Intake Form – PPS Tampa Center for Counseling

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Patient Information

Email Address *

Give us an email address so you get a copy of your intake form responses and we can reply back to you if needed

Today's Date *

Last Name *

First Name *

Patient Date of Birth (mm-dd-yyyy) *

Gender *

Male Female Genderqueer/Non-Binary Prefer not to disclose Other

Street Address *

City *

State *

Zip *

Social Security #

Home Phone Number

Cell Phone Number *

Work Phone Number

Extension

Name of Parent/Guardian (if minor)

Relationship With Patient *

Self Spouse Parent Legal Guardian Other

Patient Marital Status *

Never Married Domestic Partnership Married Separated Divorced Other

Please list any children/age

Employer

Occupation

Student?

Yes No

School

Patient Referred By *

Insurance Information

Primary Insurance Company *

Insurance Member ID # *

Insurance Group #

Primary's Employer *

Person responsible for insurance is different from patient?

Yes

In case of emergency who should be notified? *

ICE Relationship With Patient *

Self Spouse Parent Legal Guardian Other

ICE Phone Number *

Patient Record of Disclossures

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

I wish to be contacted in the following manner (check all that apply):

Disclosure Method *

Home Phone Cell Phone Work Phone Written Communication Other

Disclosures Signature *

Please note that typing your full name into this field serves as your electronic signature.

Disclosures Date *

Problems and Complaints

Below is a list of problems and complaints that some people have. Read each one and select the number that best describes how much discomfort that problem has caused you during the past 7 days, including today. Place the number in the open block to the right of the condition.

Example:

How much were you distressed by:

Body Aches: 2

0 = Not at All

1 = A Little Bit

2 = Moderately

3 = Quite a Bit

4 = Extremely

How much were you distressed by:

Nervousness of shakiness inside

0 1 2 3 4

Feeling afraid to travel on buses or trains

0 1 2 3 4

Faintness or dizziness

0 1 2 3 4

Trouble getting your breath

0 1 2 3 4

The idea that someone else can control your mind

0 1 2 3 4

Hot or cold spells

0 1 2 3 4

Feeling others are to blame for most of your troubles

0 1 2 3 4

Having to avoid certain things or places because they frighten you

0 1 2 3 4

Trouble remembering things

0 1 2 3 4

The idea that you should be punished for your sins/mistakes

0 1 2 3 4

Feeling easily annoyed or irritated

0 1 2 3 4

Numbness or tingling in parts of your body

0 1 2 3 4

Pains in heart or chest

0 1 2 3 4

Getting into frequent arguments

0 1 2 3 4

Feeling afraid in open spaces

0 1 2 3 4

Feeling hopeless about the future

0 1 2 3 4

Thoughts of ending your life

0 1 2 3 4

Trouble concentrating

0 1 2 3 4

Feeling that most people cannot be trusted

0 1 2 3 4

Feeling restless

0 1 2 3 4

Poor appetite

0 1 2 3 4

Feeling tense or keyed up

0 1 2 3 4

Suddenly scared for no reason

0 1 2 3 4

Thoughts of death or dyiing

0 1 2 3 4

Temper outbursts out of control

0 1 2 3 4

The urge to beat, injure or harm someone

0 1 2 3 4

Feeling lonely even when you are with people

0 1 2 3 4

The urge to break or smash things

0 1 2 3 4

Feeling blocked in getting things done

0 1 2 3 4

Feeling worthless

0 1 2 3 4

Feeling lonely

0 1 2 3 4

Feeling weak in parts of your body

0 1 2 3 4

Feeling blue

0 1 2 3 4

Trouble falling asleep

0 1 2 3 4

No interest in things

0 1 2 3 4

Feeling uneasy in crowds

0 1 2 3 4

Your mind going blank

0 1 2 3 4

Spells of terror or panic

0 1 2 3 4

Feeling very self conscious with others

0 1 2 3 4

Medical History

Select the adjective that describes your present physical state of health

Excellent Good Fair Poor

List any prescribed medications you are now taking, including dosages

List any history of serious illness including mental illness or substance abuse

List any history of serious illness in your family including mental illness or substance abuse

List and describe any previous psychiatric hospitalizations

Do you smoke?

Yes No

Do you drink alcohol?

Yes No

Give dates and describe any history of counseling including supervisory referrals

Have you ever had any of the following conditions or symptoms?

Trouble Sleeping Headaches Stomach Trouble Depression Thoughts about Suicide Appetite Changes Crying Spells Trouble Concentrating Unexplained Pain Extreme Nervousness Repetitive Irrational Behavior Fainting Irritability Anxiety Obsessions Nightmares Low Energy Emotional/Physical/Sexual Abuse Memory Problems Indeciciveness Numbness or Tingling Problems with Anger Seeing or Hearing things not real

List goals you would like to accomplish out of your time in therapy *

Notice of Privacy Practices

Psychiatric and Psychological Services
1211 N. Westshore Blvd., Suite 100
Tampa, FL 33607

Notice of Privacy Services

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This practice is dedicated to maintaining the privacy of your personal health information. State
law requires that no information about your treatment can be given without your permission. The only exceptions to this are 1) if it is believed that there is clear and present danger of harm to anyone, 2) if a judge requires specific information in a court case, 3) if it is suspected that a criminal offense of child, disabled adult, or elderly abuse or neglect has occurred.

Treatment covered by insurance requires authorization to release information to your insurance provider, in order to obtain treatment approval and to bill for services. If there is a need use or disclose your personal information for any other reason, this will be discussed with you and you will be asked to sign an authorization of release.

The recently enacted Health Insurance Portability and Privacy Act of 1996 (HIPPA) requires us to provide this privacy policy. This notice of privacy practices is a summarized version of the full policy that is available in the office. Please ask if you would like to review it.

When we assess, diagnose, treat, or refer you, we will be collecting what the law calls Protected Health Information (PHI) about you. This information will be used to decide on what treatment is best for you and to provide treatment to you. We may also share this information with others who provide treatment to you or who need it to arrange payment for your treatment or to perform other healthcare operations, provided that this is not in violation of state law. We will disclose the minimum information necessary. You have a right to ask and be told to whom your PHI has
been released. You have the right to request in writing that disclosure of your PHI be restricted.
While the therapist is not required to agree to the request, if the therapist agrees to the restriction,
that agreement will be honored. There may be changes to this policy, and if there are changes,
those changes will be posted in the office for review.

Please feel free to discuss with me any questions or concerns that you may have.

Initial *

Date *

Service Agreement

Treatment Authorization

Treatment Professional *

The undersigned authorizes the above treatment professional to administer mental health and/or chemical dependency treatment to the patient named above. I understand that I may revoke this consent at any time during the treatment period. No guarantee or assurance of results has been made to me regarding the treatment.

Signature *

Please note that typing your full name into this field serves as your electronic signature.

Treatment Authorization Signer *

Self Spouse Parent Guardian

Treatment Authorization Date *

Information Authorization (Primary Care Physician)

I authorize or decline authorization of the release of information to the primary care physician for the
purpose of coordinating care.

Information Authorization

Authorize Decline

Name of Primary Care Physician

Phone

Information Authorization Signature

Please note that typing your full name into this field serves as your electronic signature.

Information Authorization Date

Consent for use and disclosure of Personal Health Information (PHI):

I have reviewed the Privacy Policy and give consent for the use and disclosure of personal health information to provide treatment, to arrange payment for services, and/or for other health care operations as provided by law. I understand
that changes in the policy are possible, and that if there are changes, those changes will be posted in the office for review.

I understand that I may request in writing that disclosure of my PHI be restricted, and that the therapist is not required to agree to my request. If the therapist agrees to the restriction, that agreement will be honored. I understand that I may revoke this consent, except to the extent that information has already been disclosed.

Content For Use Signature *

Please note that typing your full name into this field serves as your electronic signature.

Content For Use Date *

Legal Acknowledgments

I understand that my therapist may be required by law to release information without my approval to legal authorities if 1.) there is a clear and serious danger of harm to anyone, 2.) a judge requires specific information in a court case, 3.) it is suspected that criminal offense of a child, disabled adult, or elderly abuse or neglect has occurred.

Legal Acknowledgement Signature *

Please note that typing your full name into this field serves as your electronic signature.

Legal Acknowledgements Date *

Payment Authorization

I understand that I am responsible for payment for any service rendered regardless of whether this service is covered by an insurance policy.
I authorize insurance benefits payable to those health care providers described above for services rendered by them.
I understand and agree to give 24 hours notice if unable to keep any appointment. I understand that if I fail to show for a scheduled appointment, or if I do not cancel with 24 hours notice, I will be charged a $50 no show fee/Late cancellation fee and will be responsible for payment of that fee.

Payment Authorization Signature *

Please note that typing your full name into this field serves as your electronic signature.

Payment Authorization Date *

Statement of Responsibility for Payment Regarding No Shows of Late Cancellations

I understand and agree to give 24-hours notice if I am unable to keep an appointment.

I understand and agree that after three consecutive cancellations, with or without 24-hours notice (or failure to show up for my scheduled appointment), I must speak with my therapist to schedule future appointments.

I understand and agree that if I fail to show up for my scheduled appointment, or if I do not cancel with 24-hours notice, I will be responsible for payment of my co-pay or a minimum of $50.00.

Electronic Signature *

Please note that typing your full name into this field serves as your electronic signature.

Date *