ADULT SELF ASSESSMENT In filling out this form you are welcome to provide as much information as you would like. If you find a question that you desire to leave blank, you are welcome to do so for any reason. Your counselor will review this form and if they have any questions regarding your answers, they will follow up with you in session. Thank you. CLIENT INFORMATION (Please print) : Client Name: of Birth: Gender: Male Female Relationship Status: Single Married Divorced Widowed Legally Separated Partnered Other Previous marriages #: Ethnicity: Caucasian African-American Hispanic Asian Mixed Other Military Service: Yes No If yes, branch Active Retired Reserves Spiritual/Religious Beliefs: Practicing Yes No Affiliation or Church attending: PRESENTING PROBLEM 1. Briefly describe the problem or concern you most wish help with currently. 2. Approximately how long have you had the current problem or concern? 3. In what ways have you attempted to cope with this problem or concern? EDUCATION AND WORK INFORMATION 1. What is your highest education level? 2. What is your current job and/or occupation? 3. ow satisfied are you with your current job and/or occupation? 4. If not employed, are you: unemployed retired disabled other FAMILY BACKGROUND 1. Who do you live with? Do you have any children? Names/Ages/Gender/Relationship (biological, step, half) 2. Who did you live with growing up? Brother: Age: Sister: Age: Other: Age: 3. Are any of your family members deceased? Names: 4. Spouse/Partner Name: Age: Gender: Occupation: Employer: Any children? Boys Girls 1
5. Please check any past, present, or impending problems/issues in your family. Name Physical/sexual abuse Deaths Frequent Relocations Legal Problems Disability Occupational Details: 6. Have you PERSONALLY experienced significant abuse? a. None Unsure Emotional Physical Sexual Details: HEALTH AND SOCIAL ISSUES 1. Do you have any medical conditions? Please list: Allergies: 2. Please list any persistent symptoms or health concerns (e.g., chronic pain, headaches, diabetes, etc.) 3. Please list any medications you are CURRENTLY taking, including dosage and frequency: 4. Are you having any problems with your sleep habits? Yes No (if yes, check where applicable) Sleeping too little Other 5. Are you having any difficulty with your appetite or eating habits? Yes No (if yes, check where applicable) Eating less Eating more Binge eating Restricting calories Other 6. Have you had a significant weight change in past two months? Yes Gain Loss 7. No How much do you drink daily? 8. 9. 10. Do you consider your alcohol consumption to be a problem? 11. How often do you eng Which drug? 12. 13. describe below) Nature or problem: 14. In the past, how would you rate the quality of your friendship relationships? Very poor Unsatisfactory Good Excellent 15. Do you have any Sexual Impulsiveness of Desire Difficulty Maintaining Arousal Worry about STD(s) Other 16. What is your sexual orientation? Heterosexual Gay/Lesbian Unsure 17. How do you spend your free time? 2
MENTAL HEALTH HISTORY Name 1. Are you currently receiving psychiatric services, professional counseling or therapy elsewhere? Yes No 2. specify the following) Reason for counseling: Counseling location: Counseling dates: Counseling duration: 3. Have you ever been hospitalized for psychiatric reasons? Yes No (If yes, please specify reason) 4. following) Name/dose of medication of Prescription: 5. Have you often?) 6. often?) 7. describe) Nature of harm: 8. when?) Nature of experience: Is there a history of attempted or completed suicides in y If yes, who? 9. Have you ever experienced any form how often?) Nature of experience: 10. Have you ever experienced sexual assault, unwanted sex or uncomfortable touching? Frequently Few Times Once Never Unsure 11. Are you feeling Anxious? Depressed? Sad? Other? 12. How does the future look for you? 13. Please describe your future plans? 15. What do you hope to accomplish through counseling? 16. Is there anything else you would like your counselor to know about you? Thank you for your valuable time and effort! 3
Today s : Email address: AAA HOPE COUNSELING (Please Print) Referral Source: PATIENT INFORMATION Last Name: First Name Middle Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid / Partner Street Address: Apt./Unit City: State: ZIP Code: Home phone Cell/Other contact Social Security # Birth : / / Employer: Occupation: Work phone Street Address: City: State: ZIP Code: Sex: M F Referring Doctor (if required by insurance): Notify Primary Care Physician? YES NO Emergency Contact Name/Relationship: Name of Primary Care Physician Contact Phone # Home phone IN CASE OF EMERGENCY INSURANCE INFORMATION Insured s Last Name (if different): First: Middle: Address: Home phone (if different) Cell/Other contact Social Security Mr. Mrs. Birth : Cell phone Marital status (circle one) Single / Mar / Div / Sep / Wid / Partner / / Insurance Company: Insurance Billing Address: Insurance phone no.: Policy Number Group # Relationship to Insured: Self Spouse Sex: M F SECONDARY INSURANCE INFORMATION (IF APPLICABLE) Insurance Company Name and address: Insured s Address if different: Insurance phone Policy number Group Insured s Name and Relationship: Self Spouse The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorize Marcia Compton, those acting on the practice s behalf, and my insurance company to release any information required to process my claims. Furthermore, I have reviewed the Notice of Privacy Practices provided. I fully understand and accept the terms of this consent. Patient/Guardian signature * PLEASE NOTE: 48 HOUR CANCELLATION POLICY Please be advised that 48 hours notice is required for cancellations. Otherwise, your account will be charged for the session amount. 4
AAA Hope Counseling Consent To Services CLIENT NAME: (D.O.B.) ADDRESS: I, hereby consent to services provided by Marcia Compton (LMHC). The undersigned understands: 1. That this consent is given only for those services within the scope of the Provider s license. 2. Before services begin. 3. After this consent has been explained. I have been informed of the Provider s training and credentials and my right to withdraw this consent at any time. I understand that the records are confidential and will not be released to other individuals or agencies without my consent. However, I realize that Marcia Compton may be legally obligated to release information about me without my consent under the following circumstances: A: Upon the receipt of a court order. B. In the event of a medical emergency. C. If there is a reason to believe that the potential for child abuse/neglect of dependent adult abuse/neglect exist or that such abuse/neglect has occurred. D. When there is imminent threat of homicide or suicide. I/We have read and received a copy of the Notice of Privacy Practices and Client Rights document. Do you give permission for us to call you at your: home work or cell and leave any messages on voice mail/or answering service machine. (Please CHECK and INITIAL your response) I give permission for your office to send email: Yes No Email: NOTE: Parents with children under (18) years of age are certifying legal guardian of said patient and give permission or consent to treat the children by the provider in signing this consent form. There is a $39.00 fee for all returned checks Signature of Client Client s Representative (if Minor) Staff _ 5
AAA Hope Counseling No Show Policy Thank you for coming to AAA Hope Counseling. When you schedule with your therapist, we do not double or triple book like some doctor s offices. The time is set aside for you alone. We ask that you give at least a 48 hour notice if you need to reschedule your appointment. You will be charged $75.00 or a no show or late cancellation (less than 48 hour notice). I have read and understand this no show policy. Additionally, if your bill is not paid 30 days after it is due, 18% annual interest will be charged, and if it would need to be sent to collections you agree to pay all costs involved in the collections, including but not limited to attorney fees, interest fees, and court costs. Client or Client s Representative 6
AAA HOPE COUNSELING HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIION. PLEASE REVIEW IT CAREFULLY. We will only release healthcare information about you in accordance with federal and state laws and ethics of the counseling profession. Uses and disclosures of your health information for the purposes of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allows us to use and disclose your health information for these purposes. TREATMENT We may need to use or disclose health information about you to provide, manage or coordinate your care or related services, which could include consultants and potential referral sources. PAYMENT Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. We may bill the person in your family who pays for your insurance. HEALTHCARE OPERATIONS We may need to use information about you to review our treatment procedures and business activity. Information may be used for certification, compliance and licensing activities. Other uses or disclosures of your information which does not require your consent There are some instances where we may be required to use and disclose information without your consent. For example, but not limited to: Information you and/or your child or children report about physical or sexual abuse: then by Indiana State Law, we are obligated to report this to the Department of Children and Family Services, if you provide information that informs us that you are in danger of harming yourself or others. Information to remind you of /or to reschedule appointments or treatment alternatives. Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order. If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. I have read and received a copy of the above information. Signature: Printed Name: : Last Updated: 06/04/2017 7