Linda Cochran, LCSW INDIVIDUAL INTAKE

Transcription

1 Linda Cochran, LCSW INDIVIDUAL INTAKE CLIENT'S FULL NAME: TODAY'S DATE: ADDRESS: STREET OR P.O. BOX CITY STATE ZIP TELEPHONE: HOME CELL WORK AGE: BIRTHDATE: SSN#: MARITAL STATUS: DRIVER'S LICENSE#: EMPLOYER OR SCHOOL (IF STUDENT): REFERRED BY: PHONE: PERSON WHO DOES NOT LIVE WITH YOU TO CONTACT IN AN EMERGENCY: NAME RELATIONSHIP PHONE INSURANCE INFORMATION INSURANCE COMPANY: INSURED'S SSN#: NAME OF INSURED: INSURED'S D.O. B.: INSURED'S POLICY #: INSURED'S GROUP #: INSURED'S EMPLOYER: AMOUNT OF CO PAYS: INSURED'S RELATIONSHIP TO CLIENT: AUTHORIZATION #: IF YOUR COUNSELING IS BEING PAID FOR THROUGH AN EMPLOYEE ASSISTANCE PROGRAM, PLEASE LIST AUTHORIZATION NUMBER AND HOW MANY SESSIONS ARE BEING AUTHORIZED. EAP COMPANY AUTHORIZATION NUMBER # OF SESSIONS CO PAYMENTS ARE DUE AT THE TIME OF SERVICE. I HEREBY ASSIGN PAYMENT OF INSURANCE BENEFITS DIRECTLY TO LINDA COCHRAN, LCSW. WHILE LINDA COCHRAN, LCSW WILL BILL MY INSURANCE COMPANY, I WILL BE RESPONSIBLE FOR ANY CHARGES INCURRED IF MY INSURANCE COMPANY DOES NOT PAY. IT IS MY RESPONSIBILITY TO CONTACT MY INSURANCE COMPANY TO OBTAIN THE PROPER AUTHORIZATIONS IF REQUIRED. IF I FAIL TO DO THIS AND CHARGES ARE DENIED I WILL BE RESPONSIBLE FOR ALL CHARGES. CLIENT SIGNATURE: Primary diagnosis DATE: To be completed by therapist: Secondary diagnosis

2 2. TO ENABLE MY THERAPIST WITH ACCURATE AND CONFIDENTIAL SERVICES PLEASE COMPLETE THE FOLLOWING: THE FOLLOWING INDIVIDUALS MAY SCHEDULE AND OR CONFIRM APPOINTMENTS. MESSAGES REGARDING APPOINTMENTS MAY BE LEFT ON MY VOICE MAIL. YES NO MILITARY HISTORY: Branch: Years: Rank: Active/Inactive/Retired status: Discharged: Y or N and Status: Deployments and where: Other: MARITAL INFORMATION: MARRIED: DIVORCED: LIVING TOGETHER: SEPARATED: SINGLE: OTHER: IF YOU CHECKED "OTHER" PLEASE EXPLAIN: UST DATES AND LENGTHS OF ANY PREVIOUS MARRIAGES: FAMILY HISTORY: LIST THE NAMES, AGES, AND RELATIONSHIP OF ALL PERSONS LIVING IN YOUR HOME: LIST THE NAMES, AND AGES OF ANY IMMEDIATE FAMILY MEMBERS THAT ARE NOT LISTED ABOVE YOU A DANGER TO SELF OR TO 0 I-HERS? :ARE YOU IN ANY DANGER FROM OTHERS? IF SO kivho AND HOW? HAS SUICIDE EVER BEEN THOUGHT OP? At ri 1:'REV/101.,/$ ATTEVOPTS'? (WHEN. I IOW, CIUTCCOIE) ANYONE. IN YOUR FAMILY COMMIT EABCIDE? IF SO, kiv1-10 AND WHEN:

3 PLEASE CHECK INDIVIDUAL ITEMS YOU WANT TO ADDRESS. CONCENTRATION FEARS BOWEL TROUBLE SELF-ESTEEM HOPELESSNESS GUILT STOMACH TROUBLE TEMPER DEPRESSED SELF-CONTROL SEXUAL PROBLEM RELAXATION HARM TO SELF HARM TO OTHERS DRUG USE FINANCES SUICIDAL CONCERNS IMPULSIVITY ALCOHOL USE WORK HIGH ENERGY HYPERACTIVE HEADACHES MOTIVATION LOW ENERGY ATTENTION DIFFICULTIES MEMORY LEGAL MATTERS ANGER SLEEP PROBLEMS THOUGHTS CAREER CHOICES TEMPER DREAMS ABUSE EDUCATION NERVOUSNESS NIGHTMARES TRAUMA MAKING DECISIONS ANXIETY HEALTH PROBLEMS SHYNESS MEANINGLESSNESS STRESS APPETITE/WEIGHT CRYING SPELLS UNRESOLVED GRIEF PANIC EATING/FOOD TROUBLE UNHAPPINESS SPIRITUAL CONCERNS PLEASE CHECK RELATIONSHIP ITEMS YOU WANT TO ADDRESS. MARRIAGE PARENTING RECREATION FRIENDSHIPS SEPARATION CHILDREN INFIDELITY/AFFAIRS HOLDING OTHER DOWN DIVORCE HOUSING PHYSICAL FIGHTING CONFLICTING SCHEDULES INTIMACY FINANCES COMMON INTERESTS PROBLEM SOLVING IN-LAWS SEXUAL DESIRE SHOWING APPRECIATION LONELINESS RELATIVES AGREEING ON CHORES TRUSTING EACH OTHER COMMON GOALS JEALOUSY SEXUAL PERFORMANCE AFFECTION VERBAL FIGHTING USE OF TIME SPOUSE'S CLEANLINESS COMMUNICATION HAVING FUN TOGETHER HEALTH INFORMATION: LIST ALL CURRENT MEDICATIONS: 3. LIST ALL CURRENT HEALTH PROBLEMS INCLUDING ALLERGIES: LIST PAST SIGNIFICANT HEALTH PROBLEMS: HAVE YOU BEEN HOSPITALIZED OR HAD OTHER PSYCHIATRIC CARE RELATED TO YOUR MENTAL HEALTH? IF YES PLEASE PROVIDE DATES AND TREATMENT OUTCOME FOR THOSE EVENTS: LIST PREVIOUS PROFESSIONAL HELP, AND DATES YOU RECEIVED FOR PERSONAL, MARITAL, OR FAMILY CONCERNS: NAME OF YOUR PRIMARY CARE PHYSICIAN: MAY WE CONTACT? PHONE NUMBER: WHEN WERE YOU LAST SEEN? I GIVE MY CONSENT FOR MY THERAPIST TO RELEASE MY RECORD TO MY PRIMARY PHYICIAN SO THAT THEY CAN DISCUSS MY TREATMENT: SIGNED DATE I DO NOT GIVE MY CONSENT FOR MY THERAPIST TO RELEASE MY RECORDS TO MY PRIMARY CARE DOCTOR TO DISCUSS MY TREATMENT: SIGNED DATE

4 DRUG AND ALCOHOL ASSESSMENT: Are drugs or alcohol used by yourself or someone else a significant factor in why you are coming to our office? _yes no If yes self other: Relationship ALCOHOL ASSESSMENT: Frequency of Alcohol use: Never Less thanl time/month 1-4 times per month 2-3 times per week Daily Usual Alcohol Consumption: None 1-2 drinks per sitting 3-4 drinks per sitting 5 or more drinks per sitting Frequency of use to levels of intoxication: Never less than 1 time/month 1-4 times per month 2-3 times per week Daily Please describe any alcohol-related problems (e.g. legal, job, physical, or social): 4. Self-perception of alcohol use: (check all that apply) Occasional or social T Problem use Psychological dependence Addicted-cannot stop Does not want to stop Motivated to stop History of treatment attempts: (check all that apply) None Stopped on own Attended AA/ other 12 step program Attended outpatient program ^ Attended inpatient program Attended community-based program Used OTHER SUBSTANCE USE ASSESSMENT: (Check Frequency and Duration for each drug used in the lost 6 months) Frequency Duration Marijuana Sedative Stimulant Cocaine Opiates Inhalants Hallucinogens Prescription Drugs Daily Weekly Monthly Less than More than Or less one year one Year Caffeine Number of cups per day Tobacco if cigarettes-number per day Please describe any drug-related problems (e.g. legal, job, physical, or social) Self-perception of Drug Use: (check all that apply) Occasional or social Problem use Psychological dependence Addicted-cannot stop Does not want to stop Motivated to stop History of treatment attempts: (check all that apply) None Stopped on own Attended NA/ other program Attended outpatient program Attended inpatient program T Attended community-based program

5 Linda T. Cochran, LCSW 840 Fleming St, Hendersonville, NC Client Statement of Understanding(Initial all that apply): I understand that I am responsible for knowing my Mental Health benefits as defined by my insurance company, such as: the name of my insurance company or employee assistance program, deductible information for Mental health services, and my co-pay amount per session. I understand that I must provide a current health insurance card before services can be rendered. I understand that I will be charged a $5.00 fee per session for providing information that is incorrect regarding the name of the insurance company that provides my Mental Health coverage, The charge would be to cover the refilling of insurance to another company that I later learn from my insurance company administers my Mental Health benefits. I understand that I will $35.00 fee for failure to show for an appointment or if I cancel with lass than a 24 hour notice. Emergencies are: sickness, auto problems, required to work over on a job and weather. They are excluded but must be reported as son as possible to avoid a same day bill being sent to me. Linda T. Cochran, LCSW, agrees to file with my insurance in good faith that I have provided accurate and current information to her for proper billing of my Mental Health insurance. A copy of this was given to me. Any questions I had were explained to me. Signature Date