Patient Packet

Complete the form below or CLICK HERE for a printable form.

Client Information

Name(Required)

First Middle Last

Date of Birth

Gender

Male

Female

Primary Phone(Required)

Is this a cell phone?

Yes

Alt. Phone

Is this a cell phone?

Yes

Physical Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

P.O. Box

PO #, City, State and Zip Code

Driver's License (State & Number)

Social Security Number

Client's Employer Info

Employer Name

Occupation

Work Phone

Employer Address

Include Street, Apt No., City, (Province), State, Zip

Household Members

List

Name

Age

Date of Birth

Relationship

Responsible Party Information

Parent, Guardian or Insured Spouse. NOT INSURANCE CO.

Name(Required)

Relationship(Required)

Date of Birth

Phone Number(Required)

Social Security Number

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employer

Occupation

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone

I will be paying for treatment by:(Required)

Cash

Check

Credit

Insurance

Disclosures

Treatment Philosophy

Therapy is goal-directed, problem-focused treatment. This means that a treatment goal or several goals are established after a thorough assessment. All treatment is then planned with the goal(s) in mind and progress is made toward accomplishment of that goal(s) in a timely manner.

You will take an active role in setting and achieving your treatment goals. Your commitment to this treatment approach is necessary for you to experience a successful outcome.

Standard appointment time is 30 to 45 minutes. If you ever have any questions about the nature of treatment or your care, please do not hesitate to ask.

Limits of Confidentiality Statement

All information between practitioner and patient is held strictly confidential. There are legal exceptions to this:

The patient authorizes a release of information with a signature.
The patient’s mental condition becomes an issue in a lawsuit.
The patient presents as a physical danger to self (Johnson v. County of Los Angeles, 1983).
The patient presents as a danger to others (Tarasoff v. Regents of the University of California, 1967).
Child or elder abuse and/or neglect is suspected (Welfare & Institution and/or Penal Code).

In the latter two cases, the practitioner is required by law to inform potential victims and legal authorities so that protective measures can be taken.

All written and spoken material from any and all sessions is confidential unless written permission is given to release all or part of the information to a specified person, persons, or agency.

If group therapy is utilized as part of the treatment, details of the group discussion are not to be discussed outside of the counseling sessions.

I authorize release of information to my Primary Care Physician, other health care providers, institutions, and referral sources for the purpose of diagnosis, treatment, consultation, and professional communication.

I further authorize the release of information for claims, certification, case management, quality improvement, benefit administration, and other purposes related to my health plan.

Emergency Access

Practitioners are available after hours to handle emergencies. By calling the main office number during after hours, you will be instructed how to contact the on-call practitioner.

I have read the above disclosures and understand them.

SIGNATURE OF PATIENT/GUARDIAN

Date

Financial Policy and Agreement

You are responsible for obtaining prior authorization for treatment from your insurance carrier. We will bill your primary insurance; however, you are responsible for co-payment amounts and deductibles as set by your benefit plan.

We will not bill your secondary insurance (if applicable). Missed appointments are not covered by insurance, and any associated charges are your responsibility.

If you are being seen under your Employee Assistance Program (EAP), services are paid by your employer.

If you have an HMO, co-payment amounts are set by your benefit plan and are due at each appointment. The co-payment amount is determined by your insurance card and/or Explanation of Benefits (EOB).

If you have a PPO, you are responsible for deductibles and co-payments according to your benefit plan.

At any time during treatment, if you become ineligible for insurance coverage, you agree to notify the practitioner and understand that you will become responsible for 100% of the bill.

If you are without insurance or your fees are covered by an outside agency, services are provided according to The Way’s current fee schedule. Payment is due at the time of treatment unless other arrangements have been made in advance.

The practitioner will inform you of costs when services fall outside your insurance benefits. For special treatment modalities not covered by your plan, a written agreement will be required outlining fees and the expected treatment plan.

Cancellation and Missed Appointment Policy

Scheduled appointment times are reserved specifically for you. If an appointment is missed or cancelled with less than 24 hours’ notice, you will be billed according to the scheduled fee or the instructions of your benefit plan.

Repeated missed appointments may result in referral back to your insurance company for reassignment to another practitioner. Insurance will not be billed for missed or cancelled appointments.

Florida law states that children under the age of 12 cannot be left unattended. Please bring only children who will be participating in treatment to your sessions.

I have read the above and agree to accept treatment and all conditions set forth herein.

SIGNATURE OF PATIENT/GUARDIAN

Date

Consent for Treatment

I authorize and request my practitioner to carry out psychological examinations, treatments, and/or diagnostic procedures that now or during the course of my treatment become advisable.

I understand that the purpose of these procedures will be explained to me upon my request and that they are subject to my agreement.

I also understand that while the course of my treatment is designed to be helpful, my practitioner can make no guarantees about the outcome of my treatment.

Further, I understand that the psychotherapeutic process can bring up uncomfortable feelings and reactions such as anxiety, sadness, and anger. I understand that this is a normal response to working through unresolved life experiences and that these reactions will be addressed between my practitioner and me.

If Patient Is a Child or Dependent

I am the legal guardian or legal representative of the patient and, on the patient’s behalf, legally authorize the practitioner or group to deliver mental health care services to the patient.

I understand that all policies described in the above statements apply to the patient I represent.

Patient/Guardian/Legal Representative Signature

Date

Witness Signature

Date

Release of Information

As a mental health practitioner committed to providing the best possible care, we may occasionally consult with professional colleagues regarding treatment planning and aftercare recommendations. Every effort is made to protect your anonymity by discussing general facts without disclosing your name.

We also coordinate care with your Primary Care Physician when appropriate. We believe it is in your best interest to collaborate with any health care professional you are currently seeing or have seen recently.

Insurance companies are required by regulatory agencies to monitor quality of care and may periodically request a review of records. In addition, limited information must be shared with your health plan in order to obtain authorization for sessions and to process payment claims.

Initial(Required)

Authorization(Required)

I authorize

I do not authorize

[I authorize/do not authorize] release of information to my Primary Care Physician and other health care providers and institutions as well as referral sources for the purpose of diagnosis, treatment, follow-up care, and quality assurances activities. Additionally, I release information for the purposes of consultations and professional communication in which my therapist or physician may engage in order to provide me with the best treatment.

Initial(Required)

Authorization(Required)

I authorize

I do not authorize

[[I authorize / do not authorize] the release of information to process claims, and for certification, case management, quality improvement, benefit administration and other purposes related to my health plan. NOTE: If you refuse to release information to process claims, our services will not be rendered.

Consent to Use Facsimile (FAX) or Cellular Phones

While The Way, Psychological Treatment Center staff and associates will always handle all information you provide with the utmost confidentiality, certain circumstances may arise that are beyond our control.

In the event of a crisis where you need to be connected with your therapist, communication may occur via a cellular phone.

Additionally, situations may arise where our office must correspond with another medical provider or your insurance company regarding your treatment using facsimile transmission.

In either case, there is a possibility that cellular communications could be intercepted or that a facsimile could be misdirected.

Untitled(Required)

I have read the above statement and do hereby give my permission to 'The Way, Psychological Treatment Center' staff/associates to correspond via facsimile or cellular phone during the course of my treatment if needed. I understand that the scanning of a cell phone or the misdirection of a facsimile may result in the unintentional violation of my confidentiality.

This release expires one year from the conclusion of treatment or immediately at my request.

Signature of Patient or Parent/Guardian of Minor(Required)

Date(Required)

Patient Packet

Patient Packet

Client Information

Client's Employer Info

Household Members

Responsible Party Information

Insurance Information

IF YOU WISH US TO BILL YOUR INSURANCE, PLEASE SIGN BELOW:

History

Disclosures

Treatment Philosophy

Limits of Confidentiality Statement

Emergency Access

Financial Policy and Agreement

Cancellation and Missed Appointment Policy

Consent for Treatment

If Patient Is a Child or Dependent

Release of Information

Consent to Use Facsimile (FAX) or Cellular Phones

This release expires one year from the conclusion of treatment or immediately at my request.

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