Adult Intake Form Adult Services CHILD/TEEN SERVICES Teletherapy Adult Intake Form Name Date Marital Status Single Married Domestic Partner Separated Divorced Widowed Date Of Birth Sex Female Male Ethnicity Address City, State, ZIP Preferred Contact Method: (Cell/Home) Secondary Contact Method: (Cell/Home) Email Occupation SSN Emergency Contact Person Phone IF DIFFERENT THAN ABOVE, GUARANTOR INFORMATION (RESPONSIBLE PARTY) Relationship to Client Spouse Parent Guardian Name Address Date of birth Gender Female Male SSN Employer Occupation Home Phone Work / other phone INSURANCE INFORMATION Primary Insurance Subscriber Date of Birth Subscriber Name Subscriber SSN Policy ID # Group # Subscriber’s Employer Work Phone Secondary Insurance Subscriber Date Of Birth Subscriber Name Subscriber SSN Policy ID # Group # Subscriber’s Employer Work Phone Treatment Contract Insurance and Financial Policy Statement Thank you for choosing Rock Landing Psychological Group for counseling. As part of providing high quality services, we need to clarify our financial policies. Should you have any questions regarding the practice policies, please ask a member of the staff for clarification. If you are using your health insurance benefits, we will bill your insurance company. To do so, we need you to provide us with accurate and timely information regarding your insurance. All co-pays, deductibles, and denied payments are your responsibility. Your health insurance company may require you to make a co-payment and/or satisfy a deductible. The co-payment is determined by your health insurance company and is due at the time of service. If you have a deductible which has not been met, then the full fee is due until the deductible has been met. I authorized a release of information to my health insurance company and I assign all benefits to Rock Landing Psychological Group. Late Cancellation/No Show Fee Rock Landing Psychological Group requires 24 hour notice for routine cancellations. Late cancellations and no shows will incur a $65.00 charge for a missed appointment with your therapist and a $75.00 charge for missed appointment with your psychiatrist to be paid at your next scheduled session. Please note that your health insurance company will not cover this fee. The practice has a 24 hour voice mail system to take your cancellations. Please call (757) 873-1736 and speak to a staff member or if it is after hours leave a message for he scheduling staff on the voice mail system. At the time of check out you are given a card with the date of your next scheduled appointment. Our office will make every effort to remind you of your scheduled appointment. However, it is your responsibility to be aware of your appointment. Repeated cancellations and/or missed appointments may result in being disengaged from this practice. Late Cancellation/No Show Fee for Psychological Testing The psychologist requires 72 hours for cancellation for testing. Late cancellations and no shows will incur a $65.00 charge for each hour the individual was scheduled for testing. Please note the health insurance company will not cover this fee. Please be aware it will be at the discretion of the examiner as to whether or not the individual will be rescheduled for testing. Signature Clear Date Date Consent to Treatment I do hereby seek and consent to take part in the treatment provided by Rock Landing Psychological Group. I understand that developing a treatment plan with my provider(s) and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures rendered by my provider(s). I am aware that I may stop treatment with my provider(s) at any time. I will still be responsible for payment of services I have already received. Signature Clear Date Coordination of Treatment If I am referred to any other clinician or physician at Rock Landing Psychological Group, I give my consent for those clinicians to obtain and release pertinent information to each other for the purpose of coordinating my care. Signature Clear Date I give permission to the following to schedule and/or speak with the office about my appointment. Agreement I hereby attest that all information contained in these pages is current and correct. I understand that I am responsible for informing Rock Landing Psychological Group of any changes. Failure to do so may delay processing of insurance claims, in which case I will incur responsibility for those unpaid claims. Falsification of this information is punishable under Federal Law. I have received a copy of the Notice of Privacy Information Practices (HIPAA) pertaining to this practice. Client Signature Clear Date Responsible Party Signature Clear Date Referral Information Who referred you to this practice? May we have permission to thank them for your referral? Yes No Have you been seen here before? Yes No If yes please give approximate date and reason for seeking counseling Additional Information Are you and/or your child currently involved in the legal system? Name of spouse/partner Age Please list names and ages of children Your Education & Training Pre-School to High School High School Diploma/GED Vocational/Technical School College Graduate/Professional School Client Signature Clear Date Health Information Prescription medications your child takes. List medication, dosage, and what it's taken for List all diseases, illnesses, significant accidents and injuries, surgeries, hospitalizations, periods of loss of consciousness, seizures, and any other medical conditions you have or have had. Are you now being treated for any medical condition? Yes No When was your last medical exam? Your health is: Excellent Good Fair Poor Describe any allergies you have by allergy, reaction and medications taken. Health Habits Do you use any tobacco products? Yes No If yes, number of packs per day Do you wish to quit? No Yes Do you drink alcohol? Yes No Drinks per day Drinks per week Has your drinking ever been a problem? No Yes Previous Treatment? Do you use street drugs? Yes No If yes, which ones? Has your drug use ever posed a problem? No Yes Treatment? No Yes How many cups of caffeinated beverages do you drink each day (coffee, tea, cola)? None 1-3 4 or more Do you frequently take over-the-counter medications? No Yes Is so, which ones? Do you take vitamins/food supplements? Yes No If so, which ones? How often do you exercise? Are you aware of the physical and mental health benefits of regular exercise? No Yes What do you do to manage stress? Social Support Hobbies Support/Interest Group Spiritual Pursuits Nothing Mental Health History Have you ever had a psychiatric hospitalization? Yes No If yes, please enter date, facility and the reason Was it helpful? Yes No Have you ever had mental health/family/marriage counseling? No Yes If yes, enter date and counselor Was it helpful? Yes No Have you ever been under the care of a psychiatrist? Yes No If yes, enter date and counselor Was it helpful? Yes No Have you ever thought a lot about trying to harm or kill yourself? Yes No If so, when and where? Please mark all of the items below that apply Name Date Mood Anger Loss of control, outbursts Aggression, violence Inferiority Nervousness, panic/anxiety attacks Loneliness Crying spells Low self-esteem Depression, low mood, sadness Mood swings Emptiness Irritability Failure Pessimism Fatigue, tiredness, low energy Shyness Fears, phobias Stress, tension Grieving deaths, losses, divorce Suspiciousness Guilt Suicidal thoughts Hopelessness Withdrawal, isolating Worry Relationship Problems Children, child management, child care, parenting Family conflict Childhood issues (own childhood) Friendships Child custody/visitation Interpersonal conflicts Dependence Divorce, separation Marital conflict, infidelity/affairs Sexual issues, dysfunctions, desire differences, etc. Health Problems & Concerns Overeating Menstrual problems Under-eating/food restriction PMS Binging Menopause Vomiting Self-neglect, poor self-care Illness/injury Sleep too much Laxative Use Sleep too little Physical problems Insomnia Headaches Nightmares Problems with thinking Attention, concentration, distractibility Decision making, indecision, mixed feelings, putting off decisions Obsessions, compulsions (thoughts or actions that repeat) Delusions (false ideas) Memory problems Confusion Abuse Physical Neglect (of child or elderly) Sexual Emotional Employment/Career Problems Career goals Problems with co-workers Career choices Unemployment Over-working Can't keep a job Other Problems Over sensitivity to rejection Low motivation, laziness Perfectionism Judgment problems, risk taking Procrastination Irresponsibility Self-centeredness Consumer debt Impulsive spending Low income Gambling Additional concerns or issues: Please look back over the concerns you have checked off and choose the one which you most want help with. It is: reCAPTCHA If you are human, leave this field blank. Submit Where We Are Rock Landing Psychological Group, PLC The James Building 11825 Rock Landing Drive Newport News, VA 23606 Phone: (757) 873-1736 Fax: (757) 873-1028
