MICHIGAN MODERN PSYCHOLOGY Client Information Form **please print clearly**

Transcription

1 MICHIGAN MODERN PSYCHOLOGY Client Infrmatin Frm **please print clearly** Client Name: Client DOB: Address: City: State: Zip: Cell Phne: Hme Phne: Vic & Text Vic Text Gender: Male Female Marital Status : Single Married Divrced Widwed Primary Language Spken: Hme Language: Emplyer: Phne: Emergency Cntact: Phne: Relatin t client: Referral Surce: Client Scial Security #: If client is under 17, list legal guardian(s) : Primary Health Insurance : Ins. Phne: Cntract #: Grup #: Check if same as client, if nt Primary Insurance Card Hlder: Relatinship t Client: Primary Card Hlder s DOB: Primary Card Hlder s Address: Check if same as client City: State: Zip: Primary Card Hlder s Cell Phne: Hme Phne: Primary Card Hlder s Scial Security Number: Emplyer: Phne: Secndary Health Insurance : _ Ins. Phne: Cntract #: Grup #: Check if same as client, if nt Secndary Insurance Card Hlder: Relatinship t Client: Secndary Card Hlder s DOB: Secndary Card Hlder s Address: Check if same as client Secndary Card Hlder s Hme Phne: Cell Phne: Emplyer: Phne:

2 CONSENT FOR TREATMENT I,, vluntarily cnsent t and authrize all psychlgical care including rutine testing prcedures as deemed necessary r advisable by the psychlgist, their assistants r designees, and emplyees f the facility participating in my care. I understand that I shall have the pprtunity t discuss any treatments r testing with the clinician and/r their assistants and designees participating in my case. I understand that in emergency situatins, it may be necessary r advisable fr the psychlgist t extend services beynd thse cntemplated at the beginning f treatment. In keeping with ethical standards f ur prfessin as well as state and federal law, all services prvided by the clinician, their assistants r designees kept cnfidential except as nted belw. All infrmatin shared with the clinicians at MMP is cnfidential. N infrmatin will be released withut yur cnsent. MMP treatment recrds are electrnic and stred n a secure server as part f yur treatment recrds. Access t recrds by MMP prviders is dne nly n a need t knw basis fr purpses f cllabrative care (e.g., referral fr medicatin, evaluatins, etc.). In all ther circumstances, cnsent t release infrmatin is given thrugh written authrizatin. Verbal cnsent fr limited release f infrmatin may be necessary in special circumstances. There are specific and limited exceptins t this cnfidentiality which include the fllwing: When there is risk f imminent danger t myself r t anther persn, the clinician is ethically bund t take necessary steps t prevent such danger. When there is suspicin that a child, disabled persn r elderly individual is being sexually r physically abused r is at risk f such abuse, the clinician is legally required t take steps t prtect the vulnerable party, and t infrm the prper authrities. When a valid curt rder is issued fr medical recrds, the clinician and the agency are bund by law t cmply with such requests. I understand that if I am unable t make decisins abut care, treatment f services, r I chse t delegate decisin making t anther individual, the rganizatin invlves the surrgate decisin-maker in making these decisins. In these events, the surrgate decisin-maker may give infrmed cnsent. I understand that the psychlgist r designees may perfrm psychlgical testing upn me and I will be infrmed f the purpse. The results f any test(s) will be treated cnfidentially, but may be disclsed as necessary t persnnel that will care, authrize service, r insure care and services t me. I understand that the practice f psychlgy is nt an exact science. NO GUARANTEES OR PROMISES have been made t me regarding the results f any psychlgical treatment. I authrize the clinic t release any and all infrmatin cntained in my medical recrds, including infrmatin prtected under Michigan Public Act 174 f 1989 as amended: and substance abuse infrmatin, if any, prtected

3 under Federal Gvernment Regulatins. Part 2: and scial and psychlgical services infrmatin, if any, including cmmunicatin made t a scial wrker r psychlgist, t {a} any third party payer, insurance agencies r carriers respnsible in whle r in part fr paying any expenses assciated with my treatment; and {b} any health care facility used by the psychlgist fr the purpse f facilitating cntinuing care and treatment. I assign and authrize direct payment f all health care benefits and ther frms f payment f any kind that relates t the care prvided t me by the clinic staff fr applicatin t my bill. I assume full FINANCIAL RESPONSIBILITY FOR PAYMENT f all expenses assciated with my care and treatment, including any prtin f charges nt cvered by insurances, wrker s cmpensatin, r scial agencies. I agree t pay the same at the time f discharge r n an interim basis while in treatment. ***Please nte, ur ffice des nt participate with ANY Medicaid plans, including straight Medicaid r any cmmercial Medicaid plans, be advised if fr any reasn yur insurance changes t a Medicaid plan, yu will be respnsible fr the bill. I understand that the clinic shall nt be liable fr the lss r damage f any persnal prperty. I CERTIFY THAT I HAVE READ THIS FORM OR THAT IT HAS BEEN READ TO ME. I UNDERSTAND ITS CONTENTS AND ACCEPT ITS TERMS UNLESS OTHERWISE INDICATED ON THIS FORM. IF THE SIGNER IS NOT THE PATIENT, THE SIGNER CERTIFIES THAT HE OR SHE IS THE PATIENT S LEGALLY AUTHORIZED REPRESENTATIVE. Signature f patient, parent, r legal guardian Date Therapist Date ADVANCED PSYCHIATRIC DIRECTIVE D yu have an advanced directive fr psychiatric services? Yes N Are yu interested in receiving infrmatin abut advanced directives fr psychiatric needs? Yes N ****Clinician Use Only**** If pt requested infrmatin abut advanced directives, did yu prvide infrmatin? Yes N Clinician Signature Date:

4 NOTICE OF PRIVACY PRACTICE Uses and Disclsures f PHI: Michigan Mdern Psychlgy may use PHI fr the purpses f treatment, payment, and health care peratins withut yur written permissin. The fllwing are examples f ur use f yur PHI. - Fr treatment: This includes any infrmatin received frm yu, ther medical persnnel, r ther medical facilities pertaining t yur medical cnditin and treatment. It als includes infrmatin we give t ther health care persnnel t whm we transfer yur care and treatment. - Fr payment: This includes any activities, filing claims, medical necessity reviews, and cllectin f utstanding accunts. - Fr health care peratins: This includes quality assurance activities, licensing, and training prgrams t ensure that ur persnnel meet ur standards f care and fllw established plicies and prcedures, btaining legal and financial services, cnducting business planning, prcessing grievances and cmplaints, creating reprts that d nt individually identify yu fr data cllectin purpses, fund raising, and certain marketing activities. Patient Rights: As a patient, yu have a number f rights with respect t the prtectin f yur PHI, including: The right t access, cpy, r inspect yur PHI. This means yu may cme t ur ffice within 30 days and inspect and cpy mst f the medical infrmatin abut yu that we maintain, fr a reasnable fee. In limited circumstances, we may deny yu access t yur medical infrmatin and yu may appeal certain types f denials. We have available frms t request access t yur PHI and we will prvide a written respnse if we deny yu access and let yu knw yur appeal rights. If yu wish t inspect and cpy yur medical infrmatin, yu shuld cntact the privacy fficer. The right t amend yur PHI. Yu have the right t ask us t amend written medical infrmatin that we may have abut yu. We will either amend yur infrmatin within 60 days f yur request, r as permitted by law, deny yur request t amend yur medical infrmatin nly in certain circumstances, such as when we believe the infrmatin yu have asked us t amend is crrect. If yu wish t request that we amend the medical infrmatin that we have abut yu, yu shuld cntact the privacy fficer. Yu have the right t appeal a denial, and we will prvide the apprpriate appeal frm. The right t request an accunting f ur use and disclsure f yur PHI. Yu may request an accunting frm us f certain disclsures f yur medical infrmatin that we have made in the last six years prir t the date f yur request. We are nt required t give yu an accunting f infrmatin we have used r disclsed fr purpses f treatment, payment, r health care peratins. The right t request that we restrict the uses and disclsures f yur PHI. Yu have the right t request that we restrict hw we use and disclse yur medical infrmatin that we have abut yu fr treatment, payment, r health care peratins, r t restrict infrmatin that is prvided t family, friends and ther individuals invlved in yur health care. Michigan Mdern Psychlgy is nt required t agree t any restrictins yu request, but any restrictins agreed t by Michigan Mdern Psychlgy are binding. Yur Legal Rights and Cmplaints: Yu als have the right t cmplain t us, Michigan Mdern Psychlgy, r t the Secretary f the United States Department f Health and Human Services if yu believe yur privacy rights have been vilated. Yu will nt be retaliated against in any way fr filing a cmplaint with us r t the gvernment. Shuld yu have any questins, cmments, r cmplaints, yu may direct all inquiries t the privacy fficer. Revisins t the Ntice f Privacy Practice: Michigan Mdern Psychlgy reserves the right t change the terms f this Ntice at any time. The changes will be effective immediately and will apply t all prtected health infrmatin that we maintain. Any material changes t this Ntice will be prmptly psted in ur facilities. I hereby acknwledge that I am entitled t receive a cpy f Michigan Mdern Psychlgy s Ntice f Privacy Practices upn request. Patient signature Please Print: Date Patient Name:

5 ATTENDANCE & COVERAGE POLICY Dear Patients, Due t the heavy vlume f last minute cancellatins, we are being frced t enfrce ur 24-Hur N Shw Plicy. If yu find that yu need t miss a scheduled appintment, please call and cancel at least 24 hurs prir t the appintment r yu will incur a N Shw fee f $ In additin, due t the cnstant changes in insurance plicies, it is n lnger pssible t interpret each individual s insurance plicy. As yu may be aware, the current healthcare market has resulted in insurance plicies increasingly transferring csts t yu, the insured. Althugh we try ur best t stay aware f the changes, insurance plicies change daily with n warning. Please keep in mind that yur insurance plicy is between yu and yur insurance cmpany and NOT between the insurance cmpany and the dctr s ffice. IT IS YOUR RESPONSIBILITY TO KNOW YOUR INDIVIDUAL COVERAGE. Sme insurance plans require deductibles and cpayments in amunts nt knwn t yu r us at the time f yur visit. Any prtins f claims that are nt cvered becme the respnsibility f the insured. By signing this dcument, I agree, in rder fr Michigan Mdern Psychlgy t service my accunt r t cllect any amunts I may we, Michigan Mdern Psychlgy and its third party billing and/r debt cllectin service prviders may cntact me by telephne at any telephne number assciated with my accunt, including wireless telephne numbers, which may result in charges t me. Additinally, I authrize cntact via text messages r s, using any address I prvide. Methds f cntact may include using pre-recrded/artificial vice messages and/r use f an autmatic dialing service, if applicable. ***Please nte, ur ffice des nt participate with ANY Medicaid plans, including straight Medicaid r any cmmercial Medicaid plans, be advised if fr any reasn yur insurance changes t a Medicaid plan, yu will be respnsible fr the bill. I/We have read this disclsure and authrize express cnsent that Michigan Mdern Psychlgy, its affiliates, and third party service prviders may cntact me/us as described abve. Patient Name: Date: Patient Signature: Date:

6 CONSENT TO INFORM PCP OF CURRENT TREATMENT If yu wuld like us t send a letter t yur Primary Care Physician infrming them that yu are receiving services here, please prvide yur PCP s name and address and yur signature which will indicate that yu grant permissin fr the release f this inf. The letter will infrm yur PCP f yur initial date f service and yur diagnsis at this agency. A letter will nt be sent if an address is nt prvided n this frm. Yu may als chse t decline t have a letter sent if yu d nt feel it is necessary. Please chse ne f the ptins belw: Yes, please send a letter t my PCP PCP NAME PCP ADDRESS CLIENT NAME CLIENT SIGNATURE (PARENT/GUARDIAN) -OR- N, I decline t have a letter sent t my PCP CLIENT NAME CLIENT SIGNATURE (PARENT/GUARDIAN) ****************************************************************************** CELL PHONE/CONTACT POLICY Yur therapist may chse t prvide yu with a cellular phne number t reach him r her directly. MMP therapists are nt n call and may nt be able t respnd immediately t calls r texts. If yur therapist prvides yu with such a number, please understand that it is nt t be used in case f crisis r emergency. In the case f emergency, g t yur nearest emergency rm, dial 911, r cntact the htline n the Crisis Resurce Frm prvided t yu tday. Patient signature/acknwledgement: Date

7 Sectin I: Health and Medical Status HEALTH, PAIN & NUTRITION SCREENING TOOL - Name f primary health care dctr: - Have yu had a physical exam within the last 12 mnths? Yes N* - Are yu currently experiencing any f the fllwing health prblems? Yes N Diabetes Heart prblems High bld pressure Seizures Hearing prblems Visin prblems Speech prblems Muscle r jint prblems Nausea r vmiting Other medical cnditins (If yes, explain) - If yu are experiencing any f the health prblems listed abve, are yu being treated by a primary health care prvider fr this prblem? Yes N* - D yu have any allergies? If yes, please list Sectin II: Pain Screening - Are yu experiencing any nging physical pain? Yes N (If N, please skip dwn t Sectin III: Nutritin Screening) If Yes, where is the pain lcated? - Hw wuld yu rate the intensity f the pain n a scale frm 1 t 10 with 10 being the wrst pssible pain yu culd imagine? - Are yu currently being treated fr this pain? Yes N - Is the treatment effective? Yes N Sectin III: Nutritin Screening - Have yu experienced an unintentinal weight lss r gain f 10 punds r mre within the last mnth? Yes N - Has a dctr r ther medical prfessinal placed yu n a special diet? Yes N If yes, are yu cmpliant with that diet? Yes N - D yu have chrnic chewing, swallwing r gastric difficulties that interfere with eating sufficient fd? Yes N

8 **CONTINUE TO NEXT PAGE - THIS PAGE TO BE COMPLETED BY CLINICIAN AND/OR MEDICAL PROFESSIONAL** Sectin IV: Review and Recmmendatins Instructins: * Asterisked items * (n page 1) indicate that a recmmendatin shuld be given t the client t seek treatment frm a primary health care prvider. Sectin I: Health and Medical Status ( Recmmend that client seek treatment frm primary health care prvider if,) - Client has nt had a physical exam within the past 12 mnths. Recmmendatin: AND/OR - Client has an acute/ chrnic health prblem that is nt being treated by a primary health care prvider Recmmendatin: Sectin II: Pain Screening (Recmmend that client seek treatment frm primary health care prvider if,) - Client is experiencing significant physical pain that is nt being treated by a primary health care prvider r the treatment is nt effective. Recmmendatin: Sectin III: Nutritin Screening (Recmmend that client seek treatment frm primary health care prvider if,) - Client has experienced an unintentinal weight lss/ gain f 10 punds r mre within the last mnth. Recmmendatin: AND/OR - Client is nn-cmpliant with a prescribed special diet. Recmmendatin: AND/OR - Client has chrnic chewing, swallwing r gastric difficulties that interfere with eating sufficient fd. Recmmendatin: Review and Recmmendatins cmpleted by: Clinician : Signature: Name: Date

9 Client Name: Date: SUICIDAL IDEATION 1. Are yu suicidal? Yes, cntinue t 1a N, cntinue t 2 a. D yu have a plan fr hw yu wuld attempt suicide? Explain b. D yu have the means r can easily access the means t cmplete yur plan? c. Wuld yu actually g thrugh with yur plan? 2. Have yu ever attempted suicide befre? Yes, cntinue t 2a N, cntinue t 3 a. Hw did yu d it? b. Did yu receive treatment fr any f these prir attempts? 3. If there is a plan, means and/r intent, what interventins were taken? (i.e., verbal cntract, resurces given, etc) HOMICIDAL IDEATION 1. D yu feel like hurting anyne else? Yes, cntinue t 1a N, cntinue t 2 a. D yu have a plan fr hw yu wuld hurt smene else? Explain. b. Wuld yu actually g thrugh with yur plan? 2. Have yu ever attempted t injure anther befre? Yes, cntinue t 2a N, cntinue t 3 a. Did yu experience any cnsequences? (i.e., legal cnsequences, treatment, etc) 3. If there is a plan, means and/r intent, what interventins were taken? (i.e., verbal cntract, resurces given, etc) PSYCHOSIS 1. D yu hear r see things that aren t really there? Yes, cntinue t 1a N, next page a. D yu have difficulty distinguishing what is real and what is nt real? b. D yur vices cmmand yu t cmplete certain actins? c. Are yu able t cntrl impulses related t what yu hear r see? **If any yes bx was checked, Therapist must cmplete a Higher Level f Care Frm** Clinician Name: Clinician Signature:

10 Patient Name: SUBSTANCE ABUSE SCREENER Alchl Age f First Use: Duratin f Use: Frequency f Use: Date f last use: Amunt f alchl cnsumed n a typical episde f use: Pattern (circle ne): episdic cntinuus binge Tbacc Cigarettes/Cigars Chewing Tbacc Age f First Use: Duratin f Use: Amunt f Use: (ppd) Date f last use: Pattern (circle ne): episdic cntinuus binge Substance: Age f First Use: Duratin f Use: Amunt f Use: Frequency f Use: Date f last use: Pattern (circle ne): episdic cntinuus binge Substance: Age f First Use: Duratin f Use: Frequency f Use: Amunt f Use: Date f last use: Pattern (circle ne): episdic cntinuus binge Substance: Age f First Use: Duratin f Use: Frequency f Use: Amunt f Use: Date f last use: Pattern (circle ne): episdic cntinuus binge Substance: Age f First Use: Duratin f Use: Frequency f Use: Amunt f Use: Date f last use: Pattern (circle ne): episdic cntinuus binge Please list any emtinal, behaviral, legal and/r scial cnsequences f substance use: Please list any physical prblems assciated with substance use: Have yu ever received previus care, treatment r services fr substance use including detx, cunseling and/r AA/NA? If yes, please give apprximate dates, length f treatment, and indicate yur respnse t treatment: Please describe relapse histry, if any:

11 LEC-5 Listed belw are a number f difficult r stressful things that smetimes happen t peple. Fr each event check ne r mre f the bxes t the right t indicate that: (a) it happened t yu persnally; (b) yu witnessed it happen t smene else; (c) yu learned abut it happening t a clse family member r clse friend; (d) yu were expsed t it as part f yur jb (fr example, paramedic, plice, military, r ther first respnder); (e) yu re nt sure if it fits; r (f) it desn t apply t yu. Be sure t cnsider yur entire life (grwing up as well as adulthd) as yu g thrugh the list f events. Event Happened t Me Witnesse d it Learned abut it Part f my jb Nt Sure Desn t apply 1. Natural Disaster (fr example, fld, hurricane, trnad, earthquake) 2. Fire r explsin 3. Transprtatin accident (fr example, car accident, bat accident, train wreck, plane crash) 4. Serius accident at wrk, hme, r during recreatinal activity 5. Expsure t txic substances (fr example, dangerus chemicals, radiatin) 6. Physical assault (fr example, being attacked, hit, slapped, kicked, beaten up) 7. Assault with a weapn (fr example, being sht, stabbed, threatened with a knife, gun, bmb) 8. Sexual assault (rape, attempted rape, made t perfrm any type f sexual act thrugh frce r threat f harm) 9. Other unwanted r uncmfrtable sexual experience 10. Cmbat r expsure t a war zne (in the military r as a civilian) 11. Captivity (fr example, being kidnapped, abducted, held hstage, prisner f war) 12. Life-threatening illness r injury 13. Severe human suffering 14. Sudden vilent death (i.e., hmicide, suicide) 15. Sudden accidental death 16. Serius injury, harm r death yu caused t smene else 17. Any ther very stressful event r experience LEC-5 (10/27/2013) Weathers, Blake, Schnurr, Kalupek, Marx, & Keane -- Natinal Center fr PTSD

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