- Aloha Counseling Associates
1/11 Welcome to Aloha Counseling Associates, LLC (ACA, LCC). We are looking forward to meeting with you. Before your first appointment, we would like you to read and complete the following forms in this packet: 1) Demographic Information, 2) Insurance Information, 3) Professional Fees, 4) Late Cancellation/No Show Policy, 5) Acknowledgement of HIPPA, 6) Release of Information, 7) Treatment Guidelines, and 8) Child/Adolesent History Form If you have any questions, please contact your provider or staff at ACA, LCC. Mahalo for your help and cooperation. DEMOGRAPHIC INFORMATION Full Name: _____________________________________________ Date of Birth: ________________ Race/Ethnicity: ____________________ Age: __________ Sex: Male/Female Preferred Phone: _________________________ Home/Cell/ Work (circle one) ¨ Check if OK to leave message Alternative Phone: _______________________ Home/Cell/ Work (circle one) ¨ Check if OK to leave message Marital Status: □ Never Married □ Married/Committed Relationship □ Divorced □ Separated □ Widowed I am presently living: □Alone □With others (please specify):_________________________________ Home Address:___________________________________________________________________________ Primary Care Physician: ___________________________________________________________________ Referred by (if different that PCP): ___________________________________________________________ INSURANCE INFORMATION Primary Insurance Company: ___________________________ Subscriber #: ____________________________ Group #: _________________________ Sponsor SS# (Tricare Only) ______________________________ Secondary Insurance Company: _________________________ Subscriber #: ____________________________ Group#:__________________________ Signature: __________________________________________ Date: ____________________________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] 2/11 PROFESSIONAL FEES Please check with your insurance company's mental or behavioral health plan or request a referral from your primary care provider or referring doctor to insure that your visit is covered by your health insurance. Please see ACA, LCC staff if you are not sure; otherwise, the patient will be financially responsible for visits/services that are not covered by your insurance. The hourly rate is $225.00 + tax per hour (except for testing and assessment). However, this rate will be adjusted if your provider works for periods less than one hour. PSYCHOTHERAPY - $225.00 + tax per 50 min. hour.*** PSYCHOLOGICAL TESTING/ASSESSMENT - $250.00 + tax per hour including administration, scoring, interpretation, and report.*** LEGAL INVOLVEMENT - $500.00 + tax per hour. If the patient becomes involved in legal proceedings that require the provider's participation, the patient will be expected to cover for all of the provider's professional time, including preparation and transportation costs, including testifying in court.*** Other additional charges include report writing, telephone consults lasting 15 minutes, preparation of records and treatment summaries, and other time used to perform services required of your provider.*** *** Indicate services that may not be covered by your health insurance. Sliding Fee Schedule: Please contact us at 680-0558 if you have no insurance or cannot afford these fees. LATE CANCELLATION AND "NO SHOW" POLICY Psychotherapy is like a contract between the patient and the provider; it's an agreement that both parties will sincerely try their best to work toward a treatment goal. To insure patients' responsibility to themselves and to the therapeutic process, and that other patients have an opportunity to schedule an appointment when there's a cancellation, there will be a $20.00 no show or late cancellation fee starting on the first business day of January 2015. However, if they were due to emergencies or unusual circumstances, this fee may be waived. To avoid this charge, please cancel 24 hours in advance. Further, we will not schedule an appointment after 3 consecutive cancellations and/or no shows. If you have any questions or concerns about this policy, please contact us or your provider. ACKNOWLEDGEMENT OF HIPAA I was offered a copy of the HIPAA form concerning privacy protection by a representative of Aloha Counseling Associates, LLC or have downloaded the HIPPA form from the ACA, LCC website. __________________________________________ Signature ___________________ Date Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] 3/11 RELEASE OF INFORMATION Patient Name: _____________________________________________________ Patient Date of Birth: ________________________________________________ Person Authorized to give permission: __________________________________ Relationship to patient: ______________________________________________ I give permission for the staff at Aloha Counseling Associates, LLC to communicate with _______________________________________________________ (name of primary care provider) and exchange information, if necessary, regarding medical and psychological information. This information will be used for evaluation, treatment, or psychological consultation regarding the patient listed above. The above permission includes oral communication and exchange of relevant patient information, including but not limited to, summaries of treatment, copies of records, and diagnosis, when necessary. ______________________________________________ Authorized Person Granting Permission Signature __________ Date ______________________________________________ Clinician Signature __________ Date Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] 4/11 TREATMENT GUIDELINES Emergency Contact: Dr. Valdez is not available on an emergency or “on-call” basis. Patients requiring immediate assistance must call the Mental Health Crisis Hotline at (808) 832-3100, 911, or go to the nearest emergency room. Limits of Treatment: There are some circumstances in which Dr. Valdez may make the decision to end therapy. Such circumstances include, but are not limited to: • • • • treatment appears to be ineffective threats are made against the therapist or his/her family the therapist does not believe he/she has the necessary training to address a specific problem there is no progress with treatment In such cases, Dr. Valdez will attempt to find a suitable referral. He cannot be responsible as to whether this referral is accepted. Confidentiality: In general, the privacy of all communications between a patient and a psychologist is protected by law, and your provider can only release information about our work to others with your written permission. But there are a few exceptions. (Your initials indicate that you read and understood each exception.) Legal Proceedings: If, for some reason, your provider is court ordered to testify or release information regarding your mental health or where your emotional condition is an important issue. Initials: ____ Abuse: If you tell your provider that you or some other identifiable person is abusing a child, elderly, or disabled person, your provider is legally mandated to file a report with the appropriate state agency. Initials: _____ Danger To Self or Others: If you tell your provider that you are threatening serious bodily harm to either yourself or another. These actions may include notifying the potential victim, contacting the police, seeking hospitalization for the patient, or contacting family members or others who can help provide protection. Initials: _____ These situations occur quite rarely. But, if this situation occurs, your provider will make every effort to fully discuss it with you before taking any action. Minors: If you are a minor, under the age of 18, please be aware that the law may provide your parents the right to information about your treatment. For teenagers, it is the policy at ACA, LLC to request an agreement from your parents that they be provided with only general information about our work together, unless there is a high risk that you will seriously harm yourself or someone else. Before giving them any information, your provider will discuss the matter with you, if possible, and do their best to address any objections you may have. Office Sharing: Please note ACA, LLC shares an office space with West Shore Neurological Services, LLC. These are two separate entities, however, we consult with each other if you are a patient at both clinics. Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] 5/11 PROFESSIONAL RECORDS ACA, LLC is required to keep records of its professional services, your treatment, or your work together. Our general policy is that patients may not review them; however, we can provide a treatment summary unless it is believed that doing so would be emotionally damaging. If that is the case, we will be happy to send the summary to another mental health professional who is working with you. DISPUTES Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which 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, lawsuits, etc.) neither you nor your attorney(s) nor anyone else acting on your behalf will call on ACA, LLC provider(s) to testify in court or at any other proceeding, nor will a disclosure of psychotherapy records be requested. (Please initial here): _____________ CONSENT FOR TREATMENT I authorize Dr. Jay Valdez, Psychologist at Aloha Counseling Associates, LCC, to provide psychological evaluation and treatment to me. I have read and understood the forms in this packet and agree to all its conditions. __________________________________________ Signature ___________________ Date Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] 6/11 Please complete to the best of your knowledge. Leave blank to those you do not know answer to. Thank You! CHILD/ADOLESCENT HISTORY Patient Name: ________________________________ Today’s Date: ___________________________________ Form Completed by: ___________________________ Relationship: ____________________________________ Date of Birth: _________________________________ Race/Ethnicity: __________________________________ Referred by: __________________________________ Reason for Referral: ______________________________ Emergency Contact: ____________________________ Emergency Phone: _______________________________ PRESENTING PROBLEM How long ago did the problem begin: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Reason(s) for seeking services: __________________________________________________________________________________________________ __________________________________________________________________________________________________ What things have you tried to deal with these concerns: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ MEDICAL HISTORY Current Medical Conditions/Concerns: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________ Primary Care Provider: _______________________________________ Last Physical Exam: _________________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] 7/11 Are you taking any medications on an ongoing basis? Yes/No Name of Medication ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Dose/Frequency ____________ ____________ ____________ ____________ ____________ Name of Prescribing Physician ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ Medical Hospitalizations/Surgeries:(Please describe and include dates) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Family History of Medical Problems: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please indicate if you have had any history of the following medical problems: Allergies Asthma Diabetes Chronic Ear Infections Headaches Head Injuries Hearing/Ear Problems Loss of Consciousness Nightmares Nutrition Concerns Problems with Pain Seizures Serious Accidents Sleep Apnea/Snoring Surgeries Thyroid Difficulties Tics/Twitching Vision/Eye Problems Alcohol Use/Abuse Illicit Drug Use/Abuse Risky Behaviors Circle One Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Ages _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Describe _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] 8/11 DEVELOPMENTAL HISTORY Mother’s Age During Pregnancy: ______________________ Child’s Birth Weight: ______________________ Mother’s Health During Pregnancy: _______________________________________________________________ Use of Cigarettes During Pregnancy Use of Alcohol During Pregnancy Use of Drugs During Pregnancy Use of Prescription Medication Complications During Pregnancy Problems at Birth Developmental Delays/Concerns Received Speech Therapy Received Physical Therapy Age Walked: ________ Yes No ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Describe: ______________________________________ Describe: ______________________________________ Describe: ______________________________________ Name: ________________________________________ Describe: ______________________________________ Describe: ______________________________________ Describe: ______________________________________ For: ___________________________________________ For: ___________________________________________ Age Talked: ________ Age Toilet Trained: ___________ Describe Child’s Personality as a Baby/Toddler: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ MENTAL HEALTH Please check any of the following stresses that apply to you or your family and describe: □ Major Relocations:___________________________________________________________________________ □ School/Job Change:__________________________________________________________________________ □ Deaths:____________________________________________________________________________________ □ Relational Problems:_________________________________________________________________________ □ Someone Significant Moving Out of the Area:_____________________________________________________ □ Experiencing a Traumatic Event:________________________________________________________________ □ Witnessing a Traumatic Event: _________________________________________________________________ □ Child Protective Services (CPS) or Adult Protective Services (APS) Involvement: ________________________ ____________________________________________________________________________________________ Past Psychiatric Evaluation Prior Diagnosis of a Mental Health Disorder Prior Use of Psychiatric Medication History of Harm to Self/Others Circle One Yes/No Yes/No Yes/No Yes/No Date(s): _________________________________ Diagnoses: _______________________________ Name(s): ________________________________ Who/When: ______________________________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] 9/11 History of Suicide in Your Family Past Psychiatric Hospitalization Yes/No Yes/No Who/When: ______________________________ Dates(s): _________________________________ HISTORY OF ABUSE Emotional Abuse Verbal Abuse Physical Abuse Sexual Abuse Yes/No Yes/No Yes/No Yes/No Who/When: _________________________________________________ Who/When: _________________________________________________ Who/When: _________________________________________________ Who/When: _________________________________________________ SCHOOL HISTORY Academic Difficulties: Elementary School Academic Difficulties: Middle School Academic Difficulties: High School Yes/No Yes/No Yes/No Describe: ________________________________ Describe: ________________________________ Describe: ________________________________ Behavioral Difficulties: Elementary School Behavioral Difficulties: Middle School Behavioral Difficulties: High School Yes/No Yes/No Yes/No Describe: ________________________________ Describe: ________________________________ Describe: ________________________________ Special Education Gifted Classes Graduated High School Attended College Grade/Age: ___________________________________________ Grade/Age: ___________________________________________ Name/Yr: _____________________________________________ Name/Yr: _____________________________________________ Yes/No Yes/No Yes/No Yes/No IMMEDIATE FAMILY HISTORY Medical Illness Mental Health Illness Substance Abuse Legal Issues (Arrests/Jail) Learning Difficulties/Disabilities Yes/No Yes/No Yes/No Yes/No Yes/No Diagnoses: _____________________________________ Diagnoses: _____________________________________ Type(s): _______________________________________ Type(s): _______________________________________ Diagnoses: _____________________________________ FAMILY INFORMATION Relationship Good Avg Poor ☐ ☐ ☐ Mother’s Name: ______________________________ Educational Level: ____________________________ Occupation: _________________________________ Age: _____ Living Deceased ☐ ☐ Father’s Name: ______________________________ Educational Level: ___________________________ Occupation: _________________________________ Age: _____ ☐ ☐ ☐ ☐ ☐ Stepmother’s Name: __________________________ Educational Level: ___________________________ Occupation: _________________________________ Age: _____ ☐ ☐ ☐ ☐ ☐ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] 10/11 Age: _____ ☐ ☐ ☐ ☐ ☐ Brother’s Name/Age: _________________________ Brother’s Name/Age: _________________________ Brother’s Name/Age: _________________________ Age: _____ Age: _____ Age: _____ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Sister’s Name/Age: __________________________ Sister’s Name/Age: __________________________ Sister’s Name/Age: __________________________ Age: _____ Age: _____ Age: _____ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ Stepfather’s Name: ___________________________ Educational Level: ___________________________ Occupation: _________________________________ Other People Living in the Home or Have Significant Influence: __________________________________________________________________________________________________ __________________________________________________________________________________________________ LEGAL HISTORY Past Trouble with the Law Gone to Court Been Arrested Yes/No Yes/No Yes/No When/Why: ___________________________________________ When/Why: ___________________________________________ When/Why: ___________________________________________ SUBSTANCE USE HISTORY Past Use of Drugs or Alcohol Use of Drugs or Alcohol Within Past Month Past Treatment for Drugs/Alcohol Addicted to Eating Addicted to Gambling Addicted to Spending Money Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No What/When: _____________________________ What/When: _____________________________ What/When: _____________________________ When: __________________________________ When: __________________________________ When: __________________________________ SOCIAL RELATIONSHIPS People are Supportive of You You have People You Can Tell Personal Information You have People to Do Things With Yes/No Yes/No Yes/No Who: _____________________________ Who: _____________________________ Who: _____________________________ EMOTIONAL AND BEHAVIORAL FUNCTIONING Strengths Limitations/Weaknesses ___________________________________________ ______________________________________________ ___________________________________________ ______________________________________________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] 11/11 ___________________________________________ ______________________________________________ Hobbies ___________________________________________ ______________________________________________ ___________________________________________ ______________________________________________ ___________________________________________ ______________________________________________ GOALS FOR THERAPY 1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. __________________________________________________________________________________________ 4. __________________________________________________________________________________________ 5. __________________________________________________________________________________________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
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