DEMOGRAPHIC INFORMATION Full Name: Date of Birth: Race
ADULT FORM_Pg. 1/11 DEMOGRAPHIC INFORMATION Full Name: _____________________________________________ Date of Birth: ________________ Race/Ethnicity: ____________________ Age: __________ Sex: Male/Female/Other Preferred Phone: _________________________ Home/Cell/ Work (circle one) Alternative Phone: _______________________ Home/Cell/ Work (circle one) 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: ___________________________ Group #: _________________________ Subscriber #: ________________________ Sponsor SS# (Tricare Only) ______________________________ Secondary Insurance Company: _________________________ Subscriber #: ________________________ Group#:__________________________ Signature: __________________________________________ Date: _________________________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] ADULT FORM_Pg. 2/11 ARE YOU COVERED FOR THIS VISIT? Generally speaking, you're covered for psychotherapy if you have the following insurances: HMSA, HMSA HMO, HMSA PPO, HMSA Quest, University Health Alliance (UHA), Hawaiian Medical Assuance Association (HMAA), and Tricare. If you don't have the following insurances, please make sure you have the proper referrals/documents that indicate your insurance company will cover your visit; otherwise, you'll be responsbile for payment before services are rendered. Please note: Insurance companies don't cover psychological testing/assessment for ADD/ADHD assessment, personality assessments, disability assessments, intelligence assessment, behavioral assessments etc. Please ask us if you have any questions about this. Please see below for psychologcal testing/assessment fees. PROFESSIONAL FEES PSYCHOTHERAPY - $225.00 + tax per hour PSYCHOLOGICAL TESTING/ASSESSMENT - $250.00 + tax per hour 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. My hourly rate is $225.00 + tax per hour (except for testing and assessment and legal involvement). However, this rate will be adjusted for services less than an hour. Examples include: report writing, any type of letter(s) you may need, telephone consults lasting 15 minutes or more, preparation of records and treatment summaries, and other time used to perform services required of your provider, etc. If you cannot afford these fees, please discuss it with me and we will figure it out together. Please note: Insurance companies don't cover for these services. Therefore, you're financially responsible for payment. CO-PAYMENTS Co-payments will be collected at time service is rendered. Copays are usually $20.00. LATE CANCELLATION AND "NO SHOW" POLICY I really enjoy my work as a psychologist; however, ACA, LLC is a small business that relies on patients making their appointments. If a patient doesn't show-up for his/her appointments, it'll be a huge financial loss for me, and I won't be able to sustain this business. Therefore, you'll be held responsible for full payment of services if you don't cancel your appointment 24 hours in advance or don't show up for your appointment. You can call 228-4165 or email [email protected] to cancel. It's primarily your responsibility for remembering your appointments but as a courtesy, we'll try to give you a call to remind you of your appointment. Please note: You won't be charged if your cancellation or no show is due to an emergency or an unforeseeable circumstance. Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] ADULT FORM_Pg. 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 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-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] ADULT FORM_Pg. 4/11 TREATMENT GUIDELINES Emergency Contact: Unfortunatley, I'm not available on an emergency or “on-call” basis. If you're requiring immediate assistance, please call the Mental Health Crisis Hotline at (808) 832-3100, call 911, or go to the nearest emergency room. Limits of Treatment: There are some circumstances in which I may make the decision to end therapy. In such cases, I'll discuss why I'm ending treatment and will attempt to find a suitable referral. However, I cannot be responsible as to whether your referral is accepted. Confidentiality: In general, the privacy of all communications between a patient and a psychologist is protected by law, and I as your provider can only release information about our work to others with your written permission. But there are a few exceptions. 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. 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. 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. Please note: These situations occur quite rarely. But, if this situation occurs, I 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. 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's believed that doing so would be emotionally damaging. If that's the case, I'll be happy to send the summary to another mental health professional who's working with you. Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] ADULT FORM_Pg. 5/11 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's 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 (Dr. Jay D. Valdez) to testify in court or at any other proceeding, nor will a disclosure of psychotherapy records be requested. CONSENT FOR TREATMENT I authorize Dr. Jay D. Valdez, Psychologist at Aloha Counseling Associates, LLC, to provide psychological evaluation and treatment to me. I've 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-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] ADULT FORM_Pg. 6/11 PATIENT INFORMATION FORM Please complete to the best of your knowledge. Leave blank to those you do not know answer to. Thank You! ADULT 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 Briefly describe your struggles and when they first began: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please indicate if you have had any history of the following medical problems: Asthma Diabetes Headaches Head Injuries Hearing/Ear Problems Loss of Consciousness Nightmares Nutrition Concerns Problems with Pain Serious Accidents Sleep Apnea/Snoring Thyroid Difficulties Tics/Twitching 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 Ages _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Describe _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] ADULT FORM_Pg. 7/11 MENTAL HEALTH Please check any of the following stresses that apply to you or your family and describe: □ Major Relocations:___________________________________________________________________________ □ Job Change:________________________________________________________________________________ □ Deaths:____________________________________________________________________________________ □ Marital/RelationalProblems:___________________________________________________________________ □ 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: ________________________ ____________________________________________________________________________________________ Circle One Past Psychiatric Evaluation Prior Diagnosis of a Mental Health Disorder Prior Use of Psychiatric Medication History of Harm to Self/Others History of Suicide in Your Family Past Psychiatric Hospitalization Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Date(s): _________________________________ Diagnoses: _______________________________ Name(s): ________________________________ Who/When: ______________________________ Who/When: ______________________________ Dates(s): _________________________________ List of Current Medications: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ HISTORY OF ABUSE Emotional Abuse Verbal Abuse Physical Abuse Sexual Abuse Yes/No Yes/No Yes/No Yes/No IMMEDIATE FAMILY HISTORY Mental Health Illness Substance Abuse Yes/No Yes/No Diagnoses: _____________________________________ Type(s): _______________________________________ JOB HISTORY Place of Employment: _________________________________________ _________________________________________ _________________________________________ Position ____________________________ ____________________________ ____________________________ Dates __________ __________ __________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] ADULT FORM_Pg. 8/11 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 Addicted to Sex Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No What/When: _____________________________ What/When: _____________________________ What/When: _____________________________ 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: _____________________________ GOALS FOR THERAPY 1. __________________________________________________________________________________________ 2. __________________________________________________________________________________________ 3. __________________________________________________________________________________________ 4. __________________________________________________________________________________________ 5. __________________________________________________________________________________________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] ADULT FORM_Pg. 9/11 GAD - 7 Over the last 2 weeks, how often have you been bothered by the following problems? (Use “✔” to indicate your answer) Not at Several All Days More than 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 that it is 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 _______________________________________________________________________________________ (For Office Coding: Total Score T ____ = ____ + ____ + ____ ) Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] ADULT FORM_Pg. 10/11 Patient Health Questionnaire – 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✔” to indicate your answer) Not at all Several More than Half the Days 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 or 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 are 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 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 ________________________________________________________________________________________________ FOR OFFICE CODING___0___ + ______ + ______ + ______ = Total Score: ______ ________________________________________________________________________________________________ If you checked off any problems, how difficult have these problems 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 ☐ __________________________________________________________________________________________________________________________________ Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected] ADULT FORM_Pg. 11/11 Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute. Aloha Counseling Associates, LLC 94-216 Farrington Highway, Suite A-203 Waipahu, HI 96797 Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
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