Get documents about "CLIENT INFORMATION FOR LIGHTHOUSE COUNSELING
Document Sample
Family Matters of Coastal Georgia, Inc.
We are glad that you have chosen to seek assistance from Family Matters Counseling. Attached please find documents that need to
be completed before your initial session with the therapist. Some of the forms ask for information from you and others provide you
with information you need to understand the process. Financial and privacy policies as well as informed consents are all part of
this package. Please read each document carefully. If you have any questions concerning the documents or their contents, please
discuss that with your provider at the beginning of the session. Forms must be completed in their entirely in order to be evaluated
for services. Listed below are other details of which we would like to make you aware:
Office Hours & Demeanor
Regular office hours are from 9 – 6 Monday – Friday. Occasional earlier, later or weekend appointments may be available. Clients
are encouraged to discuss scheduling with your provider. Minors under the age of 18 must be accompanied by a parent and/or
guardian and may be required to provide proof of guardianship at the initial appointment and as needed thereafter. We are a child
friendly environment; however, appropriate public behavior is expected in the reception area as a courtesy to other clients in the
building.
Appointment Scheduling
Appointments are made for the individual, and therapist time is scheduled around it. Your assistance in keeping appointments and
being on time is greatly appreciated. Generally appointments run 45 – 50 minutes, some sessions require a bit less and others a bit
more. Half hour and hour and a half sessions are sometimes necessary and billed as such.
Specialized Services are available:
Eye Movement Desensitization and Reprocessing. This technique is well-known in helping to decrease symptoms of PTSD (Post
Traumatic Stress Disorder) and other sensory based problems
Sensory Based Trauma Assessment & Treatment
For the treatment of sexual abuse in children and/or adults.
Equine Facilitated Psychotherapy & Equine Experiential Learning
The Horsemanship is available through a partnership with LightHorse Learning, Inc., funding is possible for barn fees
through Easter Seals for persons with developmental disabilities.
Comprehensive Psychological Assessments
This service is available through FMC Clinical Psychologists.
Animal Assisted Therapy
FMC is an animal friendly environment. Pet therapy dogs are often present during sessions. Any client having allergies or another
aversion to animals should make that known before their first session so that accommodations can be made to assist in his/her
comfort level.
After Hours Emergencies
Our phone is monitored by a live answering service that can access and triage problems and provides resources for possible
solutions. A qualified provider is available on call for emergencies 24 hour a day, 7 days a week in the event of client emergencies.
Please discuss any question or issues you may have with this information or anything in this package with your provider. The
healing relationship begins with working through the details of getting started. We are honored that you have chosen to work with
us, welcome!
Warmest Regards,
Molly McCue, LPC
Carlene Taylor, LPC, NCC
Judy Rath, LAPC
And Associates
Family Matters Of Coastal Georgia, Inc. 912-882-6448 Fax: 912-882-6804
Family Matters of Coastal Georgia, Inc.
FAMILY MATTERS CLIENT INFORMATION FORM
Client’s Full Name: ___________________________ DOB: _______________ Sex: ___M___ F
Mailing Address: __________________________City/St: _____________Zip:_______________
Street Address: ____________________________City/St: _____________Zip:______________
Home Phone: _________________Work Phone: _________________Cell/Pager: ____________
Social Security Number: ____________________________ Email: _______________________
Martial Status: Married Single Divorced Separated Widowed N/A – child (Circle One)
GUARANTOR INFORMATION (If client is a minor)
Name of Guarantor: _____________________________________________________________
Address: _______________________________City:__________ State: _______ Zip: ________
Home Phone: _________________Work Phone: _________________Cell/Pager: ____________
PRIMARY INSURANCE INFORMATION
Insurance Company: _________________________________Phone:______________________
Address: ______________________________________________________________________
Policy ID#: _______________ Group#: _________________Group Name: _________________
Policy Owner’s Name: _______________________ Phone#:________________DOB:________
Policy Owner’s Address _________________________________________________________
Social Security #:________________________________
Authorization #: ________________________ Deductible: $ _____________ Co-Pay: $______
Client’s Relationship to Policy Owner: Self Spouse Child Other (Circle One)
SECONDARY INSURANCE INFORMATION
Insurance Company: _________________________________Phone:______________________
Address: ______________________________________________________________________
Policy ID#: _______________ Group#: _________________Group Name: _________________
Policy Owner’s Name: _______________________ Phone#:________________DOB:________
Policy Owner’s Address _________________________________________________________
Social Security #:________________________________
Authorization #: ________________________ Deductible: $ _____________ Co-Pay: $______
Client’s Relationship to Policy Owner: Self Spouse Child Other (Circle One)
EMPLOYMENT INFORMATION
Company: ______________________________________ Phone: ________________________
Address: ___________________City: ___________________State: _____________ Zip: ______
WHOM MAY WE THANK FOR REFERRING YOU?
Name: ______________________________________ Phone: ____________________________
PRIMARY CARE PHYSICIAN OR PSYCHIATRIST: _____________________________ Ph: _________
Assignment of Benefits:
Family Matters Of Coastal Georgia, Inc. 912-882-6448 Fax: 912-882-6804
Family Matters of Coastal Georgia, Inc.
I hereby instruct and direct my insurance company to pay by check made out and mailed to my provider Molly McCue, Carlene H.
Taylor, Judy K. Rath and/or their Associates.
Family Matters Counseling: of Coastal Georgia
126 Osborne Road
St. Mary’s GA 31558
Or to pay by direct deposit if electronic payments have been prearranged, for the professional and/or medical expenses, benefits
allowable and other wise payable to me under by current insurance policy and as payment toward the total charges for the
professional services rendered. This is a direct assignment of my rights and benefits under this policy. This payment will not exceed
my indebtedness to the above mentioned assignee. I have agreed to pay in a current manner any balance of said professional
service charges over and above the insurance payment. A photocopy of this assignment shall be considered as effective and as valid
as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney
involved in this case. I authorize the provider to initiate a complaint to the insurance commissioner for any reason on my behalf.
Statement of Financial Responsibility
Most insurance companies require an authorization for mental health coverage. The insured is generally responsible for obtaining
that authorization. FMC files insurance claims as a courtesy to clients, and will accept the assignment of insurance benefits in lieu
of payment if the insurance has been verified/authorized prior to service. Payment in full is due at the time of service if insurance
has not been verified or approved. Co-payments and payments against unsatisfied deductibles are due at this time of service unless
other arrangements have been made in advance with the provider. An EOB showing that your deductible has been met or other
statement from your insurance company should be brought to your first visit to ensure correct billing. If there is an outstanding
balance on your account, you will be notified by a statement. Statements are sent out on the first of each month and payable by the
10th of the month. A late fee of 10% will be assessed for statement balances beyond the 15th of the month. We accept payment in
the form of cash or check and effective January 1, 2008 by Visa or Mastercard. A fee of $35 will be assessed for returned checks.
Appointments are made to reserve the providers time especially for you. Cancellations require 24 hours notice. Appointments
cancelled with less than 24 hours notice or “no show” appointments will be billed at the full fee for the time reserved. Clients may
be asked to leave a credit card on file to authorize changes for late cancellations or “no shows” if necessary. Excessive cancellations
or no shows may result in termination of service by the provider with 30 days notice to the client.
Fees for Services
Family Matters Counseling fees are as follows:
Initial Assessment $125.00
Individual Psychotherapy 50” 90.00
Individual Psychotherapy 75” 125.00
Individual Psychotherapy 30” 50.00
Family/Couples Therapy 90.00
Barn Fees for Equine Sessions 50.00 - $200.00 per month
Court Testimony $100.00 per hour – 4 hour minimum
Fees for other special services will be negotiated at the time the service is scheduled.
I have read and understood/had explained to me these financial policies and by signing below, I agree to accept these terms of
service, agree to have my insurance benefits assigned to my provider and agree to accept financial responsibility as outlined above
for any balances due beyond my insurance benefits.
_______________________________ _______________________
Signature Date
______________________________ ____________________________________
Witness Provider Name
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Family Matters of Coastal Georgia, Inc.
Explanation of Consent Form:
This treatment consent form covers all procedures that are not of a nature to require a special consent, and it provides protection
for the procedures performed by the professional staff of Family Matters Counseling (FMC). This form documents that the client
has consented to treatment at FMC including but not limited to psychotherapy and counseling. This allows the professional staff at
FMC to provide services to you.
This form provides evidence that no guarantee is made by any professional at FMC concerning the outcome of treatment. There is
no guarantee that treatment will be successful. This form also provides evidence that consent is given only after a full explanation
has been provided by the staff at FMC. If you have any questions concerning this or any other matters, it is your responsibility to
ask your therapist. By signing this form, you acknowledge that you understand your consent to treatment as explained in this form.
Consent to Treatment:
I, , for ,
(Print your name) (Print the client’s name)
do hereby voluntarily consent to care and treatment by Molly McCue, LPC &/or Carlene Taylor, LPC &/or
Judy Rath, LAPC and/or the Associates of Family Matters Counseling assistants and/or designees. I am aware
that the practice of medicine, psychiatry, clinical psychology, clinical social work, and other therapy by a
licensed professional is not an exact science and I acknowledge that no guarantees have been made as to the
result of evaluation or treatment.
I am aware that I am an active participant in the counseling process and that I share responsibility for
treatment. My responsibilities in treatment include informing the therapist of any information that may be
relevant to the problems or conditions being treated, assisting in setting goals for treatment, following
therapeutic advice to the best of my ability, and ending treatment in a responsible way.
If I am consenting to treatment for another person, I certify that I am legally responsible for that person and
am entitled to consent to treatment for them. Children in joint legal custody much have both
parents/guardians listed to be involved in treatment.
This form has been fully explained to me and I certify that I understand its contents. I also understand that it
is my sole responsibility to ask any questions or obtain any clarification necessary to my understanding this
form fully.
Consent for Family Involvement in Treatment
[ ] I consent to have the family members listed below involved in the planning and delivery of the services
that I shall be receiving from Molly McCue, LPC, Carlene H. Taylor, LPC, Judy Rath, LAPC and/or Associates
for this period of service. I understand that, without this consent, Molly McCue, LPC, Carlene H. Taylor, LPC,
Judy Rath, LAPC and/or their Associates will not be allowed even to acknowledge to any family member that I
am a client of their services.
FAMILY MEMBERS TO BE INVOLVED
NAME: _________________________________ RELATIONSHIP: ________________
NAME: _________________________________ RELATIONSHIP: ________________
NAME: _________________________________ RELATIONSHIP: ________________
(Sign your name) (Date)
(Witness) (Date)
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Family Matters of Coastal Georgia, Inc.
Consent for Release of Information
I, _____________________________________________, DOB: _______________, CID:________
Authorize: Molly McCue, LPC [ ] Carlene Taylor, LPC [ ] Judy Rath, LAPC [ ] And/Or their
Associates ___________________________________
Address: 126 Osborne St, St Mary’s, GA 31558 Fax: 912-882-6804
To release the following information from my medical, psychiatric and substance abuse (if applicable) records.
______Discharge Summary ______Psychological/Neurological testing
______Psychiatric Evaluation ______Consultations
______Medical History & Physical ______Diagnosis
______Educational Records ______Social History/Assessments
______Lab Reports ______Progress Notes
______Correspondence ______Legal
To be sent to:
_____________________________________________________________________________________
Name or Practice Name to release information
_____________________________________________________________
Address City, State Zip
________________________________________________________________________________________
Phone Fax Email
For the purpose of: (0) Continuity of Care (0) Other: _____________________________
Information released is not to be further disclosed or used for any other purpose other than that stated in this authorization.
It is understood that I have the right to revoke this consent in writing at any time. Any revocation shall be in writing,
signed by me and the signature witnessed by a person who can attest to my identity No written revocation of consent shall
be effective until it is received by the person otherwise authorized to disclose records and shall have no effect on
disclosures made prior thereto. I understand I have the right to inspect and copy the information released. I further
understand that my refusal to consent to the release of the information specified above will prevent disclosure of such
information to the facility or person named herein for the stated purpose.
This Authorization is valid until: __________________________________________
Expires One Year from Date Signed Unless Specified Otherwise
Patient’s Signature: _____________________________________ Date: _____________
Parent/Guardian’s Signature: ______________________________Date: _____________
Witness Signature: ______________________________________Date: _____________
Signatures required: Adult (18 or over) and witness; parent (or guardian) and child plus witness, if child is 12 through 17;
parent (or guardian) and witness; if child is under 12 or individual adjudicated incompetent
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Family Matters of Coastal Georgia, Inc.
Notice of Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We are required by law to maintain the privacy of your health information and provide you with a description of our privacy
ractices. This notice will also describe your rights and certain obligations we have regarding the use and disclosure of your
ealth information.
PLEASE REVIEW THIS NOTICE CAREFULLY
our health information is personal. We are committed to protecting your health information. We create a record of the care and
ervices you receive at this office. We need this record to provide you with quality care and comply with certain legal
equirements. This Notice applies to all of the records of your care generated by this office whether made by your therapist or
ne of the office's employees.
Uses and Disclosures for Treatment, Payment, and Health Care Operations
he following describes the different ways that your protected health information (PHI) may be used or disclosed by this office.
PHI" refers to information in your health record that could identify you. For clarification, we have included some examples. Not
very possible use of disclosure is specifically mentioned. However, all of the ways we are committed to use and disclose your
PHI" will fit within one of these general categories:
For Treatment. "Treatment" is when we provide, coordinate, or manage your health care and other services
related to your health care. An example of treatment would be when we consult with another health care
provider, such as your family physician or another mental health provider.
For Payment. "Payment" is when we obtain reimbursement for your healthcare. Examples of payment are
when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to
determine eligibility or coverage. We may also tell your health plan insurer about a treatment you are going
to receive in order to obtain prior approval or to determine whether your plan will cover or continue to cover
your treatment.
For Healthcare Operations. "Healthcare Operations" are activities that related to the performance and
operation of our practice. Examples of healthcare operations are quality assessment and improvement
activities, business-related matters such as audits and administrative services, and case management and
care coordination. We may use and disclose health information to provide you with appointment
information. This may be done with voice mail, messages, post cards, and other mailings.
Use. "Use" applies only to activities within our office such as sharing, employing, applying, utilizing,
examining, and analyzing information that identifies you.
Disclosure. “Disclosure” applies to activities outside of our office such as releasing, transferring, or
providing access to information about you to other parties.
I. Uses and Disclosures Requiring Authorization
We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate
uthorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only
pecific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment or health
are operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an
uthorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes we have made about our
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Family Matters of Coastal Georgia, Inc.
onversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your
medical record. These notes are given a greater degree of protection than PHI.
ou may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing.
ou may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was
btained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.
II. Uses and Disclosures with Neither Consent nor Authorization
We may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse. If we have reasonable cause to suspect child abuse or neglect, we must report this suspicion to
the appropriate authorities as required by law.
Adult and Domestic Abuse. If we have reasonable cause to suspect you have been criminally abused, we
must report this suspicion to the appropriate authorities as required by law.
Health Oversight Activities. If we receive a subpoena or other lawful request from the Department of Health
or the Georgia Composite Board for Professional Counseling, we must disclose the relevant PHI pursuant to
that subpoena or lawful request.
Judicial and Administrative Proceedings. If you are involved in a court proceeding and a request is made for
information about your diagnosis and treatment or the records thereof, such information is privileged under
state law, and we will not release information without your written authorization or a court order. The
privilege does not apply when you are being evaluated by a third party or where the evaluation is court
ordered. You will be informed in advance if this is the case.
Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may use your PHI to defend the
office or to respond to a court order.
Law Enforcement. We may release PHI about you if required by law when asked to do so by a law
enforcement official.
Serious Threat to Health or Safety. If you communicate to us a threat of physical violence against a
reasonably identifiable third person and you have the apparent intent and ability to carry out that threat in
the foreseeable future, we may disclose relevant PHI and take the reasonable steps permitted by law to
prevent the threatened harm from occurring. If we believe that there is an imminent risk that you will inflict
serious physical harm on yourself, we may disclose information in order to protect you.
Worker’s Compensation. We may disclose protected health information regarding you as authorized by and
to the extent necessary to comply with laws relating to worker’s compensation or other similar programs,
established by law, that provide benefits for work-related injuries or illness without regard to fault.
V. Patient’s Rights and Therapist’s Duties
ou have the following rights regarding the PHI that this office maintains about you.
Right to Request Restrictions. You have the right to request restrictions on certain uses and disclosures of
protected health information. However, we are not required to agree to a restriction you request.
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 being seen at
our office. On your request, we will send your bills to another address.) To request confidential
communications, you must complete our request form in writing and submit it to the Privacy Officer. We
will accommodate all reasonable requests.
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Family Matters of Coastal Georgia, Inc.
Right to Inspect and Copy. You have the right to inspect or obtain a copy (or both) of PHI in our mental
health and billing records used to make decisions about you for as long as the PHI is maintained in the
record. To inspect and/or obtain a copy of your PHI, you must complete our request form and submit it to
the Privacy Officer. If you request copies, we will charge you $0.10 per page. We may deny your access to
PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request,
we will discuss with you the details of the request and denial process.
Right to Amend. You have the right to request an amendment of PHI for as long as the PHI is maintained in
the record. To request an amendment, you must complete our request form and submit it in writing to the
privacy officer. In addition, you must provide a reason that supports your request. We may deny your
request. On your request, we will discuss with you the details of the amendment process.
Right to an Accounting. You generally have the right to receive an accounting of disclosures of PHI. On
your request, we will discuss with you the details of the accounting process. To request this accounting on
disclosures, you must complete a request form and submit it in writing to the Privacy Officer. Your request
must state a time period, which may not be longer than six (6) years and may not include dates before April
14, 2003.
Right to a Paper Copy. You have the right to obtain a paper copy of the Notice from us upon request.
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herapist’s Duties:
We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties
and privacy practices with respect to PHI.
We reserve the right to change the privacy policies and practices described in this notice. Unless we notify
you of such changes, however, we are required to abide by the terms currently in effect.
. Questions and Complaints
you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns
bout your privacy rights, you may contact the Privacy Officer at Family Matters Counseling listed below.
you believe that your privacy rights have been violated and wish to file a complaint with us/our office, you may send your
ritten complaint to the Privacy Officer at Family Matters Counseling. All complaints must be submitted in writing to:
Privacy Officer:
Family Matters Counseling
126 Osborne Road
St. Mary’s GA 31558
ou may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person
sted above can provide you with the appropriate address upon request.
ou have specific rights under the Privacy Rule. We will not retaliate against you or penalize you in any way for exercising
our right to file a complaint.
I. Effective Date, Restrictions, and Changes to Privacy Policy
his notice will go into effect on January 1, 2007. We reserve the right to change the terms of this notice and to make the new
otice provisions effective for all PHI that we maintain. If we revise our policies and procedures, we will post a copy of any
evised Notice in this office.
ther uses and disclosures of your PHI not covered by this Notice of Privacy Practices will be made only with your written
uthorization. If you provide us such an authorization in writing to use or disclose PHI about you, you may revoke that
uthorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose PHI about you for the
easons covered by your written authorization. Be aware that we are unable to take back any disclosures we have already made
ith your permission, and we are required to retain our records of care that we provide to you.
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ACKNOWLEDGMENT
By signing below, I acknowledge that I have received a copy of this office's Notice of Privacy Practices form.
________________________________________ _________________
Client Signature Date
_________________________________________ __________________
Parent/Guardian Signature Date
Refusal to Sign Acknowledgment
__________________________________________ __________________
Patient Name Date
Notice of Privacy Practices was sent
__________________________________________ __________________
Patient Name Date
Initials ___________
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Family Matters of Coastal Georgia, Inc.
Client Name: ______________________ FMC # _________________ Date: _______________
PRESENTING PROBLEMS
Presenting problems Duration (months) Additional information:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
CURRENT SYMPTOM CHECKLIST (Rate intensity of symptoms currently present)
None • Mild -to-day functioning
Moderate -to-day functioning • Severe of life and/or day-to-day functioning
None Mild Moderate Severe None Mild Moderate Severe None Mild Moderate Severe
depressed mood [ ] [ ] [ ] [ ] bingeing/purging [ ] [ ] [ ] [ ] guilt [ ] [ ] [ ] [ ]
appetite disturbance [ ] [ ] [ ] [ ] laxative/diuretic abuse [ ] [ ] [ ] [ ] elevated mood [ ] [ ] [ ] [ ]
sleep disturbance [ ] [ ] [ ] [ ] anorexia [ ] [ ] [ ] [ ] hyperactivity [ ] [ ] [ ] [ ]
elimination disturbance [ ] [ ] [ ] [ ] paranoid ideation [ ] [ ] [ ] [ ] dissociative states [ ] [ ] [ ] [ ]
fatigue/low energy [ ] [ ] [ ] [ ] circumstantial symptoms [ ] [ ] [ ] [ ] somatic complaints [ ] [ ] [ ] [ ]
psychomotor retardation [ ] [ ] [ ] [ ] loose associations [ ] [ ] [ ] [ ] self-mutilation [ ] [ ] [ ] [ ]
poor concentration [ ] [ ] [ ] [ ] delusions [ ] [ ] [ ] [ ] significant weight gain/loss [ ] [ ] [ ] [ ]
poor grooming [ ] [ ] [ ] [ ] hallucinations [ ] [ ] [ ] [ ] concomitant medical condition [ ] [ ] [ ] [ ]
mood swings [ ] [ ] [ ] [ ] aggressive behaviors [ ] [ ] [ ] [ ] emotional trauma victim [ ] [ ] [ ] [ ]
agitation [ ] [ ] [ ] [ ] conduct problems [ ] [ ] [ ] [ ] physical trauma victim [ ] [ ] [ ] [ ]
emotionality [ ] [ ] [ ] [ ] oppositional behavior [ ] [ ] [ ] [ ] sexual trauma victim [ ] [ ] [ ] [ ]
irritability [ ] [ ] [ ] [ ] sexual dysfunction [ ] [ ] [ ] [ ] emotional trauma perpetrator [ ] [ ] [ ] [ ]
generalized anxiety [ ] [ ] [ ] [ ] grief [ ] [ ] [ ] [ ] physical trauma perpetrator [ ] [ ] [ ] [ ]
panic attacks [ ] [ ] [ ] [ ] hopelessness [ ] [ ] [ ] [ ] sexual trauma perpetrator [ ] [ ] [ ] [ ]
phobias [ ] [ ] [ ] [ ] social isolation [ ] [ ] [ ] [ ] substance abuse [ ] [ ] [ ] [ ]
obsessions/compulsions [ ] [ ] [ ] [ ] worthlessness [ ] [ ] [ ] [ ] other (specify) [ ] [ ] [ ] [ ]
EMOTIONAL/PSYCHIATRIC HISTORY
[ ] [ ] Prior outpatient psychotherapy?
No Yes If yes, on occasions. Longest treatment by for sessions from / to /
Provider Name Month/Year Month/Year
Prior provider name City State Phone Diagnosis Intervention/Modality Beneficial?
[ ] [ ] Has any family member had outpatient psychotherapy? If yes, who/why (list all):
No Yes
[ ] [ ] Prior inpatient treatment for a psychiatric, emotional, or substance use disorder?
No Yes If yes, on occasions. Longest treatment at from / to /
Name of facility Month/Year Month/Year
Inpatient facility name City State Phone Diagnosis Intervention/Modality Beneficial?
[ ] [ ] Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder? If yes,
No Yes who/why (list all):
[ ] [ ] Prior or current psychotropic medication usage? If yes:
No Yes Medication Dosage Frequency Start date End date Physician Side effects Beneficial?
[ ] [ ] Has any family member used psychotropic medications? If yes, who/what/why (list all):
No Yes
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FAMILY HISTORY
Present during childhood: Parents' current marital status: Describe parents:
Present Present Not [ ] married to each other Father Mother
entire part of present [ ] separated for years full name
childhood childhood at all [ ] divorced for years occupation
mother [ ] [ ] [ ] [ ] mother remarried times education
father [ ] [ ] [ ] [ ] father remarried times general health
stepmother [ ] [ ] [ ] [ ] mother involved with someone
stepfather [ ] [ ] [ ] [ ] father involved with someone Describe childhood family experience:
brother(s) [ ] [ ] [ ] [ ] mother deceased for years [ ] outstanding home environment
sister(s) [ ] [ ] [ ] age of patient at mother's death [ ] normal home environment
other (specify) [ ] [ ] [ ] [ ] father deceased for years [ ] chaotic home environment
age of patient at father's death [ ] witnessed physical/verbal/sexual abuse
[ ] experienced physical/verbal/sexual abuse
Age of emancipation from home: Circumstances:
Special circumstances in childhood:
IMMEDIATE FAMILY
Marital status: Intimate relationship: List all persons currently living in patient's household:
[ ] single, never married [ ] never been in a serious relationship Name Age Sex Relationship to patient
[ ] engaged months [ ] not currently in relationship
[ ] married for years [ ] currently in a serious relationship
[ ] divorced for years
[ ] separated for years Relationship satisfaction: List children not living in same household as patient:
[ ] divorce in process months [ ] very satisfied with relationship
[ ] live-in for years [ ] satisfied with relationship
[ ] prior marriages (self) [ ] somewhat satisfied with relationship
[ ] prior marriages (partner) [ ] dissatisfied with relationship
[ ] very dissatisfied with relationship Frequency of visitation of above:
Describe any past or current significant issues in ADULT intimate relationships:
________
Describe any past or current significant issues in other immediate family relationships:
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Family Matters of Coastal Georgia, Inc.
MEDICAL HISTORY (check all that apply for patient)
Describe current physical health: [ ] Good [ ] Fair [ ] Poor Is there a history of any of the following in the family:
[ ] tuberculosis [ ] heart disease
List name of primary care physician: [ ] birth defects [ ] high blood pressure
Name Phone [ ] emotional problems [ ] alcoholism
[ ] behavior problems [ ] drug abuse
List name of psychiatrist: (if any): [ ] thyroid problems [ ] diabetes
Name Phone [ ] cancer [ ] Alzheimer's disease/dementia
[ ] mental retardation [ ] stroke
List any medications currently being taken (give dosage & reason): [ ] other chronic or serious health problems
Describe any serious hospitalization or accidents:
Date Age Reason
List any known allergies: Date Age Reason
Date: Age Reason
SUBSTANCE USE HISTORY (check all that apply for patient)
Family alcohol/drug abuse history: Substances used: Current Use
(complete all that apply) First use age Last use age (Yes/No) Frequency Amount
[ ] father [ ] stepparent/live-in [ ] alcohol
[ ] mother [ ] uncle(s)/aunt(s) [ ] amphetamines/speed
[ ] grandparent(s) [ ] spouse/significant other [ ] barbiturates/owners
[ ] sibling(s) [ ] children [ ] caffeine
[ ] other [ ] cocaine
[ ] crack cocaine
Substance use status: [ ] hallucinogens (e.g., LSD)
[ ] inhalants (e.g., glue, gas)
[ ] no history of abuse [ ] marijuana or hashish
[ ] active abuse [ ] nicotine/cigarettes
[ ] early full remission [ ] PCP
[ ] early partial remission [ ] prescription
[ ] sustained full remission [ ] other
[ ] sustained partial remission
Treatment history: Consequences of substance abuse (check all that apply):
[ ] outpatient (age[s] ) [ ] hangovers [ ] withdrawal symptoms [ ] sleep disturbance [ ] binges
[ ] inpatient (age[s] ) [ ] seizures [ ] medical conditions [ ] assaults [ ] job loss
[ ] 12-step program (age[s] ) [ ] blackouts [ ] tolerance changes [ ] suicidal impulse [ ] arrests
[ ] stopped on own (age[s] ) [ ] overdose [ ] loss of control amount used [ ] relationship conflicts
[ ] other (age[s] [ ] other
describe:
Family Matters Of Coastal Georgia, Inc. 912-882-6448 Fax: 912-882-6804
Family Matters of Coastal Georgia, Inc.
SOCIO-ECONOMIC HISTORY (check all that apply for patient)
Living situation: Social support system: Sexual history:
[ ] housing adequate [ ] supportive network [ ] heterosexual orientation [ ] currently sexually dissatisfied
[ ] homeless [ ] few friends [ ] homosexual orientation [ ] age first sex experience
[ ] housing overcrowded [ ] substance-use-based friends [ ] bisexual orientation [ ] age first pregnancy/fatherhood
[ ] dependent on others for housing [ ] no friends [ ] currently sexually active [ ] history of promiscuity age to
[ ] housing dangerous/deteriorating [ ] distant from family of origin [ ] currently sexually satisfied [ ] history of unsafe sex age to
[ ] living companions dysfunctional Additional information:
Military history:
Employment: [ ] never in military Cultural/spiritual/recreational history:
[ ] employed and satisfied [ ] served in military - no incident cultural identity (e.g., ethnicity, religion):
[ ] employed but dissatisfied [ ] served in military - with incident
[ ] unemployed describe any cultural issues that contribute to current problem:
[ ] coworker conflicts
[ ] supervisor conflicts Legal history: currently active in community/recreational activities? Yes [ ]
No [ ]
[ ] unstable work history [ ] no legal problems formerly active in community/recreational activities? Yes [ ]
No [ ]
[ ] disabled: [ ] now on parole/probation currently engage in hobbies? Yes [ ]
No [ ]
[ ] arrest(s) not substance-related currently participate in spiritual activities? Yes [ ]
No [ ]
Financial situation: [ ] arrest(s) substance-related if answered "yes" to any of above, describe __________
[ ] no current financial problems [ ] court ordered this treatment
[ ] large indebtedness [ ] jail/prison time(s)
[ ] poverty or below-poverty income total time served:
[ ] impulsive spending describe last legal difficulty:
[ ] relationship conflicts over finances
CLIENT GOALS FOR TREATMENT
Briefly Identify what you would like to see changed or improved by coming to therapy.
1. ____________________________________________________________________________________
2. ____________________________________________________________________________________
3. ____________________________________________________________________________________
WHAT ELSE SHOULD WE KNOW THAT WE DID NOT ASK?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
This conclude the portion that is to be completed by the patient and/or guardian, thank you!
Family Matters Of Coastal Georgia, Inc. 912-882-6448 Fax: 912-882-6804
Family Matters of Coastal Georgia, Inc.
MSE & DIAGNOSIS - TO BE COMPLETED BY THE PROVIDER
Mental Status
(Check appropriate level of impairment: N/A or OK signifies no known impairment. Comment on significant areas of impairment.)
Appearance N/A or OK Slight Moderate Severe
Unkempt, disheveled ( ) ( ) ( ) ( )
Clothing, dirty, atypical ( ) ( ) ( ) ( )
Odd phys. characteristics ( ) ( ) ( ) ( )
Body odor ( ) ( ) ( ) ( )
Appears unhealthy ( ) ( ) ( ) ( )
Posture N/A or OK Slight Moderate Severe
Slumped ( ) ( ) ( ) ( )
Rigid, tense ( ) ( ) ( ) ( )
Body Movements N/A or OK Slight Moderate Severe
Accelerated, quick ( ) ( ) ( ) ( )
Decreased, slowed ( ) ( ) ( ) ( )
Restlessness, fidgety ( ) ( ) ( ) ( )
Atypical, unusual ( ) ( ) ( ) ( )
Speech N/A or OK Slight Moderate Severe
Rapid ( ) ( ) ( ) ( )
Slow ( ) ( ) ( ) ( )
Loud ( ) ( ) ( ) ( )
Soft ( ) ( ) ( ) ( )
Mute ( ) ( ) ( ) ( )
Atypical (e.g., slurring) ( ) ( ) ( ) ( )
Attitude N/A or OK Slight Moderate Severe
Domineering, controlling ( ) ( ) ( ) ( )
Submissive, dependent ( ) ( ) ( ) ( )
Hostile, challenging ( ) ( ) ( ) ( )
Guarded, suspicious ( ) ( ) ( ) ( )
Uncooperative ( ) ( ) ( ) ( )
Affect N/A or OK Slight Moderate Severe
Inappropriate to thought ( ) ( ) ( ) ( )
Increased liability ( ) ( ) ( ) ( )
Blunted, dull, flat ( ) ( ) ( ) ( )
Euphoria, elation ( ) ( ) ( ) ( )
Anger, hostility ( ) ( ) ( ) ( )
Depression, sadness ( ) ( ) ( ) ( )
Anxiety ( ) ( ) ( ) ( )
Irritability ( ) ( ) ( ) ( )
Perception N/A or OK Slight Moderate Severe
Illusions ( ) ( ) ( ) ( )
Auditory hallucinations ( ) ( ) ( ) ( )
Visual hallucinations ( ) ( ) ( ) ( )
Other hallucinations ( ) ( ) ( ) ( )
Family Matters Of Coastal Georgia, Inc. 912-882-6448 Fax: 912-882-6804
Family Matters of Coastal Georgia, Inc.
Cognitive N/A or OK Slight Moderate Severe
Alertness ( ) ( ) ( ) ( )
Attn. span, distractibility ( ) ( ) ( ) ( )
Short-term memory ( ) ( ) ( ) ( )
Long-term memory ( ) ( ) ( ) ( )
Judgment N/A or OK Slight Moderate Severe
Decision making ( ) ( ) ( ) ( )
Impulsivity ( ) ( ) ( ) ( )
Thought Content N/A or OK Slight Moderate Severe
Obsessions/compulsions ( ) ( ) ( ) ( )
Phobic ( ) ( ) ( ) ( )
Depersonalization ( ) ( ) ( ) ( )
Suicidal ideation ( ) ( ) ( ) ( )
Homicidal ideation ( ) ( ) ( ) ( )
Delusions ( ) ( ) ( ) ( )
Estimated level of intelligence:
Orientation: Time Place Person
Able to hold normal conversation? Yes No
Eye contact:
Level of insight:
Complete denial Slight awareness
Blames others Blames self
Intellectual insight, but few changes likely ____Emotional insight, understanding, change can occur
Axis I: ___________ _________________________________________________________
___________ _________________________________________________________
Axis II: ___________ _________________________________________________________
Axis III: ___________ _________________________________________________________
Axis IV: ___________ _________________________________________________________
Axis V: GAF: ______ GAF within last year: _________
INITIAL TREATMENT GOALS TARGET DATE
1. _______________________________________________________ ___________
2. _______________________________________________________ ___________
3. _______________________________________________________ ___________
_____________________________________________________________
Provider Signature Date
( ) Molly McCue, LPC ( ) Carlene H. Taylor, LPC, NCC ( ) Judy Rath, LAPC ( ) Sue Kenyon, LCSW ( )
Rachel Haynie, LPC ( ) Terry Dean, PHD
Family Matters Of Coastal Georgia, Inc. 912-882-6448 Fax: 912-882-6804
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