Child___Teen_Intake_Packet

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					                                                                Capstone Psychologics
                                                     J. DeWayne Taylor, Ph.D., Psychologist
                                           207 Rock Prairie Rd, Suite B, College Station, TX 77845
                               Office: 979.694.7336 Fax: 979.694.7337 Email: jdtaylorphd@suddenlink.net

New Client Information: It is my desire to serve you and your family with personal, competent, and ethical mental health services. To
do so, I need to advise you of the services I offer and my office policies.
Credentials:
  Ph.D. in Educational Psychology, Texas A&M University ’87, APA approved program in School Psychology, school/clinical child psychology emphasis
  Clinical psychology internship and post-doctoral residency
  M.A. Psychology ’78, B.A. Psychology/Biology ’75, University of North Texas
  Licensed Psychologist (TSBEP) #23652; Health Service Provider in Psychology (National Register) #43097; Licensed Specialist in School Psychology
    (TSBEP) #6575
  Providing psychological services since 1978

Services:
  Specializing in comprehensive psychological testing and evaluation (ages 5-adult), including:
     o Diagnosis to assist in medical and psychological treatment planning
     o Disability determination with written documentation according to relevant policies for academic and standardized testing (SAT, ACT, LSAT, etc.)
         accommodations for college and public school students
     o ADHD, Learning Disorder, Emotional/Behavioral adjustment problems, Mood Disorders, Personality Disorders
     o Police, security and emergency service worker applicant and fitness-for-duty psychological evaluation
  Individual counseling for older children, adolescents, and adults
  Marriage and family counseling, parent consultation
  Critical Incident Stress Management, Traumatic stress resolution
  School and police agency consultation and training
  Value-based Christian counseling predicated on biblical precepts

 Usual and Customary Fees: If I am a preferred provider for your insurance or managed care plan, then special discount fee arrangements may apply.
    Initial Diagnostic Interview/Assessment                         $200 (up to 90 minutes, including screening materials)
    Individual Counseling                                           $150 (50 minutes) / $75 (25 minutes)
    Family and Marital Counseling                                   $150 (50 minutes)
    Testing and Evaluation                                          $175 per hour (testing, scoring, and report prep time)
    Consultation Services                                           Per diem or hourly fee by contract agreement

 Payment: Fees are normally due and payable in full at the time of service. Applicable co-payments and deductibles must be paid at each
session unless other arrangements are agreed upon. All other financial arrangements are made on a limited, individual basis. Please talk to me
personally if special fee arrangements are needed. When there is a balance due on your account, you will receive a monthly statement. If you have
difficult paying your bill, please let me know and I will make every reasonable effort to work out a solution. I hope this explanation helps you
understand the business side of your counseling experienced so that we can now focus on your personal concerns. If you have any questions, please
ask.
 Appointments: All services are available only by appointment. When it is necessary for you to cancel an appointment, please give notice at least
24 hours in advance of your scheduled time. A fee may be assessed for failure to give 24 hours notice.
 Emergency Calls: As part of my service to you, I want to be available to speak with you when needed. If you wish to talk with me between visits,
call my office number and leave a message for me to call you back. In an emergency situation, you may page me through my voice mail system or
secretary, after leaving me a voicemail message. Please be sure to leave detailed information as to phone numbers and times you can be reached. I
will make every effort to return your call as soon as possible. If I am unavailable, another licensed psychologist will return your call and assist you.
In a life threatening emergency, always call 911 and your family physician in addition to contacting me. Extended/frequent phone consultations
may be billed to you at my regular hourly rate Insurance does not cover phone consults.

Personal Health Information (PHI) / HIPPA: This office complies with all HIPPA regulations regarding your PHI. No PHI will be released
without your knowledge and written permission, except in some very unusual circumstances as outlined in the Notice of Privacy Practices
information available at my reception desk. Please discuss with me any concerns you may have about confidentiality. I have read the Capstone
Psychologics Notice of Privacy Practices and understand my confidentiality rights under HIPPA: (sign) ______________________________

Guarantor Responsibility and Signature On-File Statement: I have read the office policies stated above and acknowledge that psychological
services rendered and charged to the patient are the responsibility of the patient and/or guarantor. I hereby guarantee payment in full for services
rendered by Dr. Taylor to or on behalf of the patient. Guarantor agrees to pay for services at the time they are rendered or according to our fee
arrangement. Should collection efforts be necessary, all agency and/or attorney fees incurred will be the responsibility of the guarantor.

Your signature acknowledges that you have read and understand this information; authorizes release of any PHI necessary to process insurance claims, for the
benefits to be paid directly to J. DeWayne Taylor, Ph.D., for any and all service dates, and indicates your written permission for Dr. Taylor or other Capstone
Psychologics staff to provide psychological services to you or your dependent.

                                 Please sign and return to Capstone Psychologics. A copy will be made for you at your request.

______________________________________                                      ___________________________________                              ______________
Client and/or Guarantor Signature                                           Witness                                                          Date
                                                    Capstone Psychologics
                                           J. DeWayne Taylor, Ph.D., Psychologist
CLIENT INFORMATION

Full Name: __________________________________________________________________________________________________

Date of Birth: _____ / _____ / _____ Age: _______       Gender M F        Marital Status: ___________________________________

Local Address: ______________________________________________________________________________________________

City: _____________________________________________________________ State: __________ Zip Code: _______________

Permanent Address (if different): ________________________________________________________________________________

City: _____________________________________________________________ State: __________ Zip Code: _______________

Phone: Home: _____________________ Cell: ___________________Work: _____________________                      OK to call work?   Y   N

E-Mail:____________________________________________ Best Times to Call:________________________________________

Employment Status: Full-time Part-time None Retired          Employer: _________________________________________________

Student? Y N      School: _________________________         Referred by: ________________________________________________

Physician: ______________________________________            Medications: _______________________________________________

Emergency Contact: ___________________________________________               Phone: _______________________________________



PAYMENT INFORMATION (Please provide your insurance card at the first visit)

Is Client Covered by Insurance? Y N Insurance Plan: _______________________________________

Is Someone Other than Client Responsible for Payment and/or Providing Insurance on the Client?      Y    N

Full Name of Responsible/Insured Person: _________________________________________________________________________

Date of Birth: _____ / _____ / _____   Age: _______      Gender: M F

Address: ____________________________________________________________________________________________________

City: _____________________________________________________________ State: __________ Zip Code: _______________

Phone: Home: ________________________ Cell: ___________________________ Email: ________________________________

Primary Insured’s Employer: ________________________________________ Relationship to Client: ________________________



If Client Is a Minor – Please list all names, addresses, and phone numbers of non-custodial parents below.
Are there any custody-related legal proceedings in progress or pending?   Y N If yes, explain below.


Comments:
Please fill out the following information as it applies to the client:
State the nature of the problem in your own words: __________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

What is your most difficult relationship right now? __________________________________________________________________

What is your most difficult emotion right now? _____________________________________________________________________

Any anger-control problems? ___yes ____no If yes, explain: ________________________________________________________

Any recent suicidal thoughts, feelings, plans, or actions? ___yes ___no

         If yes, explain: ________________________________________________________________________________________

Any recent thoughts, feelings, or plans to harm someone else? ___yes ___no

         If yes, explain: ________________________________________________________________________________________

Any current threats of significant loss or harm (illness, abuse, divorce, custody, job loss, etc.)? ___yes ___no

         If yes, explain: ________________________________________________________________________________________


Have you or a family member ever been hospitalized for mental or emotional illness? ___yes ___no

         If yes, please explain (dates, place, reason): _________________________________________________________________

         ____________________________________________________________________________________________________

         ____________________________________________________________________________________________________

Are spiritual matters important to you? ___yes ___no

Are you a member of church or other religious organization? ___yes ___no

         If yes, which one(s)? ___________________________________________________________________________________

Comments:
                                                   Capstone Psychologics
                                           J. DeWayne Taylor, Ph.D., Psychologist

                                         Client Insurance Information
                   Psychological Testing Benefits Verification & Preauthorization of Services

Complete this form only if you are being seen for psychological testing and evaluation services or if you have been instructed to do
                              so by a staff member in order to verify benefits for counseling services

If you are covered by health insurance, we can file for coverage of psychological evaluation procedures if Dr. Taylor is a
provider on your plan. To pursue insurance benefits the following information needs to be provided to Dr. Taylor’s office prior
to your scheduled appointment. Available benefits and preauthorization of services will be obtained and then an appointment
will be scheduled. Refer to your insurance ID card and/or contact your insurance carrier to verify this information.

Insurance Company: __________________________________________________________________

Mental Health Benefits Customer Service Phone Number: ____________________________________

Primary Covered Person’s Full Name: ____________________________________________________

Employer of Covered Person (if applicable): ________________________________________________

Primary Covered Person’s Date of Birth: ______________________________

Insured’s ID No.: ___________________________________ Group No.: __________________________


Covered Dependent’s Name: ___________________________________________________________

Covered Dependent’s Date of Birth: _____________________________________________________

Ins. ID No. (if different from Covered Person’s ID): _______________________________________


For insurance benefits to be obtained and filed, the client AND the primary insured person (if the client is
insured as a minor dependent under another person’s insurance) MUST SIGN THE ATTACHED
GUARANTEE OF PAYMENT FORM.



Client and/or Guarantor Signature(s):

_______________________________________                               Date _____________________


_______________________________________                               Date _____________________

				
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