Claire E. Jacobs, Ph.D

Claire E. Jacobs, Ph.D.

Clinical Psychologist

14607 San Pedro Ave Suite 295

San Antonio, TX78232

(210) 403 -2050 FAX (210) 403 - 9890

Adult-Self Assessment

Name:______Date of birth: ______

Address: ______

Home Phone#: ______Work#: ______

Cell Phone#: ______Carrier: ATT Sprint TMobile Verizon other

Email address:______

Emergency Contact: ______Emergency Contact#:______

Who referred you to my office?

Please state the principal reason you are requesting consultation/treatment:

Sex: Male/FemaleMarital status:[] single[] married[] separated

[] divorced[] widowed[] other ______

Race:[] Caucasian[] African American[] Oriental[] Hispanic[] other

Marriages: [] none[] one[] two[] three Divorces:[] none[] one[] two[] three

Occupation: ______

Highest level of education: [] 6th or fewer [] 7th[] 8th[] 9th[] 10th[] 11th[] 12th

College level:[] 1[] 2[] 3[] 4If degree, in what? ______

Who lives with you at home and what is the relationship?

______

Suicide:

Have you ever thought about suicide? [] yes[] no

If yes, when was the last time? ______

Have you ever attempted suicide? [] yes[] no

If yes, when and how? ______

Do you have thoughts about suicide now? [] yes[] no

Injury to others:

Have you ever thought about hurting someone else? [] yes[] no

Are you thinking of hurting someone now? [] yes[] no

If yes, who and why? ______

Recent stressful life events:

Check any of the following that have occurred within the last 2 years:

[] married[] engaged[] separated[] divorced

[] serious argument[] break-up of important relationship

[] difficulty with family members

[] problems with child(ren)[] death of friend or family member

[] bad health[] personal injury, illness

[] sexual difficulties[] changes at school/work[] retired/lost job

[] changed residences[] legal difficulty[] financial difficulties

Family History:

List any mental health histories relating to immediate family members

(including suicide, drug abuse, alcoholism, depression, anxiety, etc.):

Mother:

______

Father:

______

Brothers: ______

Sisters:

______

Children:

______

Grandparents, Aunt/Uncle, cousins, other relatives:

______

Drinking (Alcohol use):

How many drinks do you consume in the average day? ______

At what time of the day do you have your first drink? ______

What is the most you had to drink in a 24-hour period in the last year?______

Was there ever a time when you felt you were, or someone told you that you were drinking too much? [] yes [] no If yes, under what circumstances? ______

Drugs (of abuse):

Check any drugs you have taken: [] none[] marijuana[] amphetamine/speed

[] heroin/opiates[] PCP[] LSD/hallucinogens

[] Cocaine/crack[] barbiturates/sedatives/downers

[] Others ______

When was the last time you took such drugs? ______

Past History:

As a child and adolescent did you experience any of the following:

[] afraid to go to school[] difficulty with math, reading or writing[] frequent falls

[] awkward at games[] wet bed after age 5[] had tics

[] had trouble with eyes[] left handed[] nightmares

[] stutter, stammer[] fear of the dark[] ran away

[] cruel to animals[] lied to family or others[] set fires

[] moved frequently[] exposed to incest[] promiscuous

[] exposed to physical abuse

Medical History:

What is your weight: ______height: ______

Has your weight increased or decreased by more than 10 pounds in the last 3-5 years? ______

Comments/explain circumstances:______

______

Name of Physician:

Address & Phone Number:

Medications you are currently taking (include dose if known):______

______

Sleep:

Do you:

[] fall asleep without difficulty [] have difficulty falling asleep

[] have difficulty getting back to sleep[] wake up still tired[]have insomnia

[] have bad dreams[] sleep walk[] wet the bed

[] other ______

Tobacco:

Do you smoke?[] yes[] noIf yes, for how long and how much? ______

Caffeine:

Do you drink:[] coffee [] tea [] colasIf so, how much? ______

Are you sensitive to caffeine? [] yes[] noComment: ______

Allergies:

List all allergies. Please be sure to include medication allergies: ______

______

Medical problems:

List all past and present medical problems as well as any surgery or accidents, also give age when they occurred: ______

______

Hospitalizations (please list reason for the hospitalization, the place & date):

Medical: _

Psychiatric Hospitalizations: ______

Please use the following space for any other information you may want Dr. Jacobs to know about yourself prior to being seen:

______

What are your goals for treatment here?

Client signature:______Date: //

Therapist signature: Date: //

Claire E. Jacobs, Ph.D.

Clinical Psychologist

14607 San Pedro Ave Suite 295

San Antonio, TX78232

(210) 403 -2050 FAX (210) 403 - 9890

Adult

OFFICE POLICIES AND PROCEDURES

Below are listed some important facts related to treatment. Please read this carefully and feel free to ask any questions. Please keep this information for your records.

Session Duration: Sessions are generally 40-45 minutes. If you are late for a session, the time will be lost in that session. Arrangements can be made to schedule longer sessions when they are appropriate for your needs. If a telephone session is needed, time can be arranged. A fee is charged for these sessions. Please note, phone sessions are not covered by many insurance plans.

Scheduling Policy: Please note, Dr. Jacobs’ schedule fills up quite quickly. In order to avoid unexpected gaps between sessions, the office staff will be happy to schedule several appointments ahead for you if you wish. Please note the cancellation policy below, however.

Cancellation/No-Show Policy: If you need to cancel or reschedule an appointment, please notify the office as soon as possible, at 210-254-4574or at 210-403-2050. Appointments that are not kept (no-shows) or which are cancelled without 24 hour notification will be billed at a rate of $50 and that amount will be charged to the credit/debit card we have on file for you. Please note that insurance companies do not cover that cost. If you no-show for two consecutive appointments,we reserve the right to cancel any additional scheduled sessions and you must contact the office and make arrangements to bring your account current before additional sessions can be scheduled.

Office Hours: Sessions are scheduled by appointment only. If you need to reach the doctor between regularly scheduled appointments, you can leave a message at 210-254-4574or at (210) 403-2050. Your call will be returned as soon as possible.

Emergency/On-call Services: Please note that Dr. Jacobs is not readily available to handle emergency calls. If the situation warrants immediate medical attention, please dial 911 or proceed directly to the emergency room.

Confidentiality: All information and records will be kept confidential, and will be held in accordance with state laws regarding the confidentiality of such records and information. Currently, both law and professional ethics require therapists to maintain complete confidentiality in the vast majority of cases. In these cases, the therapist cannot release any information about you or your family without your express permission. Records and/or information will be released regardless of consent under the following circumstances:

Limits to Confidentiality:

If the therapist has reason to believe that a health care professional has engaged in professional misconduct;

If the patient introduces his or her mental condition as a defense in a legal proceeding;

If the patient/family initiates legal action against the therapist;

If a judge orders the therapist to release patient information related to legal proceedings;

According to the state and local laws, therapists must report all cases of suspected physical and sexual abuse or neglect of minors, elderly or handicapped to the appropriate agencies;

According to the state and local laws, therapists may report all cases in which there exists a danger to self or others to the appropriate people or agencies.

It should also be noted that insurance companies reimbursing mental health services require information about these services. Therefore, if you are using insurance to pay for your treatment, information will be released to your insurer.

Finally, if your account is delinquent and you have not made appropriate arrangements with the office, confidentiality would be breached by giving your name to a collection agency.

Claire E. Jacobs, Ph.D.

Clinical Psychologist

14607 San Pedro Ave Suite 295

San Antonio, TX78232

(210) 403 -2050 FAX (210) 403 - 9890

OFFICE POLICIES AND PROCEDURES

Limits to Confidentiality:

If the therapist has reason to believe that a health care professional has engaged in professional misconduct;

If the patient introduces his or her mental condition as a defense in a legal proceeding;

If the patient/family initiates legal action against the therapist;

If a judge orders the therapist to release patient information related to legal proceedings;

According to the state and local laws, therapists must report all cases of suspected physical and sexual abuse or neglect of minors, elderly or handicapped to the appropriate agencies;

According to the state and local laws, therapists may report all cases in which there exists a danger to self or others to the appropriate people or agencies.

Finally, if your account is delinquent and you have not made appropriate arrangements with the office, confidentiality would be breached by giving your name to a collection agency.

I indicate by my signature that I consent to mental health treatment and that I understand and consent to the conditions described above. I also know that I may ask questions at any time.

Signature: Date: ______

Claire E. Jacobs, Ph.D.

Clinical Psychologist

14607 San Pedro Ave Suite 295

San Antonio, TX78232

(210) 403 -2050 FAX (210) 403 - 9890

Financial Policy and Payment Arrangements

Payment of fees: Payment is expected at each visit. This office will assist in completing health insurance claims, however, the patient, not the insurance company, is responsible for payment of the bill. If anotherarrangement is necessary, please consult with Dr. Jacobs. All efforts will be made to work out an acceptable method of payment. If the patient fails to keep the arrangement agreed upon, this office reserves the right to utilize an outside collection agency to collect delinquent accounts.

Cancellation Policy: If you need to cancel an appointment, please notify Dr. Jacobs’ office as soon as possible. Without at least 24 hours’ notice, a missed appointment will be charged to you at $50 and that amount will be charged to the preferred credit/debit card we have on file for you. This fee will NOT be billed to your insurance company; insurance does not cover the fee for a missed appointment. You are responsible for this fee.

Preferred Credit/Debit Card #:______

Expiration Date:______CVC code (3-digit code on back of card): ______

A MISSED APPOINTMENT WITHOUT 24 HOUR NOTIFICATION WILL BE CHARGED $50.

Fee Schedule:

Initial Intake (Adults)$185.00

Initial Intake (Child) $185.00

Individual Psychotherapy $150.00

Marital/Family Therapy $150.00

Inpatient Services – 45 minutes$150.00

Psychological Testing(nonforensic)$150.00/hr

Forensic Services (including eval)$250.00/hr

Additional Services:

Requested Letters$ 50.00

Depositions, Court Appearances & Preparation Time$250./hr

Telephone Calls: Under 15 minutesno charge

15-30 minutes$50.00

each 10 minutes after$15.00

I understand that my $______Co-Pay is to be paid at each session.

My signature below indicates that I have read and agree with the Financial Policy and Payment Arrangements as described above.

Signature Date

Claire E. Jacobs, Ph.D.

Clinical Psychologist

14607 San Pedro Ave Suite 295

San Antonio, TX78232

(210) 403 -2050 FAX (210) 403 - 9890

Billing Information:

Policy Holder/Responsible Party: Last Name:First:

Date Of Birth: Age: Sex: M F (circle) Marital Status:

Social Security#: Driver’s License:

Address: ______

Street City State Zip Code

Employment Information: (Policy Holder/Responsible Party)

Occupation:

Employer:

Address:

StreetCityStateZip Code

Primary Insurance:

Insurance Name:

Subscriber’s Name: ID/Policy #

Date of Birth: Phone#: Group#:

Address: Street City State Zip Code

Secondary Insurance:

Insurance Name:

Subscriber’s Name:ID/Policy #

Group Name#:Group#:

Address:

Street CityStateZip Code

Payment of fees is your responsibility, not your insurance company’s. My office will help by filing your insurance for you, if you wish, or you may file yourself. If we file your insurance and receive payments that are less than the allowed charges incurred, you are responsible for paying the balance.

Your signature below authorizes my office to release all information necessary to process your claims (including but not limited to your diagnosis, progress in treatment and treatment plan).

Signature of Responsible Party Date

Claire E. Jacobs, Ph.D.

Clinical Psychologist

14607 San Pedro, Ste. 295

San Antonio, TX78232

(210) 403-2050 (210) 403-9890

CONSENT FOR RELEASE OF INFORMATION

PATIENT’S NAME: DOB:

SOCIAL SECURITY NUMBER:

I, , authorize Claire E. Jacobs, Ph.D., Clinical Psychologist, practicing at 14607 San Pedro, Ste.295, San Antonio, TX 78232

( ) To Provide Information To: ( ) To Receive Information From:

( ) To Speak By Telephone with:( ) Other ______

The Following Information:

( ) Intake/Social History( ) Psychological Testing Report

( ) Clinical/Treatment Summary( ) Termination Summary

( ) Treatment Plan( ) Other

For the purpose of: ( ) insurance claim ( ) continued care by another provider

( ) academic placement/evaluation ( ) other

I, the undersigned, understand that I may revoke this consent at any time except to the extent that action has already been take in reliance on it. In any event, this consent will expire in within ninety (90) days from when it was signed, unless another date or condition is indicated below.

( ) Release is effective until treatment is terminated.

( ) Release if effective until the date indicated: ______

To the party receiving this information: This information has bee n disclosed to you from records, whose confidentiality is protected by federal law. Federal regulations (42CRF Part 2) prohibits you from making further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.

Signature of Patient Date

TEXAS NOTICE FORM (HIPAA)

Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations: I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

“PHI” refers to information in your health record that could identify you.

“Treatment, Payment and Health Care Operations”– Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist. - Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. - Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business- related matters such as audits and administrative services, and case management and care coordination.

“Use” applies only to activities within my office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization: I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.