NEW CLIENT INTAKE FORMS DEMOGRAPHIC INFORMATION

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					                             Lonestar Psychological Services, PLLC
                             1016 La Posada Drive, Suite 285, Austin, Texas 78752
                           Phone: (512) 206-0808           info@lonestarpsych.com
                              Fax: (512) 206-0844           www.lonestarpsych.com


                           N E W      C L I E N T        I N T A K E      F O R M S

DEMOGRAPHIC INFORMATION
Name:
Date of Birth:                                            Relationship Status:
Age:                        Gender:      M       F        SSN:
Primary Phone:                                            Is it ok to leave a message at this number?   Y    N
Secondary Phone:                                          Is it ok to leave a message at this number?   Y    N
Email:                                                    Is it ok to email you?    Y   N
Mailing Address:
City-State-Zip:
Emergency Contact Name:
ER Contact Relationship:                                  ER Contact Phone:
How were you referred?
Medical Doctor’s Name:                                    Medical Doctor’s Phone #:
May we consult with your Medical Doctor:     Y       N
Psychiatrist’s Name:                                      Psychiatrist’s Phone #:
May we consult with your Psychiatrist?   Y    N
PAYMENT FOR SERVICES
Please select the method of payment you will be using:       Insurance/EAP Benefits       Self Pay/Out of Pocket
If Insurance or EAP, please complete the following:
Primary Insurance:                                        ID #:
Group #:                                                  Insurance Telephone #:
Subscriber Name:                                          Relation to Subscriber:
Subscriber DOB:                                           Subscriber SSN:
                               Lonestar Psychological Services, PLLC
                             1016 La Posada Drive, Suite 285, Austin, Texas 78752
                           Phone: (512) 206-0808           info@lonestarpsych.com
                              Fax: (512) 206-0844           www.lonestarpsych.com
                                  TREATMENT CONSENT FORM
This information describes the ground rules under which we can work with you effectively, ethically and legally. It
is followed by a separate page that amounts to an agreement between us to accept these rules as the basis of our
working relationship and that permits you to provide us with the information we must keep on file.

Nature of Services. We provide long-term and short-term counseling and psychotherapy for individuals, couples,
groups, and families, as well as psychological evaluations. Your provider’s therapeutic approach, goals for therapy,
and duration of services will be discussed with you individually.

Appointments. Our providers are available for individual appointments most weekdays beginning at 8 a.m. and
continuing until as late as 5 p.m. (evening and weekend appointments available upon request). If for some reason
you must cancel an appointment, please notify the office staff no later than 24-hours in advance. There will be a
$50.00 no show fee if you fail to make cancellation notification.

Fees. The initial intake interview is $175.00 for a 90-minute visit. The fee for a 50-minute follow-up visit is
$125.00. It is very important that you pay the agreed-upon fee prior to leaving the office after each visit. Accounts
are considered delinquent after two unpaid visits. At this point, if payment arrangements have not been made,
routine appointments will cease until the situation is addressed. If you are having financial troubles that may affect
your ability to pay for services, please notify office staff.

Insurance: We participate in a number of insurance company panels. In the event you have a policy with an
insurance company that we are not enrolled in, we are happy to consider working as an out-of-network provider.
Please discuss this matter with office staff.

Confidentiality. We treat all information shared with great care. We will not discuss you or anything identifiable
about your situation with anyone other than to those persons authorized by you. There are several exceptions to
confidentiality mandated by Texas State law: if the client is a danger to self or others, if child abuse is suspected or
confirmed, or if a court subpoenas my records. Confidentiality is a particularly important consideration where
group work is concerned. Group work is based on mutual trust,
and violations of that trust can be detrimental to the group as a whole.

Complaints. It is our hope to resolve any misunderstandings that may arise by discussing them with you. Indeed,
working through such difficulties is one of the most effective ways to grow psychologically and emotionally.
Nevertheless, should you have a complaint that you cannot resolve by talking with us or that you do not care to
discuss with us, you have the right to call the Texas State Board of Examiners of Psychologists at (512) 305-7709.

Alternative Services. You should know that there are many forms of mental health assistance available in Austin
and that it is perfectly appropriate to ask us about such alternatives. You also should know that you have the right
to withdraw from services at any time and that we will assist you, if you desire, with finding an appropriate referral.

HIPAA Privacy Policy. Please read the Texas Notice Privacy Rights form, which may be found on our website or
in our office.
                              Lonestar Psychological Services, PLLC
                            1016 La Posada Drive, Suite 285, Austin, Texas 78752
                          Phone: (512) 206-0808           info@lonestarpsych.com
                             Fax: (512) 206-0844           www.lonestarpsych.com


INITIALS        INFORMED CONSENT FOR PSYCHOLOGICAL TREATMENT
                I hereby give my consent for psychological treatment for myself (or dependent) by Lonestar
                Psychological Services, PLLC. Treatment may include talk psychotherapy, relaxation training, or
                evaluation services rendered to me/my dependent.


INITIALS        RECEIPT OF TEXAS NOTICE PRIVACY RIGHTS
                I hereby acknowledge that I have been provided the Texas Notice Privacy Rights. I understand
                that my Protected Health Information (PHI) can be used for treatment, payment and health care
                operations. I understand that my PHI may be disclosed as mandated and without my authorization
                in the following instances: child abuse and neglect, threats to health and safety, social security
                administrative functions, and judicial procedures.

INITIALS        NO SHOW FEE ACKNOWLEDGEMENT
                I understand and agree to pay a $50 no show fee in cases where I do not attend a scheduled
                appointment or provide 24-hour advance notice to cancel a scheduled appointment.



INITIALS        PAYMENT FOR SERVICES ACKNOWLEDGEMENT
                I understand that I am responsible for payment of services at the time services are rendered.
                Notice to insurance clients: Make sure that you understand your policy requirements and benefits
                for mental health services. Most insurance companies have a disclaimer that authorization does not
                guarantee payment of services. Also, the actual co-pay may differ from the stated amount after your
                insurance processes your claims. In addition, you might have a deductible to satisfy before your
                insurance covers any charges. Furthermore, your insurance might only cover a percentage of the
                total charge, which can change according to your policy after a certain number of sessions.


By signing and dating below, I hereby acknowledge that I have read and understand the information contained in the
Treatment Consent Form. Furthermore, I agree to abide by the rules and policies described in the Treatment Consent
Form.

Client/Guardian Signature: _______________________________________________          Date: ____________________


If Client is a minor, Guardian must complete the following:

Guardian Name:         _________________________________________________________

Relationship:          _________________________________________________________
                                   Lonestar Psychological Services, PLLC
                               1016 La Posada Drive, Suite 285, Austin, Texas 78752
                             Phone: (512) 206-0808           info@lonestarpsych.com
                                Fax: (512) 206-0844           www.lonestarpsych.com

                                        DEPRESSION & ANXIETY SCREEN
                    How often have you experienced the following signs/symptoms over the past 14 days?

                                Sign and Symptom                              Score 0       Score 1      Score 2       Score 3
                                                                             Rarely 0-1   Sometimes 2-     Often     Constant 13-
                                 Depression                                     day          6 days      7-12 days     14 days
Thoughts that you would be better off dead, or suicidal thoughts
Diminished interests, enthusiasm, and experience of pleasure
Feeling depressed or hopeless
Trouble falling or staying asleep or can’t get out of bed
Loss of appetite, or excessive appetite
View self as worthless, a failure, or shameful
Difficulty concentrating
Slow movements or speech, or agitated movements or speech
Believe that you let yourself or others down

                                                                      Total Depression Score: _____________________

                                Sign and Symptom                              Score 0       Score 1      Score 2       Score 3
                                                                             Rarely 0-1   Sometimes 2-     Often     Constant 13-
                                   Anxiety                                      day          6 days      7-12 days     14 days
Worrying- thinking about threatening things
Nausea, headaches, other symptoms of tension
Shortness of breath, rapid heart rate
Avoiding places or situations
Seeing self as unable to cope
Quick to startle, or enhance startle response
Panic or anxiety attacks
Restlessness or subjective feelings or anxiety
Thinking, “What if…(some negative event)”


                                                                          Total Anxiety Score: _____________________

                                                               .
                          Lonestar Psychological Services, PLLC
                         1016 La Posada Drive, Suite 285, Austin, Texas 78752
                       Phone: (512) 206-0808           info@lonestarpsych.com
                          Fax: (512) 206-0844           www.lonestarpsych.com
                                    INTAKE QUESTIONS
What is the problem?




What caused you to seek services at this time?




What outcome are you seeking?




Please list medications you are currently taking:




Please share any other pertinent information below:

				
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