INTENSIVE TREATMENT PROGRAM What is The Ross Center's Intensive Treatment Program? The Ross Center's Intensive Treatment Program is a five day accelerated individualized program designed to provide effective, cost-efficient therapy to people seeking help for an anxiety disorder who live outside of the metropolitan Washington, D.C. area. Participants are given all of the same information, tools and techniques, therapeutic experiences and practice assignments that they would receive if they were in treatment at The Ross Center on a weekly basis. What are the components of the Intensive Treatment Program? The basic Intensive Treatment Program includes: a one-hour private consultation with our medical director; sixteen private forty-five (45) minute therapy sessions over a five-day period with one of the center's cognitive-behavioral therapists; and three fifteen (15) minute telephone follow-up sessions with the therapist upon returning home. Additional 45-minute therapy sessions and/or additional consultation sessions with a psychiatrist can be arranged for additional charges. The Intensive Treatment Program, like the regular program, is experiential and proactive. Participants are actively engaged in the recovery process during their entire stay. A major component of the program involves written and practical homework assignments, individually designed to reinforce the specific coping strategies and techniques learned during the therapy sessions. The Ross Center is an outpatient facility. Participants enrolled in the Intensive Treatment Program will be given a list of nearby hotels, in various price categories, where they can stay during their treatment. Therapy sessions may take place either in the office or in "real life" anxiety provoking situations, depending upon the nature of the individual's problem. Who will benefit from the Intensive Treatment Program? The Intensive Treatment Program is designed for people suffering from panic disorder (with or without agoraphobia), specific phobias (i.e. driving, animals/insects, and heights), social phobia, obsessive compulsive disorder and generalized anxiety. Individuals who have previously attempted to get treatment, are currently in therapy, or have never been treated for an anxiety disorder should benefit from the program. 2 The Intensive Treatment Program is not recommended for people with active substance abuse problems or certain other serious illnesses. The Ross Center reserves the right to accept only those people into the program whom they believe will most benefit from the treatment. This judgement is based on a careful review of the application and telephone conversations with the applicant and, when relevant, other involved persons, such as family members, therapists or physicians. Potential patients must read and sign a form indicating they understand the program and have ben informed about its components prior to acceptance into the Program. Can family members participate in the Intensive Treatment Program? Family members are welcome to participate in the program to the extent that is in the best interest of the patient. In some cases it is helpful for a family member to actually sit in during one or more therapy sessions, while in others it is best that the patient be seen alone. In almost all instances, however, accompanying family members can play a major role in helping patients practice and reinforce what they are learning while undergoing treatment, and upon returning home. What happens after I return home? The Intensive Treatment Program leaves participants with a strong, solid base that continues to expand as they put their newfound skills to work in their home environment. Prior to completing the program, they are given follow-up assignments, directions for practical applications of what they have learned, and detailed instructions for continued and ongoing practice at home. Armed with an array of specific tools, techniques and anxiety management skills, patients leave the fiveday program energized and highly motivated to continue the momentum of their recovery. The Ross Center staff are available by phone to program participants while they are actively engaged in the program as well as after completion of the program. It is suggested that individuals begin to use their three (3) fifteen-minute phone sessions, which are included in the program, a week or two after they have returned home. In addition, therapists will provide ongoing support, as needed and appropriate, via telephone, prorated at the regular forty-five minute session rate. Can I still participate in the Intensive Treatment Program if I live in the Washington, D.C. area? Yes. Some people find that a short, accelerated program best fits their needs. Individuals with busy work/travel schedules, for example, may find it more convenient to immerse themselves in intensive treatment rather than to try to schedule weekly therapy sessions. The Intensive Treatment Program is as inclusive and therapeutically effective as the regular program, so local patients who prefer to take advantage of it are most welcome. INTENSIVE TREATMENT PROGRAM – APPLICATION NAME: _______________________________________________________________________________________________ ADDRESS: _______________________________________________________________________________________________ PHONE: DAY: __________________________ EVENING: ___________________________ CELL: __________________________ AGE: ________ DATE OF BIRTH: _________________ E-MAIL ADDRESS: ____________________________________________ IN CASE OF EMERGENCY, PLEASE NOTIFY NAME: _______________________________________________________RELATIONSHIP:________________________________ ADDRESS: _______________________________________________________________________________________________ PHONE: DAY: __________________________ EVENING: ___________________________ CELL: __________________________ PRIMARY CARE PHYSICIAN NAME: _______________________________________________________________________________________________ ADDRESS: _______________________________________________________________________________________________ PHONE: _____________________________ PLEASE INDICATE BELOW THE CURRENT OR MOST RECENT MENTAL HEALTH PROFESSIONAL FROM WHOM YOU HAVE RECEIVED TREATMENT. PLEASE LIST ANY ADDITIONAL MENTAL HEALTH THERAPY ON REVERSE. NAME: _______________________________________________________________________________________________ ADDRESS: _______________________________________________________________________________________________ PHONE: _____________________________ DIAGNOSIS AND APPROXIMATE DATES OF TREATMENT _______________________________________________________________________________________________ _______________________________________________________________________________________________ PLEASE INCLUDE COPIES OF ANY RELEVANT MEDICAL/PSYCHIATRIC RECORDS PLEASE LIST SEVERAL PREFERRED DATES FOR THE WEEKLY TREATMENT - (BEGIN ON A MONDAY): Screening Questionnaire For Anxiety And Affective Disorders Name ___________________________________________ Today's Date _____________ Address _____________________________________________________________________ ____________________________________________________________________________ Phone: Home ( ) _____________________ Date Of Birth ______________ Age _______ Work ( Sex M __ ) _____________________ F __ Marital Status ________________No. of Children_______Education______________________ Occupation_____________________Employed by_____________________________________ 1. Do you have many problems with anxiety generally? If yes, please describe briefly: YES _____ NO _____ 2. Please answer the following statements regarding anxiety as they apply to you: a) I am anxious most of the time. If yes, the degree of my anxiety is: YES _____ NO _____ MILD ___ MODERATE ____ SEVERE ____ b) I am generally not anxious, but certain situations are anxiety provoking to me. If yes, please describe situations: YES _____ NO _____ 5 c) My anxiety fluctuates without obvious relationship to environmental conditions or situations. YES, unrelated to environment ___ NO ____ d) My anxiety: 1.) Impairs my daily functioning YES _____ NO ____ 2.) Makes it difficult for me to cope with work and/or everyday life pressures YES _____ NO ____ 3.) Makes it impossible for me to cope with work and/or everyday life pressures YES _____ NO ____ e) Sometimes I have attacks of extreme anxiety that last less than two hours 3. Do you fear and avoid certain situations? YES _____ NO ____ YES _____ NO ____ 4. If yes, which of the following do you avoid? ____Planes ____Metro-subway ____Other Public Transportation ____Driving a car ____Riding with others ____Elevators ____Being alone in unfamiliar places ____Eating in a restaurant ____Movie theatres and other crowded places ____Shopping Malls ____Leaving your home alone ____Staying at home alone ____Public speaking ____Talking to strangers ____Eating in public ____Attending social gatherings ____Talking to authority figures ____Other (specify) 5. Do you think you have ever had a panic attack? YES _____ NO _____ 6. Did a professional ever tell you that you have "anxiety attacks?" YES _____ NO _____ 7. Did a professional ever tell you that you have panic disorder? YES _____ NO _____ 8. Have you ever had a sudden attack of extreme anxiety for no apparent reason? YES _____ NO _____ 9. Have you ever awakened from sleep with a sudden attack of extreme anxiety? YES _____ NO _____ 10. Have you ever visited an emergency room for symptoms such as chest pain, breathing difficulty, palpitations, etc, for which there was no medical explanation? YES _____ NO _____ 6 11. If you answered "No" to all of numbers 5-10 above, please skip to number 14 below; Otherwise, please answer all of the following: a.) When was your first anxiety attack? Mo/yr. _________ Your age ______ b.) When was your last anxiety attack? Mo/yr. _________ Your age ______ c.) How long do your panic or anxiety attacks last? ____ ____ ____ ____ a few seconds a few minutes half-hour 1 hour ____ 1-2 hours ____ 2 or more hours ____ continuous d.) What is the frequency of your panic or anxiety attacks? ____ ____ ____ ____ always feel panicky several times daily once daily several times a week ____ once a week ____ several times a month ____ once a month ____ every few months e.) If the frequency and/or pattern has changed over time, please describe: 7 f.) Check for the frequency and severity of the following symptoms during a typical panic or anxiety attack: Frequency Always Most times Rarely Severity Never Mild Moderate Severe Shortness of breath or trouble breathing Pounding heart Skipped heartbeats Numbness around mouth Tingling in hands or feet Chest pain or tightness in chest Trembling or shaking Nausea or upset stomach Choking sensation Dizziness, or feeling faint or lightheaded Diarrhea Sweating Hot or cold flashes Headache Fear of dying Fear of going crazy Fear of becoming immobilized Bad taste in mouth Smell unusual odors Feeling that things don't seem real Feeling that things change their shape or size 12. Do your panic attacks tend to occur: a.) __ for no apparent reason, that is "out of the blue" b.) __ only in particular situations. Please describe: c.) __ sometimes for no apparent reason, but seem to occur more commonly in certain situations. Please describe: 8 13. Describe in your own words a typical panic attack as you experience it: 14. Do you tend to become extremely anxious in social situations where you feel you might be observed or evaluated by others, or where you feel that you are the center of attention? YES_____NO_____ Please describe: 15. When dealing with other people, do you become overly concerned that you may say or do something that might embarrass or humiliate yourself, or that others will think badly of you? YES_____NO_____ Please describe: 16. Have you ever been depressed for more than: One week Two weeks YES_____NO_____ YES_____NO_____ 17. If yes, give dates and duration: Date(s) of onset(s): Duration: ________________________ _______________________ ________________________ _______________________ ________________________ _______________________ ________________________ _______________________ 9 18. Have you ever been hospitalized for depression? If so, when? YES ______ NO ______ Dates: __________________ to ________________________ Where: _______________________________________________________ Dates: _________________ to _________________________ Where: _______________________________________________________ 19. Which of the following symptoms did you experience while being depressed? a.) b.) c.) d.) e.) f.) g.) h.) I had a very low mood or felt sad YES _______ NO I had low energy YES _______ NO lost interest in my work and/or usual activities YES _______ NO I was unable to enjoy things as I used to YES _______ NO I lost weight YES _______ NO I gained weight YES _______ NO I had suicidal thoughts YES _______ NO My mood during the day fluctuated and was generally better in the Morning ___ Evening ___ _______ _______ _______ _______ _______ _______ _______ No Change ___ i.) I had difficulty falling asleep j.) I woke up much earlier than usual k.) I slept more than usual YES _______ NO _______ YES _______ NO _______ YES _______ NO _______ 20. Have you ever been hospitalized in a psychiatric ward for any other reason? YES ______ NO _______ Dates: __________________ to ________________________ Where: _______________________________________________________ Reason? ____________________________________________________ Dates: _________________ to _________________________ Where: _______________________________________________________ Reason? ______________________________________________________ 10 21. Are you depressed now? YES _______ NO _________ If yes, for how long? _________________________________ 22. Have you ever attempted suicide? No, never ____ Yes, once _____ Yes, more than once ____ 23. Have you ever been diagnosed as having mitral valve prolapse? YES ____ NO _____ 24. Do you have any other medical problems? YES ____ NO _____ If yes, fill in the table below: Date Diagnosis Description 11 25. Do you drink coffee now? If yes, how many cups daily? YES _______ NO ________ _______ 26. Do you drink sodas containing caffeine now? If yes, how many ounces a day? _______ YES _______ NO ________ 27. Did you change your caffeine consumption habits (of coffee, tea, or sodas containing caffeine) at any time either before or after the onset of your anxiety problems? Please check all that apply: ___ ___ ___ ___ ___ I increased my caffeine intake before the onset of my problems I decreased my caffeine intake before the onset of my problems I increased my caffeine intake after the onset of my problems I decreased my caffeine intake after the onset of my problems No change in my caffeine habits. 28. Did you notice any casual relationship between caffeine consumption and your symptoms? YES _______ NO _______ 29. Do any of your relatives suffer from one of the following psychiatric conditions? First degree relatives (parents, siblings, children) a.) Recurrent depressions b.) Manic-depressive disorder c.) Schizophrenia d.) Panic disorder e.) Severe anxiety problems f.) Specific phobias (specify) g.) Obsessive-Compulsive disorder h.) Other emotional or mental problems, the exact nature of which you don’t know Second degree relatives (uncles, aunts, cousins, grandparents, etc.) 12 30. Do you currently work outside your home? YES ______ NO _________ If not, did you work in the past? When? _________________________ Is your anxiety problem the reason for not working? 31. Have you ever seen a physician for your anxiety problems? YES ______ NO _________ YES ______ NO _________ YES ______ NO _________ 32. Have you ever seen a psychiatrist for your anxiety problems? YES ______ NO _________ 33. Have you ever seen a therapist or counselor for your anxiety problems? YES ___ NO ____ 34. Are you currently receiving or have you previously received treatment for any of you psychiatric problems? YES ______ NO _________ If so, check which apply: ___ Medications Duration ________ NOW____In the past _____ ___ Psychotherapy Duration ________ NOW____In the past _____ ___ Cognitive behavioral/ therapy Duration ________ NOW____In the past _____ ___ Relaxation techniques Duration ________ NOW____In the past _____ 35. Please list any medications you are currently taking and their dosage: (list first the medications you take for your psychiatric problem, and then those you take for other reasons, e.g., hypertension, diabetes, etc) Name of Drug Dosage _____mg ___times per day _____mg ___times per day _____mg ___times per day _____mg ___times per day How long? Side effects 13 36. Please list any medications you have taken for your psychiatric problems in the past, and if possible, the dose: Name of Drug Dosage When taken and how long? Side effects _____mg ____times per day _____mg ____times per day _____mg ____times per day _____mg ____times per day 37. For questions 35-36: a.) Do/did any of these medications relieve your anxiety? If yes, please name drug(s): YES__ NO__ b.) Do/did any of these medications relieve your depression? If yes, please name drug(s): YES__ NO__ 38. Did you ever take anti-anxiety medication without a prescription over an extended period of time? YES__ NO__ 39. Did you ever develop dependence on one of the medications you were on? YES__ NO__ 40. Did you abuse any anxiety relieving medication? 41. Did you abuse street drugs ( including marijuana)? 42. Did you abuse alcohol (or are you currently abusing alcohol)? YES__ NO__ YES__ NO__ YES__ NO__ 43. Please briefly describe the most troublesome aspect of your current difficulties: 14 SOCIAL ANXIETY SCREENING QUESTIONAIRE NAME: ________________________________ DATE:_________________ Fear or Anxiety Avoidance 0 1 2 3 0 1 2 3 = = = = None Mild Moderate Severe = = = = None (0%) Occasionally (1% - 33%) Often (33% - 67% Usually (67% - 100%) Using the key above, please indicate to what degree each of the following socially related situations makes you fearful or anxious. Fear or Anxiety Avoidance 1. Speaking on the telephone ______ ______ 2. Drinking with others in public places ______ ______ 3. Acting, performing or giving a talk in front of an audience ______ ______ 4. Working/writing while being observed ______ ______ 5. Calling someone you don’t know very well ______ ______ 6. Talking with people you don’t know very well ______ ______ 7. Urinating in a public bathroom ______ ______ 8. Entering a room when others are already seated ______ ______ 9. Being the center of attention ______ ______ 10. Speaking up at a meeting ______ ______ 11. Taking a test ______ ______ 12. Expressing a disagreement or disapproval to People you don’t know very well ______ ______ Looking at people you don’t know very well in the eyes ______ ______ 14. Giving a report to a group ______ ______ 15. Returning goods to a store ______ ______ 16. Resisting a high pressure salesperson ______ ______ 17. Other social situations that are anxiety provoking: ______ ______ 13. ___________________________________________ 15 CONSENT FOR RELEASE OF PATIENT INFORMATION Patient Name: ____________________________________________________________ Patient Address: ____________________________________________________________ ____________________________________________________________ Date of Birth: ______________________ I Hereby Authorize: ____________________________________________________ Address: ____________________________________________________ ____________________________________________________ Phone #: _________________________ Fax #: _______________________ To release my protected health information to: The Ross Center for Anxiety and Related Disorders, LLC 5225 Wisconsin Ave NW Suite 400 Washington, DC 20015 Ph: 202.363.1010 Fax: 202.363.2383 ___all records ___psychiatry records ___psychotherapy notes ___substance abuse records ___psychological testing records ___other(specify)______________ Data shall include: Note: If this authorization is for psychotherapy notes, it may not be combined with any other authorization. Specific purpose: ___continued/coordinated care ___other (specify)______________ I understand that if the aforementioned records pertain to drug or alcohol abuse treatment, HIV/AIDS testing, treatment, or related illness that such information will be released pursuant to this authorization form. I understand and agree that 1) I have a right to inspect my Protected Health Information; 2) I may revoke this authorization in writing at any time; 3) this authorization will expire three hundred sixty five (365) days from the date written below; 4) District of Columbia Law prohibits re-disclosure of Protected Mental Health Information(PHI) by the recipient without my consent; 5) the Ross Center may disclose my PHI without my consent only in specific circumstances authorized by law; and 6) my treatment provider may refuse to disclose or allow my inspection of part or all of my PHI if he/she believes that it is necessary to protect me or someone else from psychological or other harm. This consent form has been explained to me and I understand the contents to be released, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information. I hereby acknowledge that this consent is truly voluntary and is valid until such request is fulfilled. ___________________________________ Signature (Patient or Legal Guardian) __________________________________ Witness ___________________ Date __________________ Date 16 INFORMED CONSENT FOR INTENSIVE TREATMENT PROGRAM I, ___________________, have chosen to receive treatment services at The Ross Center for Anxiety & Related Disorders. LLC. My choice has been voluntary and I understand that I may terminate therapy at any time. I understand: 1) that improvement is likely, but not guaranteed, and that therapy is a cooperative and collaborative effort between therapist and patient; 2) that during the course of my treatment, material may be discussed which will be upsetting in nature and that this may be necessary to help me address my mental health concerns. 3) that records and information collected about me will be held or released in accordance with state laws regarding confidentiality of such records and information. 4) that state and local laws require that my therapist report all cases of abuse or neglect of minors or vulnerable adults, and all cases in which there is believed to be an acute risk of danger to self or others. Signature of Patient: _____________________________________ Date:___________________ or parent or guardian if a minor Signature of Witness: ____________________________________ Date: ___________________ 17 STATEMENT OF AGREEMENT Please sign below to indicate that you have read, understand and agree to the following statements: I understand that the basic Intensive Treatment Program at The Ross Center includes a one-hour private evaluation and diagnostic consultation with the medical director or other psychiatrist, sixteen (16) private forty-five (45) minute therapy sessions with a cognitive-behavioral therapist, and three fifteen (15) minute telephone follow-up sessions with the therapist upon returning home. The cost for this program is $3,595. I further understand that should additional private therapy sessions be necessary, I will be billed at the rate of $195 per 45-minute session. I have enclosed a check or money order for $100 to cover the costs of reviewing my application and a brief phone interview to determine the feasibility of my participation in an intensive treatment program. This non-refundable administrative fee will be applied towards the $3,595 basic program cost. Once a date for the treatment has been reserved for me, I will remit the full balance of the program cost, $3,495, to The Ross Center. I understand that should it be necessary to cancel my treatment, a full refund less the $100 administrative fee will be returned to me provided The Ross Center receives written notification postmarked seven days prior to the initial scheduled appointment. I have completed the Intensive Treatment Program application and screening questionnaires and have signed and enclosed the consent for release of information form authorizing The Ross Center to obtain information about my condition and treatment from my health/mental health care providers. I acknowledge that the information I have provided on the forms requested by The Ross Center is accurate to the best of my knowledge. __________________________________ Signature _________________________________ Date 18 HOTELS PLEASE CALL AHEAD TO VERIFY; INFORMATION SUBJECT TO CHANGE American Inn of Bethesda 8130 Wisconsin Avenue Bethesda, Maryland 20814 800-323-7081 or 301-656-9300 http://www.american-inn.com/ Parking is free, but very limited (1st come, 1st served). The Metro has two stations, located in opposite directions, 5 blocks from the hotel. A complimentary continental breakfast is available, and there are two restaurants in the hotel. Savoy Suites Hotel 2505 Wisconsin Avenue, NW Washington, DC 20007 202-337-9700 http://www.savoysuites.com/ Premium Tempur-Pedic beds in each guest room. Spacious guest rooms many offering fully equipped kitchens or Jacuzzis. 37” in-room flat panel televisions by Samsung Complimentary on-site garage parking. Complimentary high-speed internet (Wi-Fi) Complimentary access to the Washington Sports Club – DC’s premier health facility. Complimentary shuttle service to the DC Metro, Georgetown University and Georgetown University Hospital. Twist Restaurant and Lounge serving breakfast, lunch and dinner daily Days Inn 4400 Connecticut Avenue, N.W. Washington, D.C. Telephone: 800-DAYSINN or 202-244-5600 http://www.daysinn.com/DaysInn/control/Booking/property_info?propertyId=06507 Parking is $8.96 day (including tax); can take car out any number of times. 1 1/2 blocks from Van Ness Metro on Red Line (2 stops from Ross Center) Each room has coffee & coffee maker; free newspaper; data ports for computer and phone; ironing board Reasonable hotel in great area of D.C.; near Zoo, restaurants Embassy Suites Hotel The Chevy Chase Pavilion 3300 Military Road, N.W. at Wisconsin Avenue, N.W. Washington, D.C. Telephone: 202-362-9300; 1-800-EMBASSY http://www.embassysuitesdcmetro.com/washington-dc-hotels.php The hotel is situated above the Friendship Heights Metro station, (our stop), and one block from our office. The hotel is an atrium style, and part of a large shopping center, which has restaurants and shops. 19 Bethesda Court Hotel 7740 Wisconsin Avenue, Bethesda, Maryland Telephone: 301-656-2100 http://www.bethesdacourtwashdc.com/ Self Parking on the premises - $14 per night Complimentary deluxe continental breakfast Free in-room wireless internet access One-and-one-half block walk to Metro Station. Residence Inn (Marriott) Address: 7335 Wisconsin Avenue, Bethesda, Maryland Telephone: 800-331-3131 or 301-718-0200 http://www.marriott.com/hotels/travel/wasbr-residence-inn-bethesda-downtown/ Suites only (Bedroom, living room w/ dining area, full kitchen); pool, workout facility; dry sauna. Complimentary buffet style breakfast. Complimentary social hour, 5:30-7:00p Mon.-Thurs. Parking: $10/day, valet only; secured garage. Within one block of two car rentals. Rates vary greatly; can be discounted based on availability; AAA and AARP discounts: ALSO: Marriott at Pooks Hill, 5151 Pooks Hill Road, Bethesda, MD 301-897-9400 – Outdoor Pool Hyatt Regency Address: 7400 Wisconsin Avenue Bethesda, Maryland 20814 Telephone: 800-233-1234 or 301-657-1234 http://www.bethesda.hyatt.com/hyatt/hotels/index.jsp On-the-grounds Parking: $10/day Hotel located above Bethesda Metro Stop Hotel features work-out facility, spa, sauna, pool Doubletree Bethesda 8120 Wisconsin Avenue Bethesda, Maryland 20814 Tel: 301-652-2000 http://www.doubletreebethesda.com/ CAR RENTALS Enterprise Rental Car (Bethesda) will pick you up at the Embassy Suites Hotel and take you to their offices. 301-907-7780 Avis Car Rental 4400 Connecticut Ave Northwest Washington, DC, 20008 , US 202-686-5149 http://www.avis.com/car-rental/location/details.ac?LOCATIONCODE=W3C