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Psychotherapist Intake Application

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Psychotherapist Intake Application Powered By Docstoc
					                                             Jessica Graves, MA, LPC, BCIAC
                  --------------------------------------------------------------------------------------------------------------------------------------------
                                                Licensed Professional Counselor
                                                 Certified Biofeedback Therapist


             PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT & DISCLOSURE FORM

Welcome to my office. This document (the Agreement) contains important information about my professional services
and business policies. It also contains summary information about the Health Insurance Portability and Accountability
Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and
disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care
operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of
PHI for treatment, payment, and health care operations. The Notice, which is posted in my waiting area, explains
HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your
signature acknowledging that I have provided you with this information. Signing this document will provide this
acknowledgement. It will also document your acknowledgment that you have received my mandatory disclosure
information, and represent an agreement between us whereby you are consenting to treatment (e.g. biofeedback,
psychotherapy) and/or evaluation with me. You may revoke this Agreement in writing at any time. That revocation will
be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health
insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial
obligations you have incurred.

BIOFEEDBACK SERVICES

Biofeedback is a highly structured therapeutic modality that can help you to learn how to regulate your own behaviors.
Learning these skills can lead to positive changes such as improved sleeping habits, blood circulation and ability to
handle stress and reduced muscle tension, pain levels, anxiety and even blood pressure. This therapy calls for a very
active effort on your part. In order for the therapy to be most successful, you will have to work on the techniques used
in session at home as well. Results will vary depending on your situation, motivation, and goals for your treatment.

PSYCHOTHERAPY SERVICES

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the
psychotherapist and patient, and the particular problems you are experiencing. There are many different methods I may
use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls
for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we
talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often
involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt,
anger, and frustration. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often
leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. As with
any treatment modality, there are no guarantees of what you will experience.

IMPORTANT INFORMATION
The Colorado Department of Regulatory Agencies (DORA) has the general responsibility of regulating the practice of
licensed and unlicensed persons in the field of psychotherapy. Questions or complaints may be addressed to:

                                     Department of Regulatory Agencies
                                     1560 Broadway, Suite 1350
                                     Denver, CO 80202
                                     Phone: (303) 894-7766
DORA also requires that I disclose to you information about my background and credentials, which is as follows: I am
a Licensed Professional Counselor (CO #4449) and a Certified Biofeedback Therapist (#B4786) by the Biofeedback
Certification International Alliance (BCIA-C). I received my B.A. in Economics and French from Trinity University
and my M.A. in Community Counseling from the University of Northern Colorado.




          Botanica Wellness Sanctuary • 244 Washington St. • Denver, CO 80203
                Main 720-279-8726 • Cell 720-413-9950 • Fax 303-557-6266
                                             Jessica Graves, MA, LPC, BCIAC
                  --------------------------------------------------------------------------------------------------------------------------------------------
                                                Licensed Professional Counselor
                                                 Certified Biofeedback Therapist
CLIENT RIGHTS

     You are entitled to receive information from me about my methods of therapy, the techniques I use, the
    duration of your therapy (if it can be determined), and my fee structure. Please ask if you have not yet received this
    information.
     You can seek a second opinion from another therapist or terminate biofeedback or psychotherapy at any time.
     In a professional relationship (such as this), sexual intimacy between a therapist and a client is never
    appropriate. If sexual intimacy occurs, it should be reported to the Department of Regulatory Agencies, Mental
    Health Section.
     Privileged Communications: The information provided by a client during therapy sessions with a
    psychotherapist is legally confidential, as defined by House Bill 102b, section 12.43.218, and the laws of medical
    confidentiality in the State of Colorado. There are exceptions, however, of which you need to be aware. Examples
    of situations that may merit departure from the standard confidentiality rules include suspicion of child and/or elder
    abuse; serious threats to health or safety of yourself or others; in the cases of some judicial and administrative
    proceedings; regarding laws related to worker’s compensation cases; and if you grant your consent to have
    information released to others (e.g. your physician) via an “Authorization Form.” These exceptions are also
    discussed in the Notice.

CLIENT RESPONSIBILITIES &OFFICE POLICIES

     Payment for services, including co-payments and/or deductible (if using insurance), is expected at the time of
    service unless prior arrangements or pre-authorization have been made through your insurance company. Please
    note that I accept payment by cash, check, or credit card.
     If you are unable to keep your scheduled appointment, you are required to provide notice of cancellation at
    least 24 hours in advance by calling (720) 279-8726 or (720) 413-9950. If it is after normal business hours,
    leaving a message is sufficient to cancel an appointment. I do reserve the right to charge you a $100 cancellation
    fee for evaluations (biofeedback, psychotherapy). For those appointments that you do not cancel as stated above or
    for missed follow-up sessions the charge will be the cost of the session, unless the missed session/late cancellation
    happens as a result of a bona fide emergency. In most cases, this fee will not be covered by your insurance
    company and must be paid directly by you.
     If you miss three visits (including late cancels or no-shows) for biofeedback and/or psychotherapy, I may opt
    to discontinue your treatment for non-compliance and not schedule further visits for you. I will also notify your
    referring provider that you will no longer be seen in my office.
     Please note that you are financially responsible for any and all services provided on your behalf, which are not
    paid by your insurance. However, I do agree to accept payment by a motor vehicle accident or workers’
    compensation carrier as full and final payment, if such carrier agrees to pay for this care. I do reserve the option of
    using legal means or collection agency to secure payment of account balances past due.
     Contacting Me: To schedule an appointment, please call (720) 279-8726. While we strive to return patient
    calls within a timely manner, we may not always be immediately available. In the case of a non life-threatening
    situation which requires urgent attention outside of normal business hours, you may reach me directly at (720) 413-
    9950. If you feel you are in a potentially life-threatening situation, please do not wait for a returned call, but
    instead go to the nearest emergency room or call 911. If I will be unavailable for an extended time, I will provide
    you with the name of a colleague to contact in my absence, if necessary.

If you have any questions about any of this information or my services, please feel free to ask. Additional information
on my practice can be found on my website: www.botanicawellness.com.

YOUR SIGNATURE BELOW SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE READ THIS
AGREEMENT AND AGREE TO ITS TERMS AND HAVE RECEIVED THE HIPAA NOTICE FORM. YOUR
SIGNATURE ALSO SERVES AS CONSENT FOR EVALUATION AND/OR TREATMENT WITH JESSICA
GRAVES, MA, LPC, BCIAC.
Patient signature_____________________________________________________________Date ______________

Provider/Witness signature_____________________________________________________Date ______________


          Botanica Wellness Sanctuary • 244 Washington St. • Denver, CO 80203
                Main 720-279-8726 • Cell 720-413-9950 • Fax 303-557-6266
                                             Jessica Graves, MA, LPC, BCIAC
                  --------------------------------------------------------------------------------------------------------------------------------------------
                                                Licensed Professional Counselor
                                                 Certified Biofeedback Therapist


                        PATIENT COPY: PLEASE KEEP FOR FUTURE REFERENCE
             PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT & DISCLOSURE FORM

Welcome to my office. This document (the Agreement) contains important information about my professional services
and business policies. It also contains summary information about the Health Insurance Portability and Accountability
Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and
disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care
operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of
PHI for treatment, payment, and health care operations. The Notice, which is posted in my waiting area, explains
HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your
signature acknowledging that I have provided you with this information. Signing this document will provide this
acknowledgement. It will also document your acknowledgment that you have received my mandatory disclosure
information, and represent an agreement between us whereby you are consenting to treatment (e.g. biofeedback,
psychotherapy) and/or evaluation with me. You may revoke this Agreement in writing at any time. That revocation will
be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health
insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial
obligations you have incurred.

BIOFEEDBACK SERVICES

Biofeedback is a highly structured therapeutic modality that can help you to learn how to regulate your own behaviors.
Learning these skills can lead to positive changes such as improved sleeping habits, blood circulation and ability to
handle stress and reduced muscle tension, pain levels, anxiety and even blood pressure. This therapy calls for a very
active effort on your part. In order for the therapy to be most successful, you will have to work on the techniques used
in session at home as well. Results will vary depending on your situation, motivation, and goals for your treatment.

PSYCHOTHERAPY SERVICES

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the
psychotherapist and patient, and the particular problems you are experiencing. There are many different methods I may
use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls
for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we
talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often
involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt,
anger, and frustration. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often
leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. As with
any treatment modality, there are no guarantees of what you will experience.

IMPORTANT INFORMATION
The Colorado Department of Regulatory Agencies (DORA) has the general responsibility of regulating the practice of
licensed and unlicensed persons in the field of psychotherapy. Questions or complaints may be addressed to:

                                     Department of Regulatory Agencies
                                     1560 Broadway, Suite 1350
                                     Denver, CO 80202
                                     Phone: (303) 894-7766
DORA also requires that I disclose to you information about my background and credentials, which is as follows: I am
a Licensed Professional Counselor (CO #4449) and a Certified Biofeedback Therapist (#B4786) by the Biofeedback
Certification Institute of America (BCIA-C). I received my B.A. in Economics and French from Trinity University and
my M.A. in Community Counseling from the University of Northern Colorado.


          Botanica Wellness Sanctuary • 244 Washington St. • Denver, CO 80203
                Main 720-279-8726 • Cell 720-413-9950 • Fax 303-557-6266
                                             Jessica Graves, MA, LPC, BCIAC
                  --------------------------------------------------------------------------------------------------------------------------------------------
                                                Licensed Professional Counselor
                                                 Certified Biofeedback Therapist
CLIENT RIGHTS

     You are entitled to receive information from me about my methods of therapy, the techniques I use, the
    duration of your therapy (if it can be determined), and my fee structure. Please ask if you have not yet received this
    information.
     You can seek a second opinion from another therapist or terminate biofeedback or psychotherapy at any time.
     In a professional relationship (such as this), sexual intimacy between a therapist and a client is never
    appropriate. If sexual intimacy occurs, it should be reported to the Department of Regulatory Agencies, Mental
    Health Section.
     Privileged Communications: The information provided by a client during therapy sessions with a
    psychotherapist is legally confidential, as defined by House Bill 102b, section 12.43.218, and the laws of medical
    confidentiality in the State of Colorado. There are exceptions, however, of which you need to be aware. Examples
    of situations that may merit departure from the standard confidentiality rules include suspicion of child and/or elder
    abuse; serious threats to health or safety of yourself or others; in the cases of some judicial and administrative
    proceedings; regarding laws related to worker’s compensation cases; and if you grant your consent to have
    information released to others (e.g. your physician) via an “Authorization Form.” These exceptions are also
    discussed in the Notice.

CLIENT RESPONSIBILITIES &OFFICE POLICIES

     Payment for services, including co-payments and/or deductible (if using insurance), is expected at the time of
    service unless prior arrangements or pre-authorization have been made through your insurance company. Please
    note that I accept payment by cash, check, or credit card.
     If you are unable to keep your scheduled appointment, you are required to provide notice of cancellation at
    least 24 hours in advance by calling (720) 279-8726 or (720) 413-9950. If it is after normal business hours,
    leaving a message is sufficient to cancel an appointment. I do reserve the right to charge you a $100 cancellation
    fee for evaluations (biofeedback, psychotherapy). For those appointments that you do not cancel as stated above or
    for missed follow-up sessions the charge will be the cost of the session, unless the missed session/late cancellation
    happens as a result of a bona fide emergency. In most cases, this fee will not be covered by your insurance
    company and must be paid directly by you.
     If you miss three visits (including late cancels or no-shows) for biofeedback and/or psychotherapy, I may opt
    to discontinue your treatment for non-compliance and not schedule further visits for you. I will also notify your
    referring provider that you will no longer be seen in my office.
     Please note that you are financially responsible for any and all services provided on your behalf, which are not
    paid by your insurance. However, I do agree to accept payment by a motor vehicle accident or workers’
    compensation carrier as full and final payment, if such carrier agrees to pay for this care. I do reserve the option of
    using legal means or collection agency to secure payment of account balances past due.
     Contacting Me: To schedule an appointment, please call (720) 279-8726. While we strive to return patient
    calls within a timely manner, we may not always be immediately available. In the case of a non life-threatening
    situation which requires urgent attention outside of normal business hours, you may reach me directly at (720) 413-
    9950. If you feel you are in a potentially life-threatening situation, please do not wait for a returned call, but
    instead go to the nearest emergency room or call 911. If I will be unavailable for an extended time, I will provide
    you with the name of a colleague to contact in my absence, if necessary.

If you have any questions about any of this information or my services, please feel free to ask. Additional information
on my practice can be found on my website: www.botanicawellness.com.

YOUR SIGNATURE BELOW SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE READ THIS
AGREEMENT AND AGREE TO ITS TERMS AND HAVE RECEIVED THE HIPAA NOTICE FORM. YOUR
SIGNATURE ALSO SERVES AS CONSENT FOR EVALUATION AND/OR TREATMENT WITH JESSICA
GRAVES, MA, LPC, BCIAC.
Patient signature_____________________________________________________________Date ______________

Provider/Witness signature_____________________________________________________Date ______________

          Botanica Wellness Sanctuary • 244 Washington St. • Denver, CO 80203
                Main 720-279-8726 • Cell 720-413-9950 • Fax 303-557-6266
                                               Jessica Graves, MA, LPC, BCIAC
                    --------------------------------------------------------------------------------------------------------------------------------------------
                                                  Licensed Professional Counselor
                                                   Certified Biofeedback Therapist


                                                                PATIENT QUESTIONNAIRE

What is your understanding of why you have been referred to my office?

_____________________________________________________________________________________________

CURRENT PROBLEMS/CONDITIONS

Please list the problems you are currently having. Which one is most bothersome? (#_______)

1.)

2.)

3.)

4.)

5.)


CURRENT INJURY/ILLNESS (if applicable) : Circle the treatments you have had up to this point.

      Biofeedback          Acupuncture                 Physical Therapy                    Pool Therapy                  Occupational Therapy                      Surgery

       Injections        Massage               Chiropractic                 Osteopathic Manipulation                         Medications                  Psychotherapy

Are there any other treatments you have had for this injury/illness?

What treatments/providers are you currently seeing? ___________________________________________________

Any upcoming surgeries, injections, or other procedures? _______________________________________________

CURRENT MEDICATIONS/VITAMINS/SUPPLEMENTS: Please list all medications, vitamins and/or
supplements you are taking (including dose, times per day, etc.).




MEDICAL HISTORY: Please list any previous surgeries, significant illnesses, hospitalizations, etc. not listed
above_________________________________________________________________________________________
Please list any significant family history of medical problems (i.e. high blood pressure, diabetes, cancer, stroke, heart

disease, neurological problems, autoimmune disease, thyroid problems, etc.) __________________________________

________________________________________________________________________________________________


          Botanica Wellness Sanctuary • 244 Washington St. • Denver, CO 80203
                Main 720-279-8726 • Cell 720-413-9950 • Fax 303-557-6266
                                           Jessica Graves, MA, LPC, BCIAC
                --------------------------------------------------------------------------------------------------------------------------------------------
                                              Licensed Professional Counselor
                                               Certified Biofeedback Therapist


Patient: _______________________________________                                                                                 Date: _________________

If applicable, please complete the following diagram, drawing the symbols below to show where you have
your typical pain.

                                                              Please draw in the face.




Please mark the scales below to indicate the intensity level of your symptoms/pain overall during the PAST
WEEK. “0” indicates no pain and “10” indicates pain so severe that it would cause you to lose
consciousness or go to the emergency room.

What was your highest level of pain?                        0       1       2       3       4       5       6       7       8       9       10
What was your lowest level of pain?                         0       1       2       3       4       5       6       7       8       9       10
What is your pain level today?                              0       1       2       3       4       5       6       7       8       9       10



         Botanica Wellness Sanctuary • 244 Washington St. • Denver, CO 80203
               Main 720-279-8726 • Cell 720-413-9950 • Fax 303-557-6266

				
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Description: Psychotherapist Intake Application document sample