A Barrie Bondurant, Phd, LPC

A Barrie Bondurant, PhD, LPC

Healing Path Counseling

Initial paperwork

Welcome! It takes about 20-30 minutes to complete this packet, but the information is required by insurance companies and to meet best care practices. It will save us time and will allow me to provide you with the best possible care.

Please bring the following to your first appointment. They are required for insurance and medical records compliance.

This Paperwork

Insurance Card

Driver’s License or Photo ID

Any additional Medical Records or notes you may have from previous practitioners

Payment or Copay required by your insurance company

COMMUNICATION

We usually communicate with you at your home address and daytime phone number about health matters, such as appointment reminders, etc. You may request that we communicate with you in a different way. Please DO NOT provide phone numbers if you do not wish for us to leave messages. If a phone number is provided, we may leave a message at that number.

Name:______

You may contact me and leave messages at (Please check all that apply):

home: ______

work:______

cell: ______

Please do not leave a message

Please DO NOT remind me of appointments

You may send mail to my home address

Please DO NOT send mail to my home address

You may email me at the following address ______.

I understand that email is NOT confidential and may possibly be accessed by others.

______

Sign Name Date

CLIENT REGISTRATION

Today’s Date: ____/____/______Date of Birth ____/____/______

Client’s Full Name:______Social Security#:______

Home Address: ______

City: ______State: ______Zip______

Mailing Address (if different)

Phone:(H)______(C)______(W)______

Client Employer:______Occupation: ______

Gender: ______Single Married Partnered Separated Divorced / Race (optional)______

Employed Retired Unemployed Disabled Are you a Student? Yes No

Family Physician: ______Phone #:______

Referred by: ______

May we contact the referral to thank them? o Yes o No

Emergency Contact Name: ______Phone#:______

INSURED/RESPONSIBLE PARTY INFORMATION All items must be completed to bill your insurance.

Policy Holder’s Full Name: DOB:

Policy Holder’s SS #: Relationship to Client:

Home Address: Phone #:

Employer and Address: ______Phone #: ______

Single Married Employed Unemployed Retired Disabled

Please provide the phone number on the back of insurance card that says mental health, behavioral health, or benefits below.

Client’s Primary Ins. Co. ______ID#: ______
Group#: Mental Health Phone #:

Clients Secondary Ins. Co. ______ID#:______

Group#: Mental Health Phone #:

OFFICE HOURS Office hours are Monday – Friday 9am-5pm. You may reach my office by phone at (828) 620-0381 to schedule an appointment. If you have a psychiatric emergency; please call Copestone at Mission Hospital at 828-213-4055, Mobile Crisis Management at 888-573-1006, dial 911, or go to the nearest Emergency Room.

Financial Information

It is important to me that you understand your financial responsibilities regarding our appointments so I wanted to provide you with the following information.

FINANCIAL/INSURANCE We will bill your insurance company if you wish. All payments and/or co-payments are due at the time of the appointment. If you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, we request that you pay the balance due at that time. We accept personal checks, cash, Discover, Visa, and MasterCard (not American Express). A returned check fee of $35.00 will be charged.

Fees for Service Fee Your Cost

Initial Assessment & Diagnosis (60 minutes) $160.00 co-pay amount

Individual Therapy Session (50 minutes) $130.00 co-pay amount

Fee Schedule for Self-Pay If you do not have insurance coverage or do not wish to file with your insurance company, we am happy to provide a discount.

Initial Assessment & Diagnosis (60 minutes) $140.00

Individual Therapy Session (50 minutes) $110.00

Cancellations There is no charge for cancellations made at least 24 hours in advance of your appointment time.

First late cancellation (less than 24 hours notice) No charge

Second late cancellation (less than 24 hours notice) $60

Third and further late cancellations (less than 24 hours notice) $90

For No Shows (missed appointment with NO notice) Full appointment fee

AUTHORIZATION and AGGREMENT

I am aware and agree to my financial responsibilities as explained above. I authorize treatment deemed necessary by Asheville Counseling and Wellness Center therapists. I authorize Asheville Counseling and Wellness Center therapists to release to my health plan any and all information that they deem necessary regarding my care and treatment to insure prompt payment of all charges for services provided. I hereby assign the payment for all insurance benefits to Asheville Counseling and Wellness Center therapists for any and all charges incurred in connection with services provided to me. I also consent to a copy of this authorization and assignment being used in place of the original.

______

Client Signature Date

Confidential Client Information

CLIENT NAME: Date:

PRESENTING PROBLEM AND PAST TREATMENT

Please briefly describe why you are seeking counseling:

______

How long have you had this problem? Did something happen before it started?

If you have been diagnosed with a mental disorder, please list here: Have you received mental health treatment before? ____ If so when? Where?

What was the reason for seeking treatment?

What was most helpful about your mental health treatment?

______

What was least helpful about your mental health treatment?

______

Have you had psychological testing before? ____ If so when? Where?

Are you receiving other mental health services such as: Psychiatrist Substance Abuse Treatment Mental Health Supports Case Management Crisis Services

If yes, Provider’s name Phone # Agency

Are you receiving services with Dept of Rehabilitative Services or other Agencies?

Have you ever been hospitalized for psychiatric reasons? If so when?

Where? Briefly describe the reason:

Have you ever had Suicidal thoughts? Yes/No

Have you ever attempted Suicide? Yes/No If so when?______

What was going on that lead to these feelings/thoughts? ______

Have you ever thought seriously about killing someone? Yes/No

Have you ever tried to kill or killed someone? Yes/No

What was going on that lead to these feelings/thoughts? ______

SYMPTOMS

Please check any problems that either you have had in the past or are currently having.

Now Past

Change in appetite (more or less)

Feeling sad

Crying spells

Too little sleep (falling or staying asleep)

Sleep more than usual

Fatigue

Loss of interest &/or pleasure

Avoiding friends or family

Expect failure

Decreased concentration

Thoughts of death

Cutting or burning oneself

Suicide plan or attempt

Depression

Often sick

Loneliness

Slow moving

Hopelessness

Confusion

Worthlessness

Friendly

Lack of confidence/Low self-esteem

Guilt

Reckless or dangerous behavior

Racing thoughts

Pressured speech

Inflated self-esteem

Obsessive thoughts

Compulsive or repetitive behavior

Marital/family problems

Sexual problems

Relationship problems

Long term memory problems

Short term memory problems

Wound up or tense more days than not

Panic attacks

Irritable

Anxiety

Easy going

Muscle tension

Irrational fear of something or someone

Talking/acting w/out thinking

Fidgety, restless, overactive

Difficulty paying attention

Frequent day dreams

Now Past

Bored easily

Learning difficulties

Often lose things

Excessive dieting/exercise

Obsessed with losing weight

Use of laxatives

Engage in self-induced vomiting

Eating things that are not food

Vandalism

Fire-setting

Lack of remorse for wrong-doing

Selfish

Bullies/gets in fights

Lying

Truancy

Theft

Argumentative/sudden anger

Defiant of authority

Temper tantrums

Stubborn

Avoid adults

Afraid to leave a loved one

Easily embarrassed

Upset by minor changes

Feeling detached from one’s body

Feelings of unreality

See or hear things others don’t

Believe things others tell you aren’t true

Fear of strangers

Difficulty trusting

Believe others are out to get you

Intrusive thoughts

Avoid things related to traumatic event

Startle easily

Flashbacks

Nightmares

Other symptoms not mentioned above

How do your symptoms affect your life?

DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult

Name

Age:

Sex: q Male q Female Date:

Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.

During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems? / None Not at all / Slight Rare, less than a day or two / Mild Several days / Moderate More than half the days / Severe Nearly every day / Highest Domain Score (clinician)
I. / 1. Little interest or pleasure in doing things? / 0 / 1 / 2 / 3 / 4
2. Feeling down, depressed, or hopeless? / 0 / 1 / 2 / 3 / 4
II. / 3. Feeling more irritated, grouchy, or angry than usual? / 0 / 1 / 2 / 3 / 4
III. / 4. Sleeping less than usual, but still have a lot of energy? / 0 / 1 / 2 / 3 / 4
5. Starting lots more projects than usual or doing more risky things than usual? / 0 / 1 / 2 / 3 / 4
IV. / 6. Feeling nervous, anxious, frightened, worried, or on edge? / 0 / 1 / 2 / 3 / 4
7. Feeling panic or being frightened? / 0 / 1 / 2 / 3 / 4
8. Avoiding situations that make you anxious? / 0 / 1 / 2 / 3 / 4
V. / 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? / 0 / 1 / 2 / 3 / 4
10. Feeling that your illnesses are not being taken seriously enough? / 0 / 1 / 2 / 3 / 4
VI. / 11. Thoughts of actually hurting yourself? / 0 / 1 / 2 / 3 / 4
VII. / 12. Hearing things other people couldn’t hear, such as voices even when no one was around? / 0 / 1 / 2 / 3 / 4
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? / 0 / 1 / 2 / 3 / 4
VIII. / 14. Problems with sleep that affected your sleep quality over all? / 0 / 1 / 2 / 3 / 4
IX. / 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? / 0 / 1 / 2 / 3 / 4
X. / 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? / 0 / 1 / 2 / 3 / 4
17. Feeling driven to perform certain behaviors or mental acts over and over again? / 0 / 1 / 2 / 3 / 4
XI. / 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? / 0 / 1 / 2 / 3 / 4
XII. / 19. Not knowing who you really are or what you want out of life? / 0 / 1 / 2 / 3 / 4
20. Not feeling close to other people or enjoying your relationships with them? / 0 / 1 / 2 / 3 / 4
XIII. / 21. Drinking at least 4 drinks of any kind of alcohol in a single day? / 0 / 1 / 2 / 3 / 4
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? / 0 / 1 / 2 / 3 / 4
23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]? / 0 / 1 / 2 / 3 / 4

SUBSTANCE USE HISTORY

This information is not used to judge you but to help understand you better

SUBSTANCE History of Use? Date of first Use: Date of Last Use:

Yes No

Alcohol ______

Marijuana ______

Barbiturates ______

Klonopin, Ativan, Xanax,

Valium ______

Cocaine/Crack ______

Heroin/Opiates ______

PCP, LSD, Mescaline ______

Inhalants ______

Amphetamines, Speed,

Uppers, Crystal Meth ______

Designer Drugs, Ecstasy ______

Over the Counter drugs ______

Caffeine ______

Nicotine ______

Other ______

If you are currently using any substances, please describe when and where you typically use: ______

Please describe how your use affects family and friends, including how they perceive your use: ______

How do you perceive your use?

Have you ever received substance abuse treatment? ____ If yes, when/where? ______

Have you ever had the following due to substance use?

Blackouts Hallucinations Seizures Tremors Legal Charges DUI

If you currently or ever have used alcohol and/or recreational drugs or overused prescription drugs, please answer below:

Have you ever felt you ought to cut down on your drinking or drug use? Yes No

Have people annoyed you by criticizing your drinking or drug use? Yes No

Have you ever felt bad or guilty about your drinking or drug use? Yes No

Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?

Yes No

MEDICAL HISTORY

Physician’s Name / Specialty / What are they treating you for? / Dates of treatment
Primary Care Physician

Date of last physical exam:______Date of last dental exam:

Please list all prescription, non-prescription medications, and supplements below:

Name of Medication / Prescribed by / Dosage/Frequency / Helpful? / Side effects/comments
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N

Do you take all your medications regularly, as prescribed?

Please mark X if you now have or ever have had any of these conditions:

Hypertension PMS/painful menstruation Seizures

Heart disease Easy bruising Head injury