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Click here or scroll down to respond to this candidateWelcome to the Center for Psychology and Wellness (CPW)!Please complete the attached registration packet and view our website to be aware of all the services offered to improve your health.Please take time to read the information in this packet and sign where necessary. Do not hesitate to ask your provider or contact the office manager with any questions that you may have (Street Address -607-1589 or EMAIL AVAILABLE).We look forward to working closely with you on making changes that you and/or your family members hope to make through therapy. We are deeply committed to providing you with the highest quality comprehensive behavioral health services for children, adolescents, adults, couples, and families. We utilize a variety of evidence-based therapeutic approaches and services to help you successfully adapt and balance lifes stressors and challenges as you move toward a fuller and richer life. We thank you for placing your confidence in us and look forward to meeting with you. We have found that those who experience the most successful outcomes have: 1. Clearly defined goals about what they hope to achieve. Usually this is done during the first or second session and revised as necessary.2. Formed an effective working relationship with their doctor. Be sure to talk over any concerns or questions you have about the therapy process with your doctor. 3. Kept appointments as scheduled because each visit builds on the ones before. 4. Done any recommended homework between sessions. In many ways, what you do at home, work, or school can have a profound effect on your progress. 5. Have discussed expectations that may exceed the scope of private practice behavioral health services.CLIENT INFORMATIONCLIENT NAME: PATRICK GREEN DOB: __11/30/1959 AGE:__61 Gender: _X__M F Preferred Pronoun: __SI NGLE MARITAL STATUS: SINGLEADDRESS: 1501 W BELMONT AVENUE APT 509 CHICAGO, IL 60657 PREFFERED TEL: _PHONE NUMBER AVAILABLE MAY WE LEAVE A MESSAGE: _X__Y N ALTERNATE TEL: EMAIL:EMAIL AVAILABLEOur system generates automatic reminder text messages to your preferred phone number unless you decide not to receive them. Please initial here if you choose to not receive an appointment reminder: How did you hear from us? website insurance friend/relative school physician other: THRESHOLDSEMERGENCY CONTACT: WILLA COLEMANRELATIONSHIP TO CLIENT: friendCONTACT TEL:PHONE NUMBER AVAILABLEI understand that in an emergency, CPW will only disclose information related to my emergency: PG (initial) Health Insurance: United Healthcare Member ID:PHONE NUMBER AVAILABLE Group # 69552 Subscriber Information: Self _x__ Parent Spouse Other Subscriber Name (if different than client): DOB: FOR MINORS ONLYNAME OF PARENT/GUARDIAN: PARENT/GUARDIAN TEL: _ RELATIONSHIP: THE MINOR RESIDES WITH: SCHOOL: GRADE: www.cpwtherapy.comHISTORY OF CONCERNSWhat concerns/symptoms brought you here:Abuse: physical, sexual, emotional, neglect (of children or elderly persons) Aggression, violence Anger, hostility, arguing, irritability Alcohol use Attention, concentration, and distractibility Anxiety, worry, nervousness Career concerns, goals, and choices Childhood problems (your own childhood) Codependence Confusion CompulsionsCustody of Children Decision making problems, indecision Delusions Dependence Depression, low mood, sadness, crying Divorce, separation Drug use (prescription meds, street drugs, etc.) Eating problems Emptiness FailureFatigue, tired, decreased energy Financial problems, impulsive spending Fears, phobias Friendship issuesGambling Grieving, mourningGuilt Headaches, other physical pain Inferiority feelings Interpersonal problems, relationship issues Impulsiveness, loss of control, outbursts Irresponsibility Judgment problems, risk taking LonelinessMarital conflict, infidelity, remarriage, etc. Memory problems Mood swings Motivation, lazinessObsessions, compulsions, repetitiveness Oversensitivity to rejection Panic attacks Parenting stressPerfectionism PessimismProcrastination, scheduling problems Relationship problems (friends/family/peers) School problems Self-care problemsSelf-esteem, self-worth Sex, sexualityShyness, oversensitivity to criticism Social Phobia, social anxiety Sleep problems(too much, too little, insomnia ) NightmaresSpiritual, religious, moral, ethical dilemmas Suspiciousness Suicidal thoughts Stress, relaxation, stress management Temper problems, low frustration tolerance Thought disorganization and confusion Weight and diet issues Withdrawal, isolationOther:When did your concerns first begin and how often do they occur? About 10 years ago or more When are they better and worse? Worse when Im addressing a lot of issues, too much on my plate. What significant changes have happened to you or your family in the last six months? My personal stuff, I like the 1-1 at first and maybe get in some groupsWhat have you already tried to resolve these problems/concerns/symptoms? Thresholds www.cpwtherapy.comMEDICAL HISTORYPRIMARY CARE PHYSICIAN: PSYCHIATRIST: NAME: Dr. Rouch, internal medicine doc at Rush NAME: PHONE: _PHONE NUMBER AVAILABLE PHONE: _ *Note: CPW does not contact these providers unless we have signed consent for disclosure provided by the patient* Have you ever been hospitalized or had outpatient therapy for mental health or substance abuse? __x_Yes No ; If yes, please specify most recent: Where: outpatient treatment for 15 years, detox a couple times at Haymarket When:2-4 years ago Please list any medications/dosages you are taking (including supplements): Substance Use: Never Occasionally Sometimes Frequently Daily Tranquilizers xMarijuana xCocaine xOpioids xSteroids xStimulants xHallucinogens xCigarettes xAlcohol xSleeping Pills xOther:Medical History: Self Family Member Outpatient Treatment Hospitalization Other Developmental DelaysHypo/Hyper ThyroidBlood PressureStrokeCancerOther:www.cpwtherapy.comConsent to the Use & Disclosure of Health Information for Treatment/Payment/Healthcare Operations I, _Patrick Green, understand that as part of my/my minors healthcare, the Center for Psychology and Wellness, P.C. originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and plans for future care or treatment. I agree to assume financial responsibility for all outstanding balances not covered by the disclosure of services to insurance policy. I understand and have been provided with a Notice of Privacy Practicesthat includes the Health Insurance Portability and Accountability Act (HIPAA) that provides a more complete description of information uses and disclosures. I do hereby consent and acknowledge my agreement to the terms set forth in the HIPPA information form. I understand that this consent shall remain enforced from this time forward. I understand that I have the following rights and privileges: the right to review the notice prior to signing this consent & the right to request restrictions as to how my/my minors health information may be used or disclosed to carry out treatment, payment, or healthcare operations. I understand that the Center for Psychology and Wellness, P.C. of Northbrook is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing to CPW Therapy, 601 Skokie Blvd Suite 402, Northbrook IL 60062, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this practice may refuse to treat me/my minor. I further understand that the Center for Psychology and Wellness, P.C. reserves the right to change their notice and practices. Prior to implementation, the Center for Psychology and Wellness, P.C. will send a copy of the revised notice to the address/contact information I have provided. TELEHEALTH: Confidentiality still applies for telepsychology services, and nobody will record the session without the permission from the others person(s). We both agree to use the video-conferencing platform selected for our virtual sessions, and the provider will explain how to use it. You need to use a webcam or smartphone during the session. It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. It is important to use a secure internet connection rather than public/free Wi-Fi. There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions. Informed consent for all parties involved or present during the telehealth session is required, whether it is consent from the parent of a minor or someone helping set up the technology equipment during the telehealth session. It is important to be on time for the telehealth appointment. If you need to cancel or change your tele-appointment, you must notify the provider in advance by phone or email. We need to agree on a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. We need to agree on a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis situation. If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions. If services continue at CPW beyond the first 4 free telehealth sessions due to COVID-19 and choose to use your insurance, you should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for your patient responsibility. As your provider, I may determine that due to certain circumstances, telepsychology is no longer appropriate and recommend that we should complete sessions in-person or refer you for services to another provider and agency. You have the right to choose your treatment modality, although the provider may not be able to accommodate in-person sessions due to concerns of health and safety for all parties involved. I wish to have the following restrictions to the use of disclosure of my/my ward/my minors health information (list): . I understand that as part of this organizations treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity. Your provider may be required by law to release information without your permission to specific professionals and authorities if there is a serious and specific threat of imminent harm to self or others, there is reasonable cause to believe a child or elder adult has been abused or neglected, and in some judicial and administrative proceedings (e.g. court proceedings, court orders, lawsuits). This disclosure may occur via phone and/or fax. I agree to the above confidentiality, general policies of CPW, and consent to disclosure for permitted uses. I fully understand and accept the terms of this consent. Signature of client or parent/guardian of minor (under 18) Date Signature of child client (12 years and older) *preteens have consenting rights too! Date Printed name of client or his/her parent/guardian of minor (under 18) Date www.cpwtherapy.comAGREEMENT FOR SERVICESPayment TermsWe believe that part of a healthy working alliance involves staying current with your account. Therefore, payments are due at the time of service. Future appointments will be scheduled if your account is current. If your insurance carrier changes, you are required to contact CPW with the updated information, as this may result in a change in your session fee. Your insurance company requires you to provide your insurance cards and photo ID to avoid insurance fraud. For convenience, we require that you keep a credit card on file with us, which will be charged if payment is not received from client via other applicable payment options at time of service. There is a 3% processing fee for each credit card payment. To help you avoid the 3% processing fee, we also accept Zelle for all telehealth and in-office sessions. Check and cash payments are only an option for in-office sessions (not an option for telehealth). Your credit card will be charged if payment is not rendered at the time of service and you have an outstanding balance. Accounts that are sixty (60) days past due may be turned over to a collection agency; the client is responsible for all collection and legal fees.Missed appointment or Late Cancellation Fees24 hour notice for all missed therapy appointments is required. If you reschedule the appointment during the same week, you will not be charged for the missed appointment. However, if you do not then there is a $100.00 fee for the missed therapy appointment. Testing appointments that are missed or cancelled without prior 24-hour notice will be charged at $150.00 to the client. These fees will be included in the outstanding balance amount. Emergencies are of course an exception. There will be a $30.00 charge for returned checks. Missed session charges must be paid before a new appointment can be scheduled.Other ChargesIf a textbook or therapy material is lent to the client and not returned, one reminder notice will be sent to the client. If lent materials are not returned after that, the cost of the lent material is the clients responsibility. If the client does not provide payment for the lent material, the cost of the material will be charged to the clients credit card on file. Minors Attending Sessions Alone and Joint Custody Accounts If minors attend sessions unaccompanied by their parent, we ask you to send payment with them at the time of service, or the session fee will be charged on the credit card on file for any outstanding balance. Consent to Treat I do hereby seek and consent to take part in, or have my ward/minor take part in, treatment at the Center for Psychology and Wellness. I understand that developing a treatment plan and regularly reviewing our work toward meeting treatment goals are in mine and my minors best interest. I understand that no promises have been made to me as to the result of treatment on any of the procedures provided at the Center for Psychology and Wellness, P.C. I fully understand and accept the terms of this consent. Patrick Green 4/7/21 Signature of client or parent/guardian of ward/minor Date Printed name of client or his/her parent/guardian of ward/minor Date www.cpwtherapy.comCLIENT PAYMENT INFORMATION & FINANCIAL RESPONSBILITY AGREEMENT There this NO extra charge for payments made via Zelle, Cash, or Check. Check and cash payments are only an option for in-office sessions (not an option for telehealth). We require that you keep a credit card on file with us, which will be charged if payment is not received from you via other applicable payment options at time of service. There is a 3% processing fee for each credit card payment. To help you avoid the 3% processing fee, we also accept Zelle for all telehealth and in-office sessions. Your credit card will be charged if payment is not rendered at the time of service and you accumulate an outstanding patient balance, according to the signed Agreement for Services.Clients Name: Name on Card: Type of Card: Visa MC Disc AmEx Exp. Date: / Card Number: CVV: Address: City/State/Zip: Preferred Phone Number of Account Holder: _ I understand that if a full payment is not rendered at the time or services, or there is an outstanding balance, (e.g. late cancellation, missed session, or unpaid deductible amount) my credit/debit card will be charged. I agree to assume financial responsibility for all outstanding balances not covered by the insurance policy. Please charge my card for ongoing services: Yes No I prefer to pay by Zelle: Yes No* Send Zelle Payments to: EMAIL AVAILABLEFor in-office appointments ONLY:I prefer to pay by check: Yes NoI prefer to pay by cash: Yes NoSignature of Responsible Party: Date: Printed name of Responsible Party: Relationship to patient: www.cpwtherapy.comINFORMED CONSENT FOR IN-PERSON SERVICES DURING COVID-19 PUBLIC HEALTH CRISIS This document contains important information about our decision (yours and mine) to resume in-person services during COVID-19 public health crisis. When you sign this document, it will be an official agreement between us. Decision to Meet Face-to-FaceWe have agreed to meet in person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyones well-being. If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss. Risks of Opting for In-Person ServicesYou understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). This risk may increase if you travel by public transportation, cab, or ridesharing service. Your Responsibility to Minimize Your ExposureTo obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, and our families, [my other staff] and other patients) safer from exposure, sickness and possible death. If you do not adhere to these safeguards, it may result in our starting / returning to a telehealth arrangement. Initial each to indicate that you understand and agree to these actions: You will only keep your in-person appointment if you are symptom free. You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, I wont charge you our normal cancellation fee. You will wait in your car or outside [or in a designated safer waiting area] until no earlier than 5 minutes before our appointment time. You will wash your hands or use alcohol-based hand sanitizer when you enter the building. You will adhere to the safe distancing precautions we have set up in the waiting room and testing/therapy room. For example, you wont move chairs or sit where we have signs asking you not to site. You will wear a mask in the office upon arrival and will discuss expectations for wearing it with therapist. You will keep a safe distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me [or staff]. You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands. If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols. You will take steps between appointments to minimize your exposure to COVID. If you have a job that exposes you to other people who are infected, you will immediately let me [and my staff] know. If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me [and my staff] know. If a resident of your home tests positive for the infection, you will immediately let me [and my staff] know and we will then [begin] resume treatment via telehealth. I may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes. www.cpwtherapy.comMy Commitment to Minimize ExposureMy practice has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Please let me know if you have questions about these efforts. If You or I Are SickYou understand that I am committed to keeping you, me, [my staff] and all of our families safe from the spread of this virus. If you show up for an appointment and I [or my office staff] believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate.If I [or my staff] test positive for the coronavirus, I will notify you so that you can take appropriate precautions. Your Confidentiality in the Case of InfectionIf you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form, you are agreeing that I may do so without an additional signed release.CPW Travel, Exposure/Possible Exposure, and Quarantine/Self-Isolation Policy If a client or staff/therapist at CPW has recently travelled, been exposed, or have the awareness that they have possible been exposed to COVID-19, then CPW requires that the client and staff/therapists self-isolate/quarantine for a minimum of 5 days after their most recent exposure/possible exposure. CPW requires that clients get tested on the 5th to 7th day of their most recent exposure/possible exposure and provide negative test results to CPW before returning to in-office sessions. If the client or staff/therapist chooses not to get tested, then CPW requires that they self-isolate/quarantine for a minimum of 10 days before completing a screening with CPW to possibly return to the in office sessions upon successful completion of the screening process. CPW requires that clients and staff/therapists adhere to CDC and any additional CPW guidelines for in-office visits. CPW requires telehealth visits for all that have been exposed, have possible been exposed, or live with someone who has frequent exposure to COVID-19. If in person or higher level of care is required for a client that has been exposed, has possibly been exposed, or lives with someone who has frequent exposure to COVID-19, then services outside of CPW will be required and recommended. This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.Your signature below shows that you agree to these terms and conditions. Patrick Green 4/7/21 Patient/Client DateCenter for Psychology & Wellness, P.C. same as above Psychologist/Therapist/Provider Datewww.cpwtherapy.com |
