NEW PATIENT INTAKE FORM

CONFIDENTIAL PATIENT INFORMATION:

First Name:

Middle Name

Last Name:

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Phone:

Social Security Number:

Birthday

REFERRAL INFORMATION:

Referred By (Physician):

Physician Phone:

Other Referral Source:

Website

Social Media

Yellow Pages

Insurance Co.

EMERGENCY CONTACT:

Emergency Name:

Relation:

Emergency Contact Phone:

Emergency Contact Email:

INSURANCE INFORMATION:

Primary Insurance Carrier:

Insurance Phone:

Policy Holder Name:

Birthdate:

Policy/ID Number:

Group Number:

Employer:

Relationship of Patient to Insured:

PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process all claims thru my insurance company. I authorize payment of medical benefits to: Ocala Consulting & Prevention, LLC.

Medications:

What Brings You to Counseling?

MINOR CHILDREN SEEKING COUNSELING:

Mother’s Name:

Father’s Name:

Who Has Legal Custody:

Full or Joint:

If Applicable, I Will Provide Copy Of Custody Agreement Upon Initial Appointment.

FINANCIAL AGREEMENT:

As a courtesy, this office will file claims with your insurance company for you and any benefit check given is not a guarantee of coverage. I understand that it is my responsibility to pay any deductibles, co-insurance or any other balance not paid by my insurance or third-party payer within a reasonable period of time, not to exceed 60 days. If you need to cancel or reschedule an appointment, please give us 24 business hours advance notice; otherwise, you will be billed a no-show fee of $25.00. Returned check fee is $25.00. Checks will no longer be accepted as a mode of payment after a “dishonored” or returned check is received on your account. Acceptable modes of payment will only be money orders, credit card, or cash.

LEGAL MATTERS AND REQUESTS FOR LETTERS Ocala Consulting & Prevention does not provide disability letters, companion pet letters, or letters regarding your ability to work, or any letters that would inform providers of your mental health history. You must discuss these needs with your medical or primary care provider. If a letter is required attesting the client’s needs the therapist will provide it for a fee of $35. Letters are only provided to clients who have been seen for 8 sessions or longer.

COURT APPEARANCE Clients are discouraged from having the therapist subpoenaed. Though the client’s attorney, who initiates the subpoena request is responsible for the court appearance and testimony fees, it does not mean that the therapist’s testimony will be solely in in the client’s favor. The Therapist will only testify their professional opinion and to the facts of the case. The following fees apply for court appearances: Preparation Time (including submission of records): $120/hour Phone Calls: $120/hour Depositions: $150/hour Time Required in Giving Testimony: $150/hour

CONSENT FOR SERVICES:

This form is to document that I give my permission and consent to the above, Ocala Consulting & Prevention, LLC., to provide psychotherapeutic treatment and/ or assessments to me and/or my child/ children or for whom I am legal guardian, custodian, or legal Power of Attorney. By signing below, I understand that Drug Testing (Urine or Swab Testing) may be part of my treatment at Ocala Consulting & Prevention, LLC. I also understand that a refusal to submit to Urine Analysis Testing or Swab Drug Testing could result in discharge from Ocala Consulting & Prevention, LLC. I understand the following: Although I expect benefits from this treatment and/or evaluation, such benefits or particular outcomes cannot be guaranteed. This therapist is not providing an emergency service. In case of an emergency, please call 911.Regular attendance will produce maximum benefits, but I am free to discontinue treatment at any time. Conversations with the therapist are confidential. However, by law, there are certain exceptions to the limits of confidentiality. These limits include actual or suspected child abuse, elder abuse, and threats of harm toward oneself or others. The therapist will make reasonable efforts to discuss these issues before breaking confidentiality, however disclosure may become necessary when ordered by a court of law. I know of no reasons that I should not undertake this therapy and I agree to participate fully and voluntarily.

RELEASE & WAIVER OF LIABILITY:

I am willingly entering Ocala Consulting & Prevention, LLC and give my consent to participate in therapeutic, psycho-educational and/or wellness counseling sessions and/or groups. I, the undersigned, agree to the following: I am participating in the programs and activities offered at Ocala Consulting & Prevention, LLC on my own accord. I understand and agree to comply with all facility and program rules. In case of emergency illness or accident, I authorize Ocala Consulting & Prevention, LLC to take me to the hospital of my choice, or, if I have no personal choice, to Ocala Regional Medical Center. I agree to follow the universal precautions: Program participants will allow staff to clean any toxic spills, blood, or other bodily fluids. I am entering Ocala Consulting & Prevention, LLC at my own request. I agree not to hold Ocala Consulting & Prevention, LLC or any of its Board of Directors and/or staff liable for any loss and/or injury to my person or property suffered by me while I am in or about the premises of Ocala Consulting & Prevention, LLC. I assume all risk involved in participation in the programs and activities. This assumption is made freely and voluntarily and with full and complete understanding of the consequences of such risk assumption.

Your Signature

GENERAL INFECTION CONTROL POLICY:

All clients are instructed to read their handbook given to them at time of admission. This outlines preventative health care. All participants at Ocala Consulting & Prevention, LLC are to be treated with universal precautions.

Your Signature

CLIENT LEGAL RIGHTS / GRIEVANCE:

All individuals who apply for services, regardless of sex, race, age, color, creed, financial status, military status, religion, sexual preference or national origin are assured that their lawful rights as Patients shall be guaranteed and protected. While being served, the Patient is assured and guaranteed the following rights: ✓ To be treated with respect and dignity. To receive timely treatment by qualified professionals. Every effort will be made to use the least restrictive, most appropriate treatment available, based on Patient need. Each Patient shall be afforded the opportunity to participate in activities designed to enhance self-image. To receive quality treatment that is best suited to his/her needs and shall include appropriate services medical, vocational, social, educational, and/or rehabilitative services. To express by signature an informed consent of the right to release information for communication purposes, with other agencies. To receive communication and correspondence from individuals. To privacy for interview/counseling sessions. ✓ To report abuse by the following toll-free number: 1-800-962-2873 ✓ To confidentiality, except where noted in the Federal Law of Confidentiality. To receive full information regarding the treatment process. To refuse treatment. To all other constitutional and legal rights, including the right to personal clothing and effects. To be informed of the Patient grievance procedure upon request. ✓ Grievance Procedure It is the policy of Ocala Consulting & Prevention, LLC to treat our patients with dignity and respect and in a humanitarian manner, utilizing standard treatment practices applicable to each patient’s needs. If, despite these efforts of Ocala Consulting & Prevention, LLC staff, a patient feels that his/her rights have been violated in any way, he/she will have a right to seek a remedy by filing a grievance.

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