Adult Intake Form
Marital Status
Sex

IF DIFFERENT THAN ABOVE, GUARANTOR INFORMATION (RESPONSIBLE PARTY)

Relationship to Client
Gender

INSURANCE INFORMATION

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.

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.

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.

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.

Referral Information

May we have permission to thank them for your referral?
Have you been seen here before?

Additional Information

Are you and/or your child currently involved in the legal system?

Your Education & Training

Health Information

Prescription medications your child takes.

Are you now being treated for any medical condition?
Your health is:

Health Habits

Do you use any tobacco products?
Do you wish to quit?
Do you drink alcohol?
Has your drinking ever been a problem?
Do you use street drugs?
Has your drug use ever posed a problem?
Treatment?
How many cups of caffeinated beverages do you drink each day (coffee, tea, cola)?
Do you frequently take over-the-counter medications?
Do you take vitamins/food supplements?
Are you aware of the physical and mental health benefits of regular exercise?
What do you do to manage stress?

Mental Health History

Have you ever had a psychiatric hospitalization?
Was it helpful?
Have you ever had mental health/family/marriage counseling?
Was it helpful?
Have you ever been under the care of a psychiatrist?
Was it helpful?
Have you ever thought a lot about trying to harm or kill yourself?

Please mark all of the items below that apply

Mood
 
Relationship Problems
Health Problems & Concerns
Problems with thinking
Abuse
Employment/Career Problems
 
Other Problems