adult new client forms - ahpdelaware.com · describes how we will work together. client concerns...
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Adult New Client Forms
This packet includes the forms listed below.
Please bring these completed forms with you to your first appointment at Associates in Health Psychology (AHP). Since your therapist may want some additional information, please arrive 5 minutes early. There will not be a receptionist so you do not need to check-in with anyone. Any additional forms for you to complete will be on a clipboard marked with your therapist's name and time of your appointment.
Welcome
Information about beginning therapy.
Intake Asks for contact information, some medical and personal background, and family history.
Office Policies Provides you with an overview of our general office policies and procedures.
Privacy Policies Gives you information about how the privacy of your health information is maintained. These pages are for you to keep.
Acknowledgment of Receipt of Privacy Policies
Only this page of the Privacy Policies needs to be signed and returned.
Consent for Therapy/Evaluation
Describes how we will work together.
Client Concerns
Checklist and Questionnaire to let us know about your concerns.
Client Survey
Survey about your goals for treatment.
Insurance Assignment,
Health Insurance Managed Care Release
and Insurance Information
Complete ONLY if our office staff has determined that we participate with your insurance plan. Please be sure to bring your insurance card and a photo ID for your therapist to copy at your initial appointment. At the time of each visit, our office will accept cash, check, or credit card (Visa, Discover or MasterCard) payments for your co-pays and deductibles. Also included is an explanation of your
your co-pay, co-insurance and deductible obligations.
Authorization to Release Information
The first Authorization form allows your therapist and AHP to coordinate care with your primary care provider. The second Authorization form may be filled out to allow us to communicate with the person who referred you, a specialist involved in your care, or anyone else you would like to keep informed of your treatment with AHP. Please complete a separate form for each contact person, providing the name, address, telephone, and fax number for that person.
If you bring the completed forms with you to your first appointment, do not
complete an extra set in the office. Please check the clipboard in case your
therapist left any additional forms for you to complete.
Forms19/Intake/FormsListAdultWebJul19
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
Welcome to Associates in Health Psychology. We look forward to helping you find meaningful solutions to the challenges you face. Beginning the important work of therapy is often a difficult decision. Even once your initial appointment has been made, you may feel both eager to begin as well as somewhat uncomfortable about coming in for your first meeting with your therapist. We understand. Many people find the thought of beginning therapy unsettling until they actually start the process. Then they feel more comfortable. Now that you’ve taken the first step toward working on some of the areas of concern in your life, try not to let some initial discomfort keep you from pursuing what you know will be in your best interest. Before your first meeting, you might think about what you hope to gain from therapy and what is most important to you. Then you can discuss these thoughts with your therapist. Some clients have found that jotting down notes about what they want to discuss helps them feel more comfortable. If you have any questions prior to your appointment, please call our office or email us. You may leave a message for our office staff or our therapists 24 hours a day, 7 days a week at 302-428-0205. Our email is: [email protected]. For directions to our locations, see: www.AHPDelaware.com/locations.htm. Location information is also available on our telephone system. Cordially yours, The Therapists at Associates in Health Psychology
Forms19\Intake\WelcomeIntroAdultWebJun19.doc
Associates in Health Psychology, LLC adult intake
(302) 428-0205 Wilmington & Newark
Name _______________________________________________________ Date__________________ First Middle Last
Address ________________________________________ Home Phone _______________________
City ________________________________________ Cell Phone _______________________
State, ZIP _______________________________________ Work Phone _______________________ Date of Birth _______________ Age _____ Sex ____ Email ______________________________
Relationship Status ❏Married ❏Never Married ❏Domestic Partnership/Civil Union
❏Partnered ❏Separated from spouse/partner ❏Divorced/permanently separated from
spouse/partner ❏Other: _________________________________________________
Employer ____________________________________ Occupation _______________________________
Highest Grade Completed _______ Educational/Vocational Specialization _________________ Notify in Emergency _______________________________________ Phone ______________________ Name / Relationship
When did symptoms first appear? _______________ Similar symptoms in past? _____________ Referred by ____________________________________________________________________________ Primary Care Doctor and Other Medical Specialist(s) Seen for Ongoing Health Conditions
Health Care Provider’s First & Last Name Specialty Area City & State
List all Health Conditions and Allergies (If you need more space for this or any other item, please attach an additional sheet.) _________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________ Current Use of: Caffeine_____ Cigarettes/Tobacco_____ Alcohol_____ Drugs_____ Past Use of: Caffeine_____ Cigarettes/Tobacco_____ Alcohol_____ Drugs_____
FOR OFFICE USE: HA SB MD CE SE JF SBJ HLS SX AR KTH CW _____
DSM-5: ________________________________________________________________________________ ICD10: _____________
DSM-5: ________________________________________________________________________________ ICD10: _____________
IntakeAdultJun19 page 1 of 3
AHP, LLC Name ________________________________________________________________ PAGE 2 First Middle Last
List all current medication, condition for which you take the medication and dosage:
Medications /Supplements/Vitamins Condition Treated by whom? Dosage
Previous Treatment History
Psychological/Psychiatric: Have you ever received outpatient or inpatient psychological or psychiatric services, drug/alcohol treatment, counseling services, or psychiatric medications prescribed by a provider other than a psychiatrist or psychiatric nurse practitioner? No Yes. If yes, please describe:
When (approx. dates)?
For what (diagnosis)?
What kind of treatment?
Where or from whom?
With what result?
Other Significant Medical Treatments (Hospitalizations, Major Injuries, Surgeries): List hospitalizations, head injuries, concussions, important accidents & injuries, surgeries, and other medical conditions not previously listed.
Condition Age Treated by whom Results
IntakeAdultJun19 page 2 of 3
AHP, LLC Name _______________________________________________________________________ PAGE 3 First Middle Last
Family: Spouse/Partner _____________________________ ______ ___________________________ Name Age Occupation
Children Name Sex Age Residence (City & State)
Client Birthplace ________________________ Childhood Residence _________________________
Father's Occupation _____________________ Mother's Occupation _________________________
Brothers & Sisters Name Sex Age Residence (City & State)
Are you currently involved in a lawsuit, custody case or accident, short term disability (STD), long term disability (LTD), FMLA, social security disability application, injury or workman’s comp case? Yes No If yes, please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________ Please indicate important or stressful life events that have impacted you, such as deaths of people close to you, job loss, abuse or other victimization, etc.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________ What else would you like me to know about you or your family, including religious, ethnic, or cultural background or hobbies, skills, talent or interests?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Forms2019/ IntakeAdultJun19 page 3 of 3
Associates in Health Psychology, LLC
Wilmington & Newark
OFFICE POLICIES
OfficePoliciesJun19 page 1 of 2
In order to prevent misunderstandings about office policies, please read the following:
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to
those sessions are confidential and may not be revealed to anyone without your written permission, except
where disclosure is required by law or by court order. The law requires disclosure where there is a
reasonable suspicion of child abuse (past or present), elder abuse or neglect; where a client presents a
danger to self, to others, or to property; is gravely disabled; or is significantly impaired from drug and/or
alcohol use. In these emergency situations, therapists will do whatever they can, within the limits of the
law, to prevent clients from injuring self or others and to ensure that clients receive the proper care.
Disclosure is also required by law when there is reasonable suspicion of a licensed medical practitioner or
other licensed healthcare provider who is guilty of unprofessional conduct or appears to be unfit to
practice. Within AHP, therapists share on-call responsibilities. All AHP therapists are legally bound to
keep disclosed information confidential. However, we can’t guarantee confidentiality if you exchange
emails, cell phone calls or texts with anyone from AHP. We will maintain client case files for 7 years
from the last session date, or until the client reaches age 21, whichever is later.
TELEPHONE & EMERGENCY PROCEDURES: If you need to reach your (or your child’s) therapist
between appointments, you may leave a message 24 hours a day, 7 days a week, on his/her voice mail at
(302) 428-0205. If your call is urgent, call (302) 428-0205 and dial extension 9. Inform the office staff
or our answering service that your call is urgent. If it is during office hours and your therapist is available,
he/she will call you back. After hours, the on-call therapist will call you back as soon as possible. If your
call is urgent and a therapist does not call you back immediately, please call the Rockford Center Needs
Assessment (302) 996-5480, Psych Crisis Team at Christiana Hospital (302) 320-2118, Psych Crisis
Team at Wilmington Hospital (302) 428-2118, Crisis Intervention Services (302) 577-2484 or (800) 652-
2929, or MeadowWood Hospital at (302) 213-3568. If your call is a life-threatening emergency, you
should go immediately to the closest hospital or call 911.
PAYMENTS: At each session, payment is expected for any fees due. Missed appointments will be
charged to you at your therapist’s usual and customary rate, unless you cancel 24 hours before the
scheduled appointment. Monday appointments must be canceled by the previous Friday. Telephone
conversations, site visits, report writing and/or form completion, consultation with other professionals,
reading records, longer sessions, and/or travel time will be charged at the therapist’s standard, non-
contractual rate. Requests to release your records will be subject to an administrative charge.
INSURANCE REIMBURSEMENT: If you have a health insurance policy, it will usually provide some
coverage for mental health treatment. AHP will provide you with assistance in helping you receive the
benefits to which you are entitled; however, you (not your insurance company) are responsible for full
payment of my fees. It is important that you find out exactly what mental health services your insurance
policy covers. Due to the rising costs of health care, insurance benefits have increasingly become more
complex. It is sometimes difficult to determine exactly how much mental health coverage is available.
These plans are often limited to short-term treatment approaches designed to work out specific problems
that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more
therapy after a certain number of sessions. Though a lot can be accomplished in short-term therapy, some
patients feel that they need more services after insurance benefits end. (Some managed-care plans will
not allow me to provide services to you once your benefits end. If this is the case, I will try to assist you
in finding another provider who will help you continue your psychotherapy.)
Associates in Health Psychology, LLC OFFICE POLICIES, page 2
Forms2019/Intake/OfficePoliciesJun19 page 2 of 2
You should also be aware that most insurance companies require that I provide them with your clinical
diagnosis. Sometimes I have to provide additional clinical information, such as treatment plans, progress
notes or summaries, or copies of the entire record (in rare cases). This information will become part of
the insurance company files. Though all insurance companies claim to keep such information
confidential, I have no control over what they do with it once it is in their hands. In some cases, they may
share the information with a national medical information databank. By using your insurance, you
authorize me to release such information to your insurance company. I will try to keep that information
limited to the minimum necessary.
It is important to remember that you always have the right to pay for my services yourself to avoid the
problems described above (unless prohibited by the insurance contract).
LITIGATION LIMITATION: Due to the nature of the therapeutic process, which often involves
making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that
should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, or
lawsuits), neither you nor your attorneys, nor anyone else acting on your behalf, will call on you (or your
child’s) therapist to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy
records be requested. If you become involved in legal proceedings that require my participation, you will
be expected to pay for any professional time I spend on your legal matter, even if the request comes from
another party. (Because of the difficulty of legal involvement, I charge three times my hourly private pay
therapy fees for professional services which involve preparation and attendance at any legal proceedings
I am asked or required to perform in relation to your legal matter.)
RECORDING: Video or audio recording of any part of a session by either the therapist or client requires
the written consent of both.
TERMINATION: After the first one or two meetings, your therapist will assess if he/she can be of benefit
to you (or your child). Our therapists accept clients only if, in their opinion, they have the particular skills
and experience necessary for treatment. If at any point the therapist assesses that he/she is not effective
in helping you reach your therapeutic goals, your therapist will discuss it with you. If appropriate,
treatment will end and you will be given referrals to other treatment providers. You also have the right to
terminate services at any time. If you wish to do so, please inform your therapist directly so the necessary
steps may be taken to discharge you from care and close your file. If you do not show up for two scheduled
appointments without notice, or you miss an appointment and your therapist does not receive a message
from you during the next 4 weeks, your therapist will assume that you are terminating services, discharge
you from care, and close your file.
WEBSITE: Associates in Health Psychology has a website that you are welcome to access:
https://ahpdelaware.com. It provides information to others about our practice as well as provides
resources to promote emotional well-being. You are invited to review the information on the website and,
if you have questions about any of the information, please discuss this during your therapy sessions.
I have read the Office Policies. I understand them and agree to abide by them.
___________________________________________________________________________________
Signature of Client (or if minor, Date Client Name (Print)
Parent/Guardian’ Signature) Reviewed at initial meeting: _________
Forms05\HIPPAtx\AHPPrivNoticeSep13
Associates in Health Psychology, LLC
Notice of Privacy Policies & Practices
Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
I. Uses and Disclosures for Treatment, Payment, and Healthcare Operations
We may use and disclose your protected health information (PHI) for treatment, payment, and healthcare operations with
your consent. To help clarify these terms, here are some definitions.
A. “PHI” refers to information in your health record that could identify you.
B. “Treatment, Payment and Health Care Operations”
– Treatment is providing, coordinating or managing your health care and other services related to your health
care. For example, we may use PHI to provide counseling to you. Or, we may disclose your PHI to other health care providers involved in your treatment, such as your family physician or another psychologist.
– Payment is obtaining reimbursement for your healthcare. For example, we will disclose your PHI to your
health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. – Health Care Operations are activities that relate to the performance and operation of our practice. Examples
of health care operations are quality assessment and improvement activities, business-related matters such as audits
and administrative services, and case management and care coordination.
C. “Use” applies only to activities within Associates in Health Psychology such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
D. “Disclosure” applies to activities outside of our practice, such as releasing, transferring, or providing access to
information about you to other parties.
II. Uses and Disclosures Requiring Your Authorization
AHP may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your
appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that
permits only specific disclosures.
A. Psychotherapy Notes: Notes recorded by your therapist documenting the contents of a counseling session with you
("Psychotherapy Notes") will be used only by your therapist and will not otherwise be used or disclosed without your
written authorization. Psychotherapy Notes are given a greater degree of protection than PHI.
B. Other Uses and Disclosures: Uses and disclosures other than those described in Section I. above will only be made
with your authorization. For example, you will need to sign an authorization form before AHP can send PHI to your life
insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in
writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the
authorization was obtained as a condition of obtaining insurance coverage; the law provides the insurer the right to contest
the claim under the policy.
III. Uses and Disclosures with Neither Consent nor Authorization
Your therapist may use or disclose PHI without your consent or authorization when required or permitted to do so by
law. The most common such disclosures are listed below.
A. Child Abuse: If a therapist knows or in good faith suspects child abuse or neglect, the therapist is required to report
such knowledge or suspicion to the appropriate authority.
B. Adult and Domestic Abuse: If a therapist has reasonable cause to believe that an adult person is infirm or incapacitated and in need of protective services, the therapist must report such information to the Delaware Department
of Health and Social Services.
C. Health Oversight Activities: If the Division of Professional Regulation is investigating our practice, we must
comply with any subpoenas issued by the Division.
D. Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for
information about your diagnosis and treatment and the records thereof, such information is privileged under state law,
and AHP will not release information without the written authorization of you or your legally appointed representative or
Forms05\HIPPAtx\AHPPrivNoticeSep13
a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is
court ordered. You will be informed in advance if this is the case.
E. Serious Threat to Health or Safety: If you communicate to your therapist an explicit and imminent threat to kill or
seriously injure a clearly identified victim or victims, or to commit a specific violent act or to destroy property under
circumstances which could easily lead to serious personal injury or death, and you have an apparent intent and ability to
carry out the threat, the therapist may disclose information in order to provide protection for the identified victim. If your therapist believes that there is an imminent risk that you will inflict serious physical harm on yourself, the therapist may
disclose information in order to protect you.
F. Privacy Rule Exceptions: When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law. This includes certain narrowly-
defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of
health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and
intelligence.
IV. Your Rights
A. Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket. You have the right to restrict
certain disclosures of PHI to a health plan when you pay out-of-pocket in full for AHP services.
B. Right to Request Other Restrictions: You have the right to request other restrictions on certain uses and disclosures of protected health information. However, AHP is not required to agree to your request.
C Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have
the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing a therapist.) On your request, we will
send your bills to another address.
D. Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in the AHP mental
health and billing records used to make decisions about you for as long as the PHI is maintained in the record. AHP may
deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. If you are
a parent or legal guardian of a minor, please note that certain portions of the minor's medical record will not be accessible to you. On your request, the AHP Privacy Officer will discuss with you the details of the request and denial process.
E. Right to Request Amendment: You have the right to request an amendment of PHI for as long as the PHI is
maintained in the record. Your request must be in writing, and it must explain why the information should be amended. AHP may deny your request under certain circumstances.
F. Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for purposes
other than treatment, payment or health care operations, excluding disclosures made to you or disclosures otherwise
authorized by you. On your request, the AHP Privacy Officer will discuss with you the details of the accounting process.
G. Right to Be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a
breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not
been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.
H. Right to a Paper Copy: You have the right to obtain a paper copy of the AHP Privacy Notice upon request to your
therapist or the office staff at any time.
I. Questions and Complaints: You may contact the AHP Privacy Officer at Associates in Health Psychology, LLC;
1521 Concord Pike, Suite 103, Wilmington, DE 19803 with questions or complaints. You may also file written
complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. AHP will
not retaliate against you if you file a complaint.
V. Effective Date and Changes to this Notice
A. Effective Date: The original version was effective on April 14, 2003. This Notice was revised February 8, 2010, and
revised again under the “Final Rule” effective September 23, 2013.
B. Changes to this Notice: AHP may change the terms of this Notice and the changes will apply retroactively to all
PHI we maintain. The revised notice will be available upon request, in our office and on our web site.
Forms05\HIPPAtx\AHPPrivNoticeSep13
Associates in Health Psychology, LLC
ACKNOWLEDGMENT OF RECEIPT OF
NOTICE OF PRIVACY POLICIES & PRACTICES
By my signature below I, , acknowledge that I received a copy of the
Notice of Privacy Policies & Practices for Associates in Health Psychology, LLC.
Signature of client (or personal representative) Date
If this acknowledgment is signed by a personal representative on behalf of the client, complete the following:
Personal Representative’s Name:
Relationship to Client:
For Office Use Only
I attempted to obtain written acknowledgment of receipt of our Notice of Privacy Policies & Practices, but
acknowledgment could not be obtained because:
Individual refused to sign
Communications barriers prohibited obtaining the acknowledgment
An emergency situation prevented us from obtaining acknowledgment
Other (Please Specify)
This form will be retained in your medical record.
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
CONSENT FOR THERAPY/EVALUATION
THE PROCESS OF THERAPY/EVALUATION Psychotherapy is not easily described in general statements.
It varies depending on the personalities of the therapist and client and the particular problems you bring
forward. There are many different methods that therapists at AHP may use to deal with the problems you hope
to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part.
In order for therapy to be most successful, you will have to work on things talked about in our sessions.
Psychotherapy can have benefits and risks. Since therapy sometimes involves discussing unpleasant aspects of
your life, you may at times experience uncomfortable feelings such as sadness, guilt, anger, frustration,
loneliness, and helplessness. At the same time, psychotherapy has been shown to have many positive benefits
for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and
significant reductions in feelings of distress. There are no guarantees of what you will experience, however.
Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal
relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions
about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a
decision that is positive for one family member is viewed quite negatively by another family member.
Sometimes change will be easy and swift, but it can also be slow and even frustrating.
The first one or two meetings will involve a discussion of your concerns and other important aspects of your
life. These meetings allow the therapist to get to know you and to have a context in which to understand your
goals. By the end of the evaluation, your therapist will be able to assess if he/she can be of benefit to you. If so,
your therapist will give you an initial plan of what your work together will include. During the course of
working together, your therapist may ask you for your feedback and views on your therapy, its progress or
about other aspects of the therapy. You are encouraged to respond openly and honestly. It is always
appropriate for you to ask questions about your therapy and your therapist’s view of your progress. All of the
therapists at AHP do their best to create an atmosphere in which you feel safe to disclose your true thoughts and
feelings.
We look forward to working with you to help you successfully face the challenges in your life. Your signature
below indicates that you have read this Consent and understand it.
________________________________________ _________________________________________
Client's Signature Client's Name (please print)
________________________________________ _________________________________________
Parent/Guardian's Signature if client is a minor Date
Forms19\Intake\ConsentTherapy&EvalApr14.doc
Associates in Health Psychology, LLC Newark & Wilmington __________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Adapted from The Paper Office Forms19/Intake/tConcernsFeb19
Concerns Your honest responses to the questions below will help me get to know you better.
Name: _____________________________________________________________ Date: _____________________
For each item on this list, please use the 0-to-3 rating to indicate how much it has concerned you during the past month. Draw a circle around the most appropriate number, using these definitions:
0 = Not at all 1 = A little concern 2 = More than a little 3 = A lot of concern
Aggression, violence 0 1 2 3
Alcohol use 0 1 2 3
Anger, hostility, arguing, irritability 0 1 2 3
Anxiety, nervousness, worry 0 1 2 3
Attention, distractibility, can’t concentrate 0 1 2 3
Career concerns, goals, and choices 0 1 2 3
Childhood issues (your own childhood) 0 1 2 3
Children, child management, child care, parenting/guardianship
0 1 2 3
Codependent, dysfunctional relationships 0 1 2 3
Conflicts with others 0 1 2 3
Confusion, disorganized thoughts 0 1 2 3
Decision making, indecision, mixed feelings, putting off decisions
0 1 2 3
Delusions (false ideas) 0 1 2 3
Dependence 0 1 2 3
Depression, low mood, sadness, crying 0 1 2 3
Divorce, separation, child custody 0 1 2 3
Drug use: prescription medications, over-the-counter medications, street drugs
0 1 2 3
Eating problems – overeating, under-eating, appetite issues, vomiting
0 1 2 3
Failure 0 1 2 3
Fatigue, tiredness, low energy 0 1 2 3
Fears, phobias 0 1 2 3
Financial or money troubles, debt, impulsive spending, low income
0 1 2 3
Friendships, lack of social support 0 1 2 3
Gambling 0 1 2 3
Grieving, death, other losses 0 1 2 3
Guilt, feeling guilty 0 1 2 3
Health, illness, medical concerns, physical problems, pain, nausea
0 1 2 3
Hopelessness 0 1 2 3
Inferiority feelings, lack of confidence 0 1 2 3
Impulsiveness, loss of control, outbursts 0 1 2 3
Irresponsibility, judgment problems, taking unnecessary risks
0 1 2 3
Jealousy, feeling jealous 0 1 2 3
Legal matters, charges, lawsuits 0 1 2 3
Loneliness, emptiness 0 1 2 3
Marital conflict, distance/coldness, infidelity/affairs, remarriage
0 1 2 3
Memory problems 0 1 2 3
Menstrual problems, PMS, menopause 0 1 2 3
Mood swings 0 1 2 3
Motivation, feeling lazy, lack of interest 0 1 2 3
Nervousness, restlessness, fidgeting 0 1 2 3
Obsessions and/or compulsions (thoughts or actions that repeat themselves)
0 1 2 3
Oversensitivity to rejection or criticism 0 1 2 3
Panic or anxiety attacks 0 1 2 3
Perfectionism 0 1 2 3
Pessimism 0 1 2 3
Relationship problems 0 1 2 3
School problems 0 1 2 3
Self-cutting, self-mutilation 0 1 2 3
Self-neglect, difficulty with self-care 0 1 2 3
Sexual issues, sexual orientation, gender identity issues
0 1 2 3
Shyness 0 1 2 3
Sleep problems – too much, too little, insomnia, nightmares
0 1 2 3
Stress, stress management, stress disorders, tension
0 1 2 3
Suicidal thoughts 0 1 2 3
Suspiciousness, problems trusting people 0 1 2 3
Temper problems, self-control, low frustration tolerance
0 1 2 3
Thoughts of death or dying 0 1 2 3
Threats, fear of being harmed 0 1 2 3
Traumatic experiences, re-living trauma 0 1 2 3
Urges to beat, injure, or harm someone 0 1 2 3
Urges to break or smash things 0 1 2 3
Weight and diet issues 0 1 2 3
Withdrawal, self-isolation 0 1 2 3
Work problems, employment, trouble keeping a job, workaholic/overworking
0 1 2 3
Other concerns:
0 1 2 3
Other concerns:
0 1 2 3
Associates in Health Psychology, LLC
Forms2019/PHQ9&GAD7 Jun19
Client Name: _________________________________________________ Date: __________________
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all Somewhat difficult Very difficult Extremely difficult
Over the past 2 weeks, how often have you been bothered by the following problems?
Not at all sure
Several days
Over half the days
Nearly every day
1. Feeling nervous, anxious, or on edge 0 1 2 3
2. Not being able to stop or control worrying 0 1 2 3
3. Worrying too much about different things 0 1 2 3
4. Trouble relaxing 0 1 2 3
5. Being so restless it’s hard to sit still 0 1 2 3
6. Becoming easily annoyed or irritable 0 1 2 3
7. Feeling afraid as if something awful might happen 0 1 2 3
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all Somewhat difficult Very difficult Extremely difficult
© 1999 Pfizer Inc. Depression Screening; Spitzer RL, et.al., Arch Intern. Med. 2006;166:1092-1097, A brief measure for assessing anxiety.
FOR OFFICE USE: PHQ-9: __________ GAD-7: _________ Administration number: _____
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Not at All
Several Days
More than Half the Days
Nearly Every Day
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed or hopeless 0 1 2 3
3. Trouble falling asleep, staying asleep, or sleeping too much 0 1
2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself--or that you're a failure or have let yourself or your family down
0 1 2 3
7. Trouble concentrating on things, such as reading the newspaper or watching television
0 1 2 3
8. Moving or speaking so slowly that other people could have noticed being so fidgety or restless that you have been moving around a lot more than usual
0 1 2 3
9. Thoughts that you would be better off dead or of hurting yourself in some way
0 1 2 3
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Not at All
Several Days
More than Half the Days
Nearly Every Day
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed or hopeless 0 1 2 3
3. Trouble falling asleep, staying asleep, or sleeping too much 0 1
2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
Associates in Health Psychology, LLC Newark & Wilmington ______________________________________________________________________________________________________________________________________________________________________________________________
Forms19/Intake/ClientSurveyApr12
Client Survey Name: ________________________________ Date: _______________
Part 1: We are interested in the goals you have for therapy. For each potential goal on
the list, please circle Yes or No to indicate whether this is one of your goals, and if it is, whether or not you are making progress toward this goal.
Therapy Goals Is this one of your goals?
Are you making progress toward this goal?
1. Improve relationships Yes No Yes No N/A
2. Increase self-esteem Yes No Yes No N/A
3. Decrease depression Yes No Yes No N/A
4. Improve school/work functioning Yes No Yes No N/A
5. Cope with anger/frustration Yes No Yes No N/A
6. Decrease stress/anxiety Yes No Yes No N/A
7. Improve family functioning Yes No Yes No N/A
8. Increase satisfaction in friendships Yes No Yes No N/A
9. Take better care of myself Yes No Yes No N/A
10. Change addictive behavior ___ Alcohol ___ Eating Disorder
___ Other:
Yes No Yes No N/A
11. Reduce self-destructive behavior Yes No Yes No N/A
12. Other:
Yes No Yes No N/A
What are the concerns or goals that you most want help with? _________________
___________________________________________________________________
___________________________________________________________________
Part 2: Please answer these questions about any current alcohol or drug use.
1. Have you ever felt you should cut down your drinking or drug use? Yes No
2. Have people annoyed you by criticizing your drinking or drug use? Yes No
3. Have you ever felt bad or guilty about your drinking or drug use? Yes No
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
Yes No
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
ASSIGNMENT OF INSURANCE BENEFITS
You must complete and sign this form in order for us to bill your insurance
company. We will also need to copy your insurance card and photo ID at your initial
meeting and any time there are changes to your policy. Please note that your
insurance will not cover missed sessions and you will be responsible for the fee.
It is the policy of Associates in Health Psychology to require 24 hours notice for a
missed session. You may leave a message for your therapist 24 hours a day, 7 days a
week.
I authorize release of all information necessary to process my insurance claims for services received from Associates in Health Psychology, LLC. I assign all medical
and/or mental health benefits to which I am entitled for these services to Associates in Health Psychology, LLC. This assignment will remain in effect until revoked by me in
writing. A photocopy of this assignment is to be considered as valid as the original.
I understand that I am responsible for knowing what my insurance policy covers, and
I am financially responsible for paying co-pays, deductibles, and any other balances not paid by my insurance, such as those listed in the AHP Office Policies. I have read this information and understand it.
Please print all responses:
Insurance Company covering client:
Insurance ID# for policy covering client:
Name of POLICY HOLDER (if not client):
POLICY HOLDER’S Date of Birth:
POLICY HOLDER’S relationship to Client: POLICY HOLDER’S Place of Employment:
Financially Responsible Party (if not Client): Include First Name, Middle Initial, and Last Name
___________________________________ ____________________________
Client’s Name (please print) Client’s Date of Birth
___________________________________ ____________________________
Signature of Financially Responsible Party Date
Forms19\Intake\InsurAssignmentApril19.doc
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
Health Insurance and Managed Care Release
I have agreed to see you under the terms set by the health insurance/managed care company which oversees your
mental health benefits. Managed care means that an outside company selects approved therapists and determines
both the need for treatment and the length of time treatment will be provided. The following paragraphs outline
some of the general aspects of managed care contracts you should know about.
1) The managed care company may require regular and somewhat detailed reports regarding your symptoms,
diagnosis and treatment. There are no restrictions on the type or amount of information they may require. I will be
glad to discuss the content of these reports with you. Although my experience is that the information provided has
been treated with an appropriate degree of confidentiality, I cannot be responsible in any way for the health
insurance/managed care company's use or re-disclosure of the information provided to them.
2) In some instances, the managed care company must approve all sessions in advance. Each company has its own
criteria regarding what it considers as a "medical need" for therapy, which may differ from your and my assessment
of your need for therapy. I will take responsibility for the timely filing of requests for additional sessions, and I will
notify you of the outcome of these requests. However, provided I have met my responsibilities as stated above, you
will be financially responsible for direct payment of any charges which are not paid by your insurance.
3) At times, the managed care company may provide us with information concerning your previous mental health
history. This may include information on symptoms, diagnosis, and/or treatment. If you have ever had any
treatment that included substance abuse issues, provide the name(s) of the treatment facility and/or provider(s)
and the dates of treatment. Your initials below give me permission to obtain more information about your prior
substance abuse issues and/or related treatment from your managed care company, which in turn will help me to
support you more fully. Not applicable _____
Prior Treatment Facility & or Provider Name(s) and Address:____________________________________________
______________________________Dates of Treatment: Client Initials: ____________
Prior Treatment Facility & or Provider Name(s) and Address:____________________________________________
______________________________Dates of Treatment: Client Initials: ____________
4) As explained in our Office Policies, it is our practice to charge for all canceled sessions if at least 24-hours notice
is not provided. Monday appointments must be canceled by the previous Friday. Please note that you can leave a
message for me 24 hours a day, 7 days a week. Insurance companies will not pay for missed sessions. Therefore,
you will be responsible for the full fee. You are also responsible for any co-payments and deductibles not covered
by your insurance. You may find out what these are by asking your insurance company or I will have information
available by your next appointment.
I will be glad to answer any questions you may have. Please sign this form indicating that you have read this
information and authorize release of information to your managed care company. This release will expire 3 months
beyond the period of time that you are in treatment with a behavioral health therapist at Associates in Health
Psychology, LLC.
_______________________________________________ _____________________
Client Signature Date
____________________________________
Parent/Guardian Signature if client is a minor forms19\intake\ins managcare release jun13.doc
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
CO-PAYS, CO-INSURANCES, and DEDUCTIBLES
Due to policy provisions in your contract with your insurance carrier, at each visit we are obligated to collect your co-pay, co-insurance, and/or deductible. Payment is expected at the time of the visit. If your insurance policy has provisions such as deductibles, co-insurances, or co-payments, please note that these provisions have been agreed to between you and your carrier. We cannot legally discount fees submitted for services submitted for insurance reimbursement. If our office had verified that your therapist has contracted with your mental health insurance plan, we have additional contractual obligations to collect the balances as outlined by your insurance company. Your out-of-pocket maximum will not be calculated correctly if we do not collect what your insurance company expects us to collect. Furthermore, Associates in Health Psychology’s contract with your carrier will be jeopardized if we do not collect your co-insurance, co-payment, and/or deductible. Additionally, for those Medicare clients who receive services eligible under Medicare, the terms of the anti-kickback laws obligate us to collect the co-insurance, co-payment, and/or deductible. We sincerely regret any inconvenience which might be caused by these regulatory or contractual provisions, but we must be bound by all provisions of insurance policy and federal law. Associates in Health Psychology will be happy to assist you in resolving any issues or concerns regarding your insurance. Please feel free to contact us with any questions you may have.
forms19\intake\co-pays deductibles Jun19.doc
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
AUTHORIZATION to RELEASE INFORMATION to
PRIMARY CARE PROVIDER
This form, when completed and signed by you, authorizes AHP to release and obtain protected information from your clinical record to the person you designate below.
I, ___________________________________________________________, authorize _____________________________,
a therapist at Associates in Health Psychology (AHP), LLC, and/or their office staff, to release and/or obtain information in
medical records for myself (DOB: ______/______/_________) OR
for a minor child (Child’s name: ___________________________________________ DOB: ______/______/_________).
This release of information pertains to only the following person (circle and provide contact information):
Primary Care Provider Psychiatrist Medical Specialist Therapist Teacher Other: _____________________
Name: ________________________________________________ Phone: ___________________
Address: _________________________________________________ Fax: ___________________
The purpose of this release is (circle one): Coordination of Care Evaluation Results Background Information
At the request of the Client/Parent/Guardian Other: _____________________________________
This information may include diagnoses, treatment information and other notations; substance abuse information; and
information on AIDS/HIV status.
You have the right to revoke this authorization, in writing, at any time by sending such written notification to the AHP
office address. However, your revocation will not be effective to the extent that AHP has taken action in reliance on the
authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal
right to contest a claim. This consent, if not withdrawn, will be valid for the duration of treatment and billing requirements.
I am aware of my right to confidential communications under psychologist-patient privilege.
I understand that the information used or disclosed pursuant to the Authorization may be subject to redisclosure by the
recipient and no longer protected by HIPAA Privacy Rule. However, any disclosure of information that pertains to the
treatment or diagnosis of drug abuse or alcohol abuse or a referral for such treatment or diagnosis, and which would
identify a patient as an alcohol or drug abuser, permitted hereunder shall be accompanied by the following written
statement: “This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR
part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is
expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A
general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules
restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.”
I understand that my signing this authorization is not required for obtaining psychological services unless these services are
being provided for the purpose of creating health information for a third party.
Any facsimile, copy, or photocopy of this Authorization shall have the same effect as the original.
___I do not have a PCP ___I do not want information sent to my PCP
_____________________________________________ _________________________
Signature of Client or Parent/Guardian Date
Forms19\Release\PCPReleaseJul19
J-25 Omega Drive, Newark, DE 19713 • 1521 Concord Pike, Suite 103, Wilmington, DE 19803
(302) 428-0205 • Fax: (302) 428-1123 • www.AHPDelaware.com
AUTHORIZATION TO RELEASE INFORMATION
This form when completed and signed by you, authorizes me to release and obtain protected information from your clinical record to the person you designate below.
I, ___________________________________, authorize __________________________________, a therapist at
Associates in Health Psychology, LLC, to release and/or obtain protected information in medical records for myself
(DOB: ___/___/_____) OR
for a minor child (Child’s name: ______________________________ DOB: ___/___/______).
This release of information pertains to only the following person (circle and provide contact information):
Primary Care Provider Psychiatrist Medical Specialist Therapist Teacher Other: __________________
Name: ________________________________________________ Phone: __________________
Address: _________________________________________________ Fax: __________________
The purpose of this release is (circle one): Coordination of care Evaluation Results Background Information
At the request of the client/parent/guardian Other: ____________________________________________
This information may include diagnoses, treatment information and other notations; substance abuse information; and
information on AIDS/HIV status.
You have the right to revoke this authorization, in writing, at any time by sending such written notification to the AHP
office address. However, your revocation will not be effective to the extent that AHP has taken action in reliance on the
authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a
legal right to contest a claim. This consent, if not withdrawn, will be valid for the duration of treatment and billing
requirements.
I am aware of my right to confidential communications under psychologist-patient privilege.
I understand that the information used or disclosed pursuant to the Authorization may be subject to redisclosure by the
recipient and no longer protected by HIPAA Privacy Rule. However, any disclosure of information that pertains to the
treatment or diagnosis of drug abuse or alcohol abuse or a referral for such treatment or diagnosis, and which would
identify a patient as an alcohol or drug abuser, permitted hereunder shall be accompanied by the following written
statement: “This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR
part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure
is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part
2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal
rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.”
I understand that my therapist generally may not condition psychological services upon my signing an authorization
unless the services are provided for the purpose of creating health information for a third party.
Any facsimile, copy, or photocopy of this Authorization shall have the same effect as the original.
_______________________________________________ ______________________
Signature of Client or Parent/Guardian Date
Release\ReleaseOct16.doc