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Signature of Clinician

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Date