Patrick A. Quigley, Ph.D., LSAC
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1 Psychologist Patrick A. Quigley, Ph.D., LSAC Addiction Counselor Thank you for considering my services. The material on this site will take you through the intake paperwork that you will need to bring to the first session. I look forward to meeting you and the work ahead. (480) Fax (480) E. Ray Road, Suite 101B Phoenix, Arizona 85044
2 Patient Information City State Zip Phone Cell Phone Date of Birth Marital Status Employer or School Referred By Field 2 Work Phone Pager# Social Security Number Gender ( ) Male ( ) Female Is the patient covered by insurance?( ) Yes- Go to section 2 Section II - Insured Information Ext Employment Status Field Field 3 ( ) No - Go to section V on back page of this form Patient Relationship to Insured: ( ) Self ( ) Spouse ( ) Child ( ) Other If "Patient Relationship to insured" is other than "Self' please complete the following. If patient is the insured go directly to section Ill. Insured's City State Zip Phone Work Phone Date of Birth I I Social Security Number Marital Status Employer or School Gender ( ) Male ( ) Female Employment Status Section Ill - Insurance Policy Information ( ) Medicare ( )Medicaid ( ) ChampUS ( ) ChampVA ( ) Group Health Plan Other Insurance Company City State Zip Plan Policy Number Group Number Is the patient covered by more than one insurance? ( ) Yes - Please complete Section 4 - Page 2 ( ) No - Please return this form to the Receptionist (Over)
3 Section IV- Secondary Insurance Policy Information ( ) Medicare ( ) Medicaid ( ) ChampUS ( ) ChampVA ( ) Group Health Plan Other Insurance Company City State Zip Plan Policy Number Group Number Section V - Billing Information (Complete only if there is no insurance coverage.) Who is responsible for charges for this patient. ( )Patient - Please return this form to the Receptionist. ( )Other- Please Complete the following information. City State Zip Phone Work Phone Date of Birth I I Social Security Number Marital Status Employer or School Gender ( )Male ( ) Female Employment Status
4 Section VI- Mental Health Authorization and Billing: If you intend to use insurance for mental health or substance abuse treatment, call the customer service number on your card and find out the specifics of your coverage. In some cases, this will involve a behavioral health provider network and a utilization management company providing any required authorization and benefit payments that is different from your insurance company. In addition, if provider services are limited to a restricted panel, you must verify that Patrick A. Quigley, Ph.D. is recognized as a member of that provider group. The following information must be completed in order to access insurance benefits. If this section is not filled out, it is assumed insurance does not apply. Behavioral health management company: Phone Number (including area code) Your mental health ID # (if different from your insurance plan ID #) Patient Co-pay (per Session) $ or % of fee patient pays $ Plan Deductible (if any) $ Deductible already paid $ Sessions available yearly Treatment authorization number (if applicable) Number of sessions authorized --- Claims are mailed to: NOTE: Fee Payments: Cash, checks, credit cards, and PayPal are accepted.
5 Patrick A. Quigley, Ph.D., CSAC HAVE YOU HAD AN PRIOR PSYCHIATRIC CONSULTATIONS? ( ) No ( ) Yes When: WHERE Therapist: HAVE YOU EVER BEEN HOSPITALIZED FOR PSYCHIATRIC REASONS? ( ) No ( ) Yes When: Where: Therapist: FAMILY MEMBERS AND OTHERS NOW IN HOUSEHOLD Relationship Birthdate OCCUpation ORIGINAL FAMILY (Mother Father Brother& Sister) Relationship Birthdate. Birthplace OCCUPATION M.ARITAL STATUS. CHILDREN LIVING AWAY FROMHOME - '7.
6 :. HEALTH HISTORY QUESTIONNAIRE Date:. - D.O.B.:. Age:. Sex: Hgt:. Wt:.-:--- Therapist: Primary Care Physician:. Date last seen by Medical Doctor;,. Date last Physical Exam: ;. Laboratory Used: Allergies: Drugsd : Other: Current Medication: of Medication Frequency FAMILY HISTORY Relationship Emotional Problems Substance Abuse Cardiovascular Disease Hypertension Kidney Disease Respiratory Disease. Cancer Diabetes Mellitus Yes [] No[] Yes [] No[] Yes (] No[l Yes [ ] No(] Yes [] No[] Yes [] No[] Yes []. No[]. Yes [] PERSONAL IDSTORY Emotional Problems Yes [] No[] Substance Abuse Yes [ ] No['] Cardiovascular Disease Yes [] No{] Hypertension Yes [ ] No[ 1 Kidney Disease Yes [] No[] Liver Disease Yes ( ] No[] Respiratory Disease Yes [] No[ 1 TuBerculosis Yes ( ] No[]. Diabetes Mellitus Yes[] No{] - Cancer- - Yes ( ] No[ ] Thyroid Yes(] No[] Neurological Abnormalities Yes ( ] No{] Abnormalities Head Injuries Yes [] No[ ] Past Surgeries (Date and Types): Hospitalizations (Date and Types): Medical: Psychiatric:.;..: ;..----: ; Do you Smoke? Yes [ ] No ( ] How much per:day? How many years? Do you use alcohol or drugs?. Yes [ ] No [ ] Type: ; How much per day? If yes, have you felt the need to cut down? Do you have access to a gun or other weapon? Yes NO
7 Psychologist Patrick A. Quigley, Ph.D., LSAC Addiction Counselor AN AGREEMENT FOR PSYCHOLOGICAL SERVICES A psychologist is a licensed health care professional. Psychologists, who practice in a community or neighborhood setting, usually offer psychological counseling and sometimes psychological testing to their clientele. These services are offered to people of all ages and in.individual, family, or group settings. My psychological practice is a general, clinical practice. I work with children, adolescents, and adults. I see people individually, in couples, or as a family. Most of my work involves psychotherapy. This is the use of verbal communications to help individuals resolve personal behavioral, emotional, mental, or relational problems. Psychotherapy comes in different varieties. I will make the best match between your goals, the resources you make available for these services, and the commitment you are willing to make to achieve your personal goals. Where your goals are unclear, I will strive to help you define them. If your goals or resources change in the course of treatment, please let me know so that I can make adjustments. Honesty, candor, and trust are obviously essential for this process to work. The work of personal change can be quite anxiety provoking and at times you may feel that you are not making progress when, in fact, you are. I will make every effort to provide a safe, nurturing, and informative environment. Anything less than total candor will undermine the goals for treatment. You will need to let me know about any feelings of discomfort so that I can make appropriate adjustments or help you understand why we should not. I will not knowingly ask or suggest that you do anything harmful. Your treatment is confidential and privileged. I will not disclose your presence here or the content of our sessions without your explicit consent. Imminent danger to yourself or another is a legally and ethically limiting condition to this confidentiality. Also I am a mandated reporter of child abuse and neglect. Should you decide to use insurance to pay for part or all of your treatment, I may have to disclose some information to help you access your benefits. My practice, whether doing psychotherapy or assessment, is clinical and not forensic. My work with people is for the resolution of personal issues and difficulties and not for legal documentation or assessment. If you would like your records for this purpose, I will provide you with a copy and not more than this. I do not work as an expert witness. I do not do custody evaluations. Custodial and forensic psychology services are best handled by specialists and I will be glad to make the appropriate referral. My fees are $175 for the initial consultation and $160 for subsequent sessions. The sessions are usually 45 minutes. Full fees or insurance plan co-pays are due at the end of each session. Time spent scoring tests or preparing reports are billed the same as individual, face-to-face sessions. Many people use their insurance to pay for part or all of their treatment. Your insurance plan will have its own requirements and limitations, which may or may not coincide with the goals and purposes of your treatment. I will make the clinical differences known to you, as I am aware of them. However, it is your responsibility to know the parameters of your insurance coverage and you are ultimately responsible for the pavment of services received. Insurance is accepted only as an accommodation to you. Professional time spent obtaining insurance benefits authorizations, completing insurance-related reports or coordinating with insurance care managers is billed directly to you at the session rate in quarter-hour increments. Delinquent accounts overdue at 90 days may be sent to collections. Return appointments are scheduled in advance, at the end of each session. This is the best time to change the schedule if necessary. An appointment must be cancelled at least 24 hours in advance to avoid a $100 late cancellation fee. If we decide that your treatment should involve an additional health care provider, at your discretion, I will endeavor to establish coordination of care with the other provider. Your participation in psychotherapy is voluntary. You may stop at any time. I feel that this decision is best discussed face to face. Likewise, if i feel that our work together should suspended or terminated, I will share this with you. Accepted by: Signature of responsible party Date form date 11/14/2012
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Welcome to our practice. We strive to make the registration process go as quickly for you as possible on the day of your appointment with for / / at in (Provider name) (date) (time) (location) In order
REGISTRATION INSTRUCTIONS
REGISTRATION INSTRUCTIONS It is important that you check-in 15-20 minutes prior to your scheduled appointment with your completed intake forms. Patient Profile & Health History These forms should be filled
Do you have or have you ever had any of the following: Circle Yes (Y) or No (N)
PATIENT MEDICAL HISTORY FORM West Georgia Urology Associates, P.C. 150 Clinic Avenue, Suite 202 Carrollton, GA 301117 Phone:( 770) 834-6988 Fax: (770) 834-1090 Today s Date: Name: _ (Last) (First) (Middle
COLLAR CITY PODIATRY
Richard Altwerger, DPM COLLAR CITY PODIATRY PATIENT INFORMATION FORM Timothy Fauler, DPM Name: Email PATIENT INFORMATION Date of Birth: Sex: M F Marital Status: City: State: Zip: Home Phone: Cell Phone:
Andrew Weissman, Psy.D., P.C. Clinical Psychologist
Andrew Weissman, Psy.D., P.C. Clinical Psychologist 428 South Gilbert Rd #109 A Gilbert, AZ 85296 Phone: (480) 750-0022 Fax: 866-273-7138 New Client Information Referred By: Today s Date: I. Client Information
VASCULAR HEART & LUNG ASSOCIATES
PATIENT INFORMATION Last Name: First Name: M.I: Address: City: State: ZIP: Telephone (Cell): (Home): (Circle preferred contact method). Email: Date of Birth (MM/DD/YEAR): / / Age: Sex: SS# Ethnicity [circle]:
Ravi Yalamanchili M.D, P.A. Patient Registration / Information Sheet Last Name: M.I. Sex: Female Male First Name: Marital Status:
We do not Accept Checks Ravi Yalamanchili M.D, P.A. 141 Thomas Johnson Drive, Suite 200 Frederick, MD 21702 Phone 301-846-0100 Fax 301-846-0244 Please Print Patient Registration / Information Sheet Last
BARIATRIC SURGERY PROGRAM APPLICATION Updated: 1/2018 Page 1 of 6
Updated: 1/2018 Page 1 of 6 Date: SELF Last Name: First: MI: Maiden: Home #: Cell #: Work #: Date of Birth: SSN#: Gender: Male Female Marital Status: Married Divorced Widowed Separated Never Married White
SKINNER FAMILY PRACTICE 1
SKINNER FAMILY PRACTICE 1 Health History Patient Name: DO YOU HAVE A PERSONAL HISTORY OF DIABETES (E11.9) COPD (J44.9) BLOOD PRESSURE (I10) CROHNS DISEASE (K50.10) HEART DISEASE (I51.9) TUBERCULOSIS (A15.9)
CENTRAL OHIO PLASTIC SURGERY, INC. (740)
(740) 653-5064 Patient s Name Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Last First Middle Nickname Address Street & Apt # City State Zip Home
Namaste Health Care. New Patient Registration, Age 14 and Under. Father s Name Father s Mailing Address Work Phone (Father) Cell Phone (Father)
Namaste Health Care Bridget P. Early, M.D. Kate Branham, F.N.P. New Patient Registration, Age 14 and Under Date: Patient Name Date of Birth Age Sex M F Social Security # Race American Indian/Alaskan Native
NOTICE TO OUR PATIENTS
NOTICE TO OUR PATIENTS Although we participate with most insurance plans, you as the patient and/or insured party are responsible for co-pays, deductibles and any non-covered services, which are outlined,
CareFirst Applicants
CareFirst Applicants Application Instructions for Care First 1.Print all pages of the application including instructions 2.Complete all questions and sections of the application. 3.Select your preferred
PETER A. POWERS, PH. D. 511 East 12 th Avenue Eugene, OR CLIENT RIGHTS AND RESPONSIBILITIES
PETER A. POWERS, PH. D. 511 East 12 th Avenue Eugene, OR 97401 CLIENT RIGHTS AND RESPONSIBILITIES Prior to beginning treatment, it is important for you to familiarize yourself with my approach to treatment,
Application Date: MONTGOMERY COUNSELING CENTER th Ave Rd Nampa, ID Telephone: (208) ; Facsimile:
Application Date: MONTGOMERY COUNSELING CENTER 323 12th Ave Rd Nampa, ID 83686 Telephone: (208) 463-0212; Facsimile: 461-5452 SERVICE APPLICATION-INTAKE PACKET Revised June 9, 2014 1 2 1. GENERAL INFORMATION
Mailing Address: Name: FIRST MIDDLE LAST. Mailing address: If different from patient. Telephone Numbers: Home Day Number
Dermatology Center South PC 2800 Ross Clark Circle, Suite 2 DOTHAN, ALABAMA 36301 REGISTRATION FORM FOR DEPENDENTS] Patietnt Name: First Middle Initial Last of Birth: / / Sex: Male Female Month Day Year
Phone Home Work Cell. Other Emergency Contacts Name Name Phone Home Phone Home
FLORIDA HOSPITAL TRANSPLANT CENTER CLINIC DEMOGRAPHIC INFORMATION This application MUST be filled out completely. ALL incomplete applications will be returned to sender Name (First) (MI) (Last) (Maiden)
Please Present Insurance Card at Each Office Visit
PATIENT REGISTRATION FORM RONALD J ESCUDERO, MD, FACS Please print clearly and fill out completely Patient Legal Name Birthdate Age Address Social Security # City ST ZIP Email Phone Numbers ( ) Home (
PARKVIEW PRIMARY CARE PHYSICIANS 20 Losson Road, Suite 105 Cheektowaga, NewYork (716) Fax (716)
Orville Hendricks, M.D. John Kavcic, M.D. Deirdre Bastible, M.D. PARKVIEW PRIMARY CARE PHYSICIANS 20 Losson Road, Suite 105 Cheektowaga, NewYork 14227 (716)558-7727 Fax (716)558-7720 Office Policy (revised
AUTHORIZATION FOR TREATMENT
Thank you for choosing ARIZONA MANUAL THERAPY CENTERS. Please read each section below carefully, sign and date, and return to the front office personnel. If you have any questions or concerns, please ask
Welcome to Bay Area Gastroenterology Associates. We look forward to caring for you. To better serve you, please complete the information below..
1 Welcome to Bay Area Gastroenterology Associates. We look forward to caring for you. To better serve you, please complete the information below.. Patient name: Marital Status: Single Married Divorce Widowed
Stacy Harris LMFT. Address: City: Zip Code: Phone: Date of Birth: Soc. Sec. # Employer: Work Phone: Okay to call Yes / No
Licensed Marriage and Family Therapist 1314 Oregon St., Redding, CA 96001 Telephone: 530-242-6012 Fax: 530-243-0327 CLIENT INFORMATION Please fill this form our in its entirety. This information is not