Registration Form for Andrew O. Taylor, LCSW-R

							                        Registration Form for Andrew O. Taylor, LCSW-R

                                               Client Information

First Name _______________________           Middle Initial ______      Last Name ___________________________

Date of Birth ____________________           Marital Status: Single/Married/Div/Separated/Widow (please circle)

Street Address _________________________________________________________________________________

City ________________________                State _____________                 Zip ______________

Home Phone _________________                 Work Phone _____________             Mobile Phone ________________

Occupation ___________________               Employer ___________________________

     Is it okay for us to contact you at home to confirm your future appointments with us? Yes No (circle one)


                                            Insurance Information

Person responsible for bill ____________________________________________                  DOB: _____________

Address (if different) ___________________________________________________________________________

Home phone (if different) ___________        Work Phone __________ Employer & Occupation _______________

Name of primary insurance _______________________              Name of Policy Holder _______________________

Policy Number _________________________________                Group number _____________________

Client’s relationship to policy holder:      self     spouse child      other    (please circle)



                                            Emergency Information

Name of friend or relative to contact during an emergency ____________________________________________

Home phone ______________                    Work phone _____________            Mobile phone _________________



                                            Financial Responsibility

I understand that I am financially responsible for all charges whether or not paid by my insurance and that full
payment is expected at the time of each appointment. I authorize Andrew O. Taylor, LCSW-R to release all
information necessary to secure payment. I am responsible for all fees and fiancé charges for the above name
patient regardless of insurance coverage.

      Client Signature ___________________________________________                     Date: ______________
                        Intake Form for Andrew Taylor, LCSW-R


Name ________________________________________________ Today’s Date ____________

                                      Medical History

Serious Illness/Injuries: __________________________________________________________

Hospitalizations:________________________________________________________________

Operations:____________________________________________________________________

Amount or use of cigarettes, alcohol and other drugs: __________________________________

______________________________________________________________________________

Allergies (especially to medications): _______________________________________________

Current Medications: ____________________________________________________________

______________________________________________________________________________

Previous contact with mental health professionals: ____________________________________

______________________________________________________________________________

                                       Family History

Please describe any mental health problems among relatives: ___________________________

______________________________________________________________________________

Do you have children? Yes _______         No _______            How Many ______________

Who is living in your home and what is their relationship to you? _________________________

______________________________________________________________________________
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                     Please Read The Following and Sign Below

  Payment:      I understand that full payment is expected at the time of each appointment.

Cancellations: I understand that there is a $25 charge for missing or canceling an
appointment in less than 24 hours of the actual appointment time. I understand that this
fee is my responsibility and cannot be billed to my insurance company. Exceptions are
made in emergency situations.

Signature & Date of Person Responsible for Payment: __________________________________
                                      Andrew O. Taylor, LCSW-R
                                           145 East 2nd Street
                                           Corning, NY 14830
                                            (607) 936-9090

                                 INFORMED CONSENT TO TREATMENT

Psychotherapy involves individuals, families, couples or groups talking with a mental health professional
specifically trained to guide events toward positive, constructive change. Although there are no absolute
guarantees, therapy can be beneficial for a variety of problems which without treatment may result in
further impairment of functioning and decreased family cohesion and enjoyment. The benefits of
treatment can include improved sense of well being, clearer view of choices and goals, improved
relationship satisfaction and increased ability to be productive at home, school and work. At times
during treatment, it may seem that the problem’s impact has worsened, but this is usually temporary
and often necessary to the change process.

The risks of treatment are minimal under the guidance of a properly qualified, ethical practitioner. You
are encouraged to discuss any risks in your treatment with me. You may also want to explore
alternatives to treatment available to you such as pastoral care, self-help groups and/or changes in your
environment which may prove beneficial. I am a state-licensed, certified (R) social worker with
approximately eighteen years of work experience treating a variety of individuals, couples and families.
I received my Master’s Degree in Social Work from Boston College, located in Chestnut Hill,
Massachusetts.

Therapy deals with important personal matters and the sharing of information (with some exceptions) is
controlled by the client, NY State law, and professional ethics regarding confidentiality. Exceptions to
confidentiality include physical and sexual abuse of others which must be reported to the authorities
under New York State Law and threats to harm self and/or others which the courts have determined
should be reported both to the authorities and the intended victim.

Other limits to confidentiality may exist in particular cases and should be discussed. Information may be
released upon signing a Release of Information form or Managed Care Release. Please feel free to
discuss with me any specifics regarding releasing information. Please feel free to discuss your questions,
therapy procedures being used, and your fees with me at any time. Due to managed care and different
health insurance plans, fees for counseling can vary greatly. Your fee and/or co-pay will be explained to
you prior to starting counseling.
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                                        CONSENT TO TREATMENT
I have read, understand and agree to the above Consent To Treatment. I understand the fees and my
responsibility for payment.

           Signature and Date: ___________________________________________________
  RELEASE OF INFORMATION TO YOUR MANAGED CARE/HEALTH INSURANCE
                             COMPANY

I give permission to Andrew O. Taylor, LCSW-R, to communicate as needed with
my insurance company listed below. Communication to my insurance company
may be regarding billing, goals and treatment for therapy.



                  (___________________________________) .
                             Insurance Company

          ___________________________________________________
                            Signature and Date

**********************************************************

                       Lifetime Release of Information
Billing services for Andrew O. Taylor, LCSW-R are performed by AGA Billing &
Consulting, P.O. Box 2147, Elmira Heights, NY 14903. Please be advised that AGA
Billing & Consulting has signed a HIPAA confidentiality statement with Andrew O.
Taylor, LCSW-R and that billing matters will be kept strictly confidential.

For any billing questions please call AGA Billing & Consulting at (607) 739-3181.

By signing below I give Andrew O. Taylor, LCSW-R my permission to use AGA
Billing & Consulting services as needed.

Client Signature (or responsible party): __________________________________

Client Name (or responsible party):    ___________________________________

Date: ___________________________