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SHD Registration Document with boxes


									                                                   REGISTRATION INTERVIEW

                                             Michael Traub, MBA, LCSW, ACSW

                                             Counseling and Clinical Social Work Services

CONFIDENTIALITY               All information from this form is considered Protected Health Information (PHI) and will be
                              safeguarded in accordance with HIPAA Notice of Privacy Practices


Name:                                                                                           Date:
              (Last)                          (First)                            (Initial)

                          (City)                    (State)              (Zip Code)                     (E-mail Address)

Client Birthdate:                               Age:                         Social Security No.:

Marital Status:                                                              No. of Children:

Name of Spouse:                                                              Date of Birth-Spouse:

Telephone (Home):         (              )                                   Cell Phone (               )

Message Telephone: (                     )                                   Message Source:

Client Job Title:

Employer Name:                                                               Work Phone No.: (              )

Employer Address:

Person to Notify in case of emergency:                                                       Phone: (           )


Who will be responsible for payment for services received? (If other than client)

Name:                                                                        Social Security No:
         (Last)                    (First)                 (Initial)
Relationship to Client:                                                      Birthdate:


                          (City)                                       (State)               (Zip Code)

Telephone: (Home)         (          )                                       (Work) (           )

                                                        (Continued on next page)

                                                                  Page 1
                                            REGISTRATION INTERVIEW

Who Is Your Insurance Provider?

Name of Company:

Policy No.:                                                      Group No.:

Phone No.: (       )

Address:                                                         City                   State           Zip

Who sent you to this office? How did you hear about the services?

Name or Place:


1) What is your reason for coming to counseling?

On a scale of 1 – 10 (1 being the least severe, 10 being the most severe), how severe would you rate the problem for
which you are seeking treatment?

2) What are your goals for counseling and what do you want to accomplish?

On a scale of 1 – 10 (1 being the least severe, 10 being the most severe), how severe would you like the problem to be at
completion of treatment?

                                               (Continued on next page)

                                                        Page 2
                                               REGISTRATION INTERVIEW


Are you :      single        married        divorced           separated

If married, how long?                                    Do you have children by this marriage?          Yes   No

                    Child’s Name                       (M)ale or           Age                 Date of Birth

Who do they live with?

Any previous marriages?         Yes         No           How Many?

Do you have children by a previous marriage?           Yes            No

Names & Ages & Birthdates:

Who do they live with?

Do you have Brothers?          Yes        No             Sisters?           Yes     No

Names & Ages:

What is your educational (school) history?
(Please list name of school, city & state school is located, year you graduated or how long attended)

Grammar School:

High School:

College or Technical School:

What is your work history?

      Company                                    City & State of Company                                Year

                                                 (Continued on next page)

                                                             Page 3
                                               REGISTRATION INTERVIEW


Do you prefer to communicate in
   English?        Spanish?            Sign Language?                   Other?

If you are deaf or have a hearing impairment, what is the degree of your loss?
          right ear?                         left ear?

When did your hearing loss first occur and how old were you?

What was the reason for your hearing loss?


Do you have any medical or physical problems or limitations?         (Example: heart, back problems, vision)

Are you under a doctor's care?        Yes         No       Please complete page 9 of this registration form

Are you taking any prescription medications?         Yes         No

         Name of Prescription Medication(s)                       Dosage                           Taken Since

Do you take any over-the-counter drugs/medications?               Yes            No

      Name of Over-The-Counter Medication(s)                      Dosage                           Taken Since

Please check any of the following boxes if you experienced them in your childhood:
        Recurrent and severe physical abuse                                 Recurrent and severe emotional abuse
        Contact sexual abuse                                                An alcoholic or drug-user in the household
        A household member being imprisoned                                 Your mother being treated violently
        Both biological parents not being present in the household
        A mentally ill, chronically depressed, or institutionalized household member

                                                 (Continued on next page)

                                                            Page 4
                                              REGISTRATION INTERVIEW


Have you ever had any psychological counseling?               Yes          No
Name:                                                                             Telephone:

Have you ever had any psychiatric care?           Yes          No
Doctor's Name:                                                                    Telephone:

What were your reasons for treatment or counseling?

                                             SUBSTANCE USE INFORMATION:
Do you drink for "enjoyment"?         Yes          No

How long since your last drink?                               How much did you drink at that time?

How many days drinking in last 30 days?

Have your parents or spouse ever complained about your drinking?                  Yes          No
Have you ever missed work or appointments because of your drinking?                  Yes            No

If yes, how much did you drink?

Have you ever had a "blackout" because of drinking too much?                Yes         No

Have you ever been arrested for a D.U.I.?          Yes          No

Age first used alcohol?

Have you ever been involved in a 12-step/AA program?                Yes, currently          Yes, but not currently        No

Do you use drugs for "enjoyment"?           Yes          No

What kind of drugs do you use?

How long since you last used drugs?                           How much drugs did you take at that time?

How many days using drugs in last 30 days?

Have your parents or spouse ever complained about your using drugs?                   Yes         No
Have you ever missed work or appointments because of using drugs?                    Yes         No

How much did you use?

Have you ever been arrested for possession?             Yes           No

Have you ever been arrested for D.U.I.?           Yes          No

Age first used drugs?

Have you ever been involved in a 12-step program?             Yes, currently          Yes, but not currently         No

                                                  (Continued on next page)

                                                              Page 5
                                              REGISTRATION INTERVIEW

                                       SUBSTANCE USE INFORMATION, continued:


Do you currently smoke cigarettes?          Yes          No

If yes, how many cigarettes do you smoke a day?

Have you smoked cigarettes in the past?            Yes        No

If yes, how many cigarettes did you smoke a day and when did you quit?


How much caffeine do you consume each day?

# of ounces:                              Types:


What do you do for enjoyment or as hobbies?

What are your strengths?

SYMPTOMS (check all that apply)

        Anxiety or nervousness                     Panic or anxiety attacks           Stress
        Depressed, sad, empty mood or              Mood swings                        Memory problems
        Irritability                               Decreased need for sleep           Paranoia
        Loss of pleasure, including sex            More talkative than usual          Tearfulness or crying
        Weight gain or loss                        Easily distracted                  Inappropriate anger
        Change in appetite, eating more            Obsessions/compulsions
        or less than usual
        Change in sleeping pattern,                Hyperactivity                      Other, please describe
        more or less than usual
        Decreased energy or fatigue                Spending more money than usual
        Feeling worthlessness or guilt             Fear of something specific, i.e.
                                                   heights, crowds, etc.
        Concentration problems                     Nightmares                         How long have you had
                                                                                      these symptoms?
        Difficulty making decisions
        Thoughts of death or suicide
                                                  (Continued on next page)

                                                           Page 6
                                                   REGISTRATION INTERVIEW

                                                          SIGNATURE PAGE

          CANCELLATION: Since scheduling of an appointment involves the reservation of time specifically for you, a
Initial   minimum of 24 hours notice is required for re-scheduling or canceling an appointment. Unless we reach a
          different agreement, a fee will be charged for sessions missed without such notification. Most insurance companies
          do not reimburse for missed sessions, therefore payment of this fee is the responsibility of the client.

          I/we have read the document entitled Agreement/Informed Consent for Psychotherapy Services and Office Policies
          and General Information carefully; have had the opportunity to ask questions; understand the agreement, policies,
          and information; agree to comply with them; and agree to begin treatment:

                 Signature                               Date                     Client/parent/guardian (print)

                 Signature                               Date                     Client/parent/guardian (print)

          For office use only - Verification that client/parent/guardian has read the document entitled Agreement/Informed
          Consent for Psychotherapy Services and Office Policies and General Information, had the opportunity to ask
          questions, understands the agreement, policies, and information, agrees to comply with them, and agrees to begin

          Michael Traub, MBA, LCSW: _____________________________________              Date: _____________________

          I/we acknowledge receipt of the HIPAA Notice of Privacy Practices and have read and understand my rights:

                 Signature                               Date                     Client/parent/guardian (print)

                 Signature                               Date                     Client/parent/guardian (print)

                                                                Page 7
                                                REGISTRATION INTERVIEW

                              PAYMENT, AND HEALTH CARE OPERATIONS (TPO)

Federal regulations (HIPAA) allow me to use or disclose Protected Health Information (PHI) from your record in order to
provide treatment to you, to obtain payment for the services we provide, and for other professional activities (known as “health
care operations.”). Nevertheless, I ask your consent in order to make this permission explicit. The Notice of Privacy Practices
describes these disclosures in more detail. You have the right to review the Notice of Privacy Practices before signing this
consent. I reserve the right to revise the Notice of Privacy Practices at any time. If I do so, the revised Notice will be posted in
the office. You may ask for a printed copy of the Notice at any time.

You may ask me to restrict the use and disclosure of certain information in your record that otherwise would be disclosed for
treatment, payment, or health care operations; however, I do not have to agree to these restrictions. If I do agree to a restriction,
that agreement is binding.

You may revoke this consent at any time by giving written notification. Such revocation will not affect any action taken in
reliance on the consent prior to the revocation.

This consent is voluntary; you may refuse to sign it. However, I am permitted to refuse to provide health care services if this
consent is not granted, or if the consent is later revoked.

I hereby consent to the use or disclosure of my Protected Health Information as specified above.

         Signature                                     Date                        Client/parent/guardian (print)

         Signature                                     Date                        Client/parent/guardian (print)

                                                              Page 8
                                    Michael Traub, MBA, LCSW, ACSW
                                          3200 N. Hayden Road, Suite 150
                                            Scottsdale, AZ 85251-6654
                       Phone: (480) 515-0490 Urgent: (602) 451-7899 Fax: (480) 515-0015
                          Email: Website:

                              Consent for Release of Confidential Information To Medical Providers

I, ________________________________                     __________ ,
      (Participant’s Name)                                                            (DOB)
          hereby authorize Michael Traub, LCSW to disclose to my medical service provider(s) all clinical information about me as
may be necessary to permit my physician(s) or their medical staff to monitor the continuity of my care and to inform my physician(s)
of my status.
          This authorization becomes effective as of the date of my signature below and may be revoked by me in writing at any time,
with the exception of any actions already taken to coordinate my care. Unless earlier revoked by me, this authorization automatically
expires at the termination of treatment with Michael Traub, LCSW. I understand that this authorization does not extend to the release
of any AIDS/HIV information unless I also placed my initials here _______. I further understand that the information authorized by
this release will be released to the authorized representative(s) only, for purposes noted above. I understand I (or my legal
representative) am entitled to a copy of this authorization form for my records if requested.

Medical Provider(s) Name(s) and contact information:

                                         Refusal for Requested Consent to Coordinate Care

          I am currently receiving treatment from Michael Traub, LCSW, who has requested my permission to notify my physician(s)
and their medical staff of my diagnosis and treatment plan for the purpose of coordinating my behavioral health and my medical care.
Michael Traub, LCSW has explained to me that the lack of coordination of care between all of my treating providers could complicate
my overall healthcare, particularly in the case where medications are being prescribed by different physicians.
          I have had a full opportunity to ask questions concerning the coordination of care and my Michael Traub’s request for my
consent. I understand the risks to me if I refuse to permit communication between my healthcare providers and hereby release my
medical provider(s) and Michael Traub, LCSW from any and all liability for any negative results from their inability to work together
to coordination a holistic healthcare plan for me.
          With this understanding, I hereby deny consent to communicate with my physician(s) or their medical staff regarding the
status of my care.

______________________________________                                    _______________________________
Legal Signature of Participant or Legal Guardian                                        Date:

______________________________________                                    _______________________________
Printed Name of Participant                                                             Witness

Notice to Recipient: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part
2) and/or state law. In accordance with federal and State law requirements, this information received pursuant to this document is
confidential and recipient is prohibited from making further redisclosure of this information to any other person or entity, or to use it
for any purpose other than as authorized herein, without the written consent of the person to whom it pertains or as otherwise
permitted by law. 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 patients.

                                                                 Page 9

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