3735 Mt. Juliet Rd, Suite 100

Mt. Juliet, TN 37122

Today’s Date:

Client Information

Name _ SS#

Address:

City/State: Zip:

E-Mail address: Mobile Phone:

Home Phone: Office Phone:

Employer Occupation/School:

Emergency Contact Person: Phone

Referred to this office by:

May I thank the person(s) who referred to you? YES NO

If referred by a doctor or therapist, would you like me to send a summary of our first session? YES NO

Please complete the section below if someone other than the client is responsible for the bill.

Name _ Relationship to Client

Address:

City/State: Zip:

E-Mail address: Mobile Phone:

Home Phone: Office Phone:

Occupation and Employer

Employer’s Address and Phone Number:

X Signature of client or Legal Guardian

Rbs Insurance verification form

Client questionnaire

Page 15 of 15

Psycho/Social/Medical Information

Date of Birth: Purpose of Visit:

Marital Status M S D W Number of times married:

Length of marriages:

Number of Children: Ages:

Number of Stepchildren: Ages:

Persons Living in Household

Name / Relationship / Age

Children living outside the household? YES NO

Name / Locstion/Relationship / Age

Current School/Employment:

Name of School Religion (optional)

What do you like best about your work?

Number of jobs in past five years Years of education completed

Past or Present Legal problems? YES NO If yes, describe:

Have you ever been hospitalized for any psychiatric issues/chemical dependency? YES NO

If YES, please complete information below

Dates / Name of Facility / General outcome of treatment

Previous Outpatient Therapy

Therapist(s) / Approximate Dates / Location / Was it Helpful

Primary Care Physician:

Specialists you see:

Current Medication

Name / Dosage / Prescribing Physician

Medications within the past year:

Do you drink alcohol? How often

How much Age of first drink

Do you use drugs recreationally? if so, which ones

Do you think you have a problem with drugs or alcohol?

Have you ever had problems in work or relationships because of substance abuse?

If so, please describe.

Do others think you have a problem with alcohol and other drugs?

What are the past or present circumstances relevant to your decision to come to therapy at this time?

What do you like best about yourself?

When you make the changes or decisions that you want to make, how will you and your life be different from now?

Have you ever attempted suicide?

If yes, please explain when, circumstances and method.

Have you had suicidal thoughts or plans within the past year?

Are you currently having suicidal thoughts or plans?

Have you ever had problems with anger, rage or aggressive behavior?

If yes, please describe history:

Have you ever had – or are your currently experiencing – urges or plans to hurt or kill someone?

If yes, please explain:

Please list significant emotional or medical problems of family.

Please circle any conditions listened that you’ve HAD or ARE CURRENTLY EXPERIENCING

Condition / Approximate date(s) of onset/additional details / Experiencing
Now?
Alcohol use
Anger
Anorexia
Anxiety episodes/symptoms
Bereavement
Bizarre thoughts
Body image distortion
Bullying
Compulsive drinking
Compulsive drug use
Compulsive eating/bulimia
Compulsive sexual activity of some kind
Compulsive spending
Compulsive working
Condition / Approximate date(s) of onset/additional details / Experiencing
Now?
Confusion
Cruelty
Depression
Destructiveness
Drug use
Encopresis (soiling)
Enuresis (bed wetting)
Excessive sleeping
Fatigue/loss of energy
Fatigue/Loss of interest in activities
Feeling inferior
Feelings of hopelessness
Fire setting
Frequent crying
Harming animals
Condition / Approximate date(s) of onset/additional details / Experiencing
Now?
Headaches
Hearing voices
Hyperactivity
Impulsivity
Inattention
Increase of appetite
Insomnia (can’t sleep)
Jealousy
Loneliness
Loss of appetite
Loss of interest in activities
Loss of memory/missing time
Lying
Memory problems
Nervousness
Condition / Approximate date(s) of onset/additional details / Experiencing
Now?
Nightmares
Obsessive (repetitive or hypervigilant) thinking or behavior
Oversensitivity
Phobias/Fears
Physical abuse of someone by you
Seeing visions
Sexual abuse of someone by you
Sexual conduct
Shyness
Smoking cigarettes
Stealing
Stomach trouble
Suicidal thoughts
Talking back
Traumatic experience
Condition / Approximate date(s) of onset/additional details / Experiencing
Now?
Unhappiness
Victim of physical abuse
Victim of sexual abuse

Psychotherapy Services Consent Form

Client Information

Client Name _ Today’s Date

SS# - - Date of Birth Living With

Primary Responsible Party (Person responsible for any charges or fees not covered by insurance)

Responsible Party _ Relationship to Client

Address:

City/State: Zip:

Responsible Party SS# - -

Responsible Party Date of Birth

Responsible Party Employer

Responsible Party Work Phone:

Responsible Party Home Phone:

Responsible Party Cell Phone:

Insured Party (Person carrying the insurance that covers the client. Please indicate if same as above)

Insured Party _ Relationship to Client

Address:

City/State: Zip:

Insured Party SS# - -

Insured Party Date of Birth

Insured Party Employer

Insured Party Work Phone:

Insured Party Home Phone:

Insured Party Cell Phone:

Referral Source

Name _ Telephone

Address:

City/State: Zip:

Relationship to Client

Informed Consent for Psychotherapy Services

I voluntarily consent to participate in the assessment and treatment that may be performed during this visit, or a series of visits.

I hereby authorize Ms. Scott or her designated staff to release to any appropriate insurance-related entity or collection agency the information needed to collect payment for services rendered.

I hereby authorize Ms. Scott or her designated staff to notify the above named referral source of having made this appointment. This alone will be disclosed to the referring professiona and is done as a professional courtesy.

I understand that payment is due in full at the time of services rendered. Should my account become delinquent and be referred to a third party for collection effort, I agree to pay all reasonable attorney’s fees, court costs and any collection expenses.

I authorize the payment of my insurance benefits directly to Ms. Scott on my behalf. I understand that I am responsible for all deductibles, co-insurance and non-covered costs.

I understand that clients are seen by appointment only and that any appointment cancellation made less than one business day in advance of the scheduled time will incur a cancellation fee equal to the regular session fee. (note: Insurance companies do not reimburse for missed appointments)

I understand that I will be responsible for compensating Ms. Scott at the rate of $240/hour for court related services if she must prepare for or spend time in court on behalf of the client or client family. A deposit in the amount of $350 is required prior to the court date.

I understand that the information shared with Ms. Scott or her designated staff is completely confidential with the following exceptions:

·  If any person being treated threatens violence or harm to him/herself or to another person, Ms. Scott or her designated staff will contact the appropriate people to ensure ???????

·  Ms. Scott and her designated staff are bound by law to report any suspicion of child or elder abuse to the appropriate authorities

·  Ms. Scott and her designated staff will comply with any and all valid court orders including those to release confidential information

·  Ms. Scott and her designated staff regularly consults with other therapists during which she discusses the specific aspects of psychotherapy sessions in order to ensure quality treatment. Nevertheless, the consulting therapist is bound by the same confidentiality as Ms. Scott. Information of any kind about your treatment or appointments will not be released without your prior written permission, except as outline above or as required by law.

Emergencies

Office hours are by appointment only. In case of emergencies, you may contact your nearest hospital emergency room. You may also call the Crisis Intervention Center 24 hours a day at 244.7444.

Please sign below and indicate the date that you have read and agree to the arrangements outlined above concerning psychological services provided by Ms. Scott and her designated staff. You may request a copy for your records.

Client Signature Date

Signature of the Responsible Party Date

(Relation to client: )

FEES POLICY

Alcohol/Drug Assessment / $300
Initial Interview/Assessment / $130
Individual Psychotherapy (50 minutes) / $90
Couples Therapy (50 minutes) / $90
Family Therapy (50 minutes) / $90
Group Therapy (90 minutes) / $40
Telephone Calls over 10 minutes / Charged at hourly rate
Returned Check / $25
Appointment No Show / $90
Appointment Cancellation less than 24 hours / $90

PAYMENT POLICY

Fees or Co-Pay due in full at the time of your session. Please have your check made out to Sara Scott ready before the beginning of your session, as this will preserve the full time for your session. Service fee for returned checks applies.

As a courtesy to you, I am willing to file your insurance claim. You are responsible, at the time of your session, to pay any fees not covered by your insurance company (i.e. co-pay or deductible). Should your insurance company refuse to pay or if you change insurance policies you are responsible for any unpaid charges. I also reserve the right to stop filing for you if your insurance company is excessively slow in payment or if I change my policy. You will be notified if any of these circumstances arise.

For balances over 30 days, the maximum allowable rate will be applied. You are responsible for the balance plus interest charged. I reserve the right to collect unpaid fees/charges through any standard means of collection, as well as any reasonable costs incurred in the process of collection.

APPOINTMENT CANCELLATION POLICY

Should it become necessary for you to cancel your appointment, you need to notify me at least 24 hours prior to your appointment to avoid the cancellation fee. Note that you are responsible for the late cancellation fee, as your insurance company will not pay for missed sessions.

I have read and understand the Fees Policy, Payment Policy and Appointment Cancellation Policy.

Client (Guardian) Signature Date

Therapist/Witness Date

Rbs Insurance verification form