Joliet Center for Clinical Research

Joliet Center for Clinical Research 210 N Hammes Ave. Suite 205 Joliet, IL 60435 Phone: 815-729-7790 Fax: 815-725-8144 Patient Information: : First Name: Middle Initial: Last Name: Address: _ City: State: Zip Code: S.S. #: Sex: Birth date: E-mail Address: Primary Phone: (Circle one) HOME CELL WORK OTHER Secondary Phone: (Circle one) HOME CELL WORK OTHER How would you like to receive your appointment reminders? (Circle one) Phone call Text Email No Reminder Marital Status (circle one) SINGLE MARRIED DIVORCED WIDOWED SEPERATED Language (circle one) ENGLISH SPANISH Race (circle one) WHITE BLACK OR AFRICAN AMERICAN HISPANIC INDIAN ASIAN MIDDLE EASTERN NOT GIVEN Ethnicity (circle one) NON-HISPANIC MEXICAN NOT GIVEN Responsible party: Responsible Party Name: Responsible Party Address: City: State: Zip Code: Responsible Party Employer: Insurance Information: Insurance Company: Policyholder Name: Policyholder Birth date: S.S.#: Patient Relationship to Insured (circle one): SELF SPOUSE CHILD OTHER

Office Hours: Monday Thursday Friday 9:00 a.m. 5:00 p.m. 9:00 a.m. 2:00 p.m. Responsibility Statement: Your insurance is a method for you to receive reimbursement for fees you have paid to Joliet Center for Clinical Research for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages based on your contract with them and not with our office. It is your responsibility to pay in advance for the copay, and also pay for deductible, coinsurance, or any other balance not paid for by your insurance. We will assist you in receiving as much reimbursement as possible; YOU ARE ULTIMATELY RESPONSIBLE FOR YOUR BILL. Insurance Patients: It is the patient's responsibility to inform our office if your insurance carrier changes within a timely matter. We will bill according to insurance guidelines as long as the proper insurance information is provided to us within the timely filing limit. If the patient's insurance company does not pay within a certain time limit, the professional fees are due and payable in full from the patient. If insurance pays to the patient for the services provided by us, payment is expected to be sent to our office promptly. Copayments are due IN FULL at the time of service. Prescription Medication Guidelines: We DO NOT accept phone request for prescriptions medication refills other than Schedule II medications (Adderall, Concerta, Ritalin, etc.). All patients must have their pharmacy fax a medication refill request form to our office at (815) 725-8144. The physician or nurse practitioner will then fax the request back to the pharmacy if approved. Written medication refill information needs to be left on the medication refill line at (815) 729-7790 ext. 109. ALL REQUESTS MUST BE MADE AT LEAST 3 BUSINESS DAYS BEFORE YOU RUN OUT OF YOUR MEDICATIONS! MEDICATION IS NOT REFILLED FRIDAY THRU SUNDAY OR AFTER OFFICE HOURS, NO EXCEPTIONS! Cancelling or not showing up for appointments: There is a 24 hour cancellation fee. When an appointment is scheduled, that time is reserved for the patient and if the patient cannot attend at the time, the patient must give 24 hours notice or will be charged a $75 fee. If patients fail to let the office know and no show for their appointment, patient will also be charged a $75 fee. These fees CANNOT be billed to insurance companies and the patient is responsible for the total amount. If you incur two (2) consecutive no shows, you will be terminated from the facility. If you have an appointment and believe you might be late, you should call to inform the staff as early as possible. However, we still may require you to reschedule in order to be respectful and courteous to other patients. Non-emergency Telephone Calls: A minimum fee of $15 will be charged to the patients account for non-emergency telephone calls made to the practice. This includes telephone calls for medication refills, and test results, and other non-emergency requests, unless the patient was directed specially by the doctor to call. This charge may change at the discretion of the practice. This fee is payable directly by the patient, with credit card over the telephone prior to the message being answered, as it is not a covered expense by insurance companies.

Financial Responsibility: By signing this statement you agree to be financially responsible for all charges. If an account goes unpaid, a finance charge of 33.33% is added to accounts sent out to Collections. If your check is returned from your financial institution, we will no longer be able to accept them. All returned NSF checks will be charged a service fee of $25.00 and in the future you will be required to pay with either cash credit/debit card. Authorization to Release Medical Information: In order to obtain/release your medical records, a separate Release of Information form must be filled out and signed in our office. This will remain in effect one year from the date it is signed. When medical records are requested for legal reasons, there is a $25 fee that is usually paid by the attorney's office. The fee for medical records by patient request or for personal use is $25. There is no charge if our clinic doctor refers a patient to another physician. This fee is payable directly to the patient as it is not a covered expense by insurance companies. Paperwork and Miscellaneous Forms: To request any type of paperwork or forms to be completed, one will be charged a fee of $100, which must be paid in advance, prior to the physician completing the paperwork. This fee is payable directly by the patient as it is not a covered expense by insurance companies. When requesting these forms, one must allow up to 7 (seven) business days to receive paperwork. COMPLETION OF THESE FORMS IS DONE AT APPOINTMENTS ONLY. Appropriate Conduct We have a ZERO tolerance policy for any patient who behaves inappropriately to clinical staff, office staff, and/or physicians and will be discharged immediately (ex: cursing, violence, verbal threats, sexual inappropriateness etc). By signing below, I agree to all the terms and conditions of this form and also certify that all the information I have provided is true. Patient/Responsible Party Name: Signature of Patient Signature of Parent, Guardian, or Personal Representative* If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power or attorney, healthcare surrogate, etc.).

JOLIET CENTER FOR CLINICAL RESEARCH 210 N. Hammes Ave., Suite 205 Joliet, IL 60435 Phone: 815-729-7790 Consent to Release Information to Primary Care Physician Communication between your psychiatrist/therapist and your primary care physician can be important to help ensure that you receive comprehensive and quality health care. This information may include diagnosis, treatment plans, progress and medication, if necessary. You may revoke this consent at any time except to the extent that action has been take in reliance upon it and that in any event this consent shall expire one (1) year form the date of signature, unless another date is specified. I, Patient Name Printed Birth Patient SS# Please Check One: I agree to release mental health/substance abuse information to my Primary Care Physician. I do NOT give my consent to release any information to my Primary Care Physician. Physician Name: Physician Address: City, State, Zip: Phone: Fax: Signature of Patient Signature of Parent, Guardian, or Personal Representative* If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power or attorney, healthcare surrogate, etc.).

JOLIET CENTER FOR CLINICAL RESEARCH 210 N. Hammes Ave., Suite 205 Joliet, IL 60435 Phone: 815-729-7790 Please let us know how you were referred to our practice by circling and/or indicating one of the following options: Primary Care Physician Hospital/Facility Other Doctor Insurance Company Other Self-Referral Who: Which: Who: Insurance Name: Specifics: Additional Info:

JOLIET CENTER FOR CLINICAL RESEARCH 210 N. Hammes Ave., Suite 205 Joliet, IL 60435 Phone: 815-729-7790 Paperwork and Miscellaneous Forms Disclosure To request any type of paperwork or forms to be completed, one will be charged a fee of $100, which must be paid in advance, prior to the physician completing the paperwork. This fee is payable directly to the patient as it is not a covered expense by insurance companies. When requesting these forms, one must allow up to 7 (seven) business days to receive paperwork. COMPLETION OF THESE FORMS IS DONE AT APPOINTMENTS ONLY. By signing below, I acknowledge to all the terms and conditions regarding paperwork and miscellaneous forms. Patient/Responsible Party Name: Signature of Patient Signature of Parent, Guardian, or Personal Representative* If you are signing as a personal representative of an individual, please describe your legal authority to act for this individual (power or attorney, healthcare surrogate, etc.

Joliet Center for Clinical Research Cosme Lozano MD, Paulette Trum MD, Amanda Twait APRN, John Jauch LCPC, Anthony Kokalj LCPC, Angela Connor LPC, Allison Hubbard LPC Psychiatric Intake Form *All Information on this form is strictly confidential* Name of Birth Primary Care Physician Referred By Current Therapist/Counselor Therapist Phone What are the problem(s) you are seeking help for? 1. 2. 3. Current Symptoms Checklist: (Check once for any symptoms present, twice for major symptoms) Depressed Mood Racing Thoughts Excessive Worry Unable to enjoy activities Impulsivity Anxiety Attacks Sleep Pattern Disturbance Increase Risky Behavior Avoidance Loss of interest Increased Libido Hallucinations Concentration/Forgetfulness Decreased Need for Sleep Suspiciousness Change in appetite Excessive Energy Excessive Guilt Increased irritability Fatigue Crying Spells Decreased Libido Suicide Risk Assessment Have you ever had feelings or thoughts that you did not want to live? Yes No Have you ever tried to kill or harm yourself before? **If you are currently having thoughts about harming yourself and feel that you may act on these thoughts or impulses, STOP filling out his form, CALL 911 OR VISIT THE EMERGENCY ROOM AT YOUR NEAREST HOSPITAL** Medical History Allergies Current Weight Current Height For Women Only: Are you currently pregnant or do you think you might be pregnant? Yes No

List ALL current prescription medications and how often you take them: (if none, write none) Medication Name Total Daily Dosage Estimated Start Please check any family medical issues that apply to you and indicate the family member Yes No Thyroid Disease Anemia Liver Disease Chronic Fatigue Kidney Disease Diabetes Asthma/Respiratory Problems Stomach or intestinal problems Cancer (type) Fibromyalgia Heart Disease Epilepsy or seizures Chronic Pain High Cholesterol High blood pressure Head trauma Liver Problems Other Past Psychiatric History Outpatient Treatment Yes No If yes, please describe when, by whom, reason for treatment and nature of treatment. Psychiatric Hospitalization Yes No If yes, please describe for what reason, when, where, and the dates of hospitalization

Family Psychiatric History Please check and indicate the family member who has been diagnosed or treated for: Yes No Bipolar Disorder Depression Anxiety Anger Suicide Schizophrenia Post-Traumatic Stress Alcohol Abuse Other Substance Abuse Has any family member been treated with a psychiatric medication? Yes No If yes, who was treated, with what medications and how effective was the treatment? Substance Use Have you ever been treated for alcohol or drug use or abuse? Yes No If yes, please indicate the treatment, for what, and when Tobacco History Have you ever smoked cigarettes? Yes No Currently? Yes No How many pack per day on average? How many years? In the Past? Yes No How many years did you smoke? When did you quit? Do you use pipe, cigars, or chewing tobacco? Yes No Currently? Yes No In the past? Yes No What kind? How often per day on average? How many years? Educational History Did you attend college? Yes No Where? Major What is your highest level of education or degree obtained? Occupational History Are you currently: Working Not working by choice Unemployed Disabled Retired How long in the present position? What is/was your occupation? Social History Are you currently: Married Divorced Single Widowed How long? Have you had any prior marriages? Yes No If so, how many? How long?

Social History Cont. Do you have children? Yes No If yes, list ages and gender Legal History Have you ever been arrested? Yes No Do you currently have any pending legal problems? Yes No Please describe By signing below, I agree that all the information provided is true and accurate. Signature of Patient Emergency Contact Telephone #

Attentions Patients: July 13, 2016 Effective immediately, all patients will be required to follow our medication refill policy. Failure to do so will result in a fee of $25.00 that cannot be billed to any insurance company and which will be the responsibility of the patient. This fee must be paid before additional medications are filled. BEFORE calling to request a refill from the office, please contact your pharmacy to check for refills. If refills are available, please have the pharmacy send a request to the office either by fax or electronically. Under no circumstances will medications be filled early. If you cannot get a refill through the pharmacy, please call the office at 815-729-7790 ext. 2 and leave ALL of the requested information on the refill line. This includes your name, date of birth, your doctor, the medication, strength of medication, and the name and address of your pharmacy even if we have sent prescriptions to them before. Print name CLEARLY Signature