Henslin & Associates714-256-4673 Office

745 S. Brea Blvd., Suite 23 714-256-0937 Fax

Brea, CA 92821

Patient Registration Agreement

Therapist: Fee: $ (per -hour)

Please read all the information provided on the following eight pages and print the requested information clearly and completely. Make sure to sign on the bottom of pages three, four and eight. Please give to your therapist when he/she calls you. Thank You.

PATIENT INFORMATION

Last Name: ______First Name: ______MI: _____ Birth Date ___/___/_____

Billing Address:Apt. /Space#:

(Street Address)

City:State: _____ Zip:______

Home Ph#: (_____)______Work Ph#: (_____)______

Pager/Cell#: (_____)______Fax#: (_____)______

Email Address:

Occupation:How Long?:

Work Place:SS#:

(Name)(City)

If student, current grade in school ______Name of School ______

HOW MAY WE CONTACT YOU:

At Home? _____Yes _____No At Work? _____Yes _____No By Cell? _____Yes _____ No

Please indicate any restrictions regarding calls or leaving messages at above numbers______

REFERRAL SOURCE (If applicable)

Name: ______Address: ______

Phone: (_____)______Fax: (_____)______

Do we have permission to secure records? Yes_____ No_____

Primary Care Doctor (if different from above): ______Date of last physical? ___/___/_____

Address: ______City: ______State: _____ Zip: ______

Phone: (_____)______Fax: (_____)______

PARTNER/SPOUSE INFORMATION

Name: ______Work Phone: (_____)______

Employer: ______Occupation: ______

Henslin & Associates714-256-4673 Office

745 S. Brea Blvd., Suite 23 714-256-0937 Fax

Brea, CA 92821

Emergency Contact: Name: ______Phone: (_____)______

Please List the other members of your household:

Name of MemberRelationshipAge or Birth Date

CURRENT MEDICATIONS (use other side if needed)

Name / Strength (mg) / Directions
(ie. 2 pills each morning) / Date Started / Side Effects

ALLERGIES OR UNUSUAL REACTIONS TO MEDICATIONS (Name of medication and reaction)

Medication / Reaction


Henslin & Associates714-256-4673 Office

745 S. Brea Blvd., Suite 23 714-256-0937 Fax

Brea, CA 92821

Confidentiality

Please read the following information carefully:

Confidentiality: The law, professional ethics, and common sense require that whatever is said during a psychotherapy session is not to be shared with a third party without your written permission. However, there are exceptions to this rule you should know about. They are as follows:

  1. If you report to us information that you are currently, or have been, the perpetrator or the victim of child abuse, molestation, or elder abuse, or if you give information about someone else who is doing this, we are mandated, by law, to report it to the authorities.
  2. If you indicate that you intend to injure or take the life of yourself or someone else, we must act to notify potential helpers or victims.
  3. Parents have access to their child’s records but are encouraged to withhold their requests for information to allow the child a greater sense of privacy and thus encourage a stronger therapeutic relationship. Please discuss any limitations to this with your therapist.
  4. If a court of law issues a legitimate subpoena we are required by law to provide the information described in that subpoena. If you are in therapy or being tested by order of a court of law, the results of the treatment or tests ordered must be revealed to the court of law.
  5. If you fail to pay the balance on your account, your account may be turned over to an outside collections agency. We will only turn over that information which will be used to collect on your account. Session notes and topics will remain confidential.
  6. If an insurance company is paying or reimbursing you or us for any part of your fee they often require certain information be released. Information such as billing information, dates of service, diagnosis and clinical information for approval of additional sessions.
  7. To the best of our ability we will maintain confidentiality. However, because of the technical age we live in others can monitor communication without us being aware. At times we use mediums of communication that may not be completely secure, for example cell phones, emails, faxes, cordless phones, etc. We cannot be held responsible if these mediums prove to be insecure.
  8. If you and your spouse are seeking marital therapy together, it will be at your therapist’s discretion to disclose any information you have shared privately with your therapist, to your spouse.
  9. If you choose to invite a person or persons to be present during a session with your therapist, your confidentiality may be compromised. Your therapist will use his/her discretion and reasoning in sharing any information. This may be upsetting or uncomfortable for you. If you feel that specific topics should not be mentioned please notify your therapist in writing prior to the session.
  10. If you are being seen by a registered Marriage, Family, and Child Counseling Intern or Psychological Assistant your case will be discussed with their licensed supervisor.

I have read and understand all of the above, and all of my questions have been answered to my satisfaction. My signature attests to this.

Signature:Date:

(Patients Name)

Signature:Date:

(Parent/Guardian, if patient under 18 years of age)

Henslin & Associates714-256-4673 Office

745 S. Brea Blvd., Suite 23 714-256-0937 Fax

Brea, CA 92821

Concerning Nutritional Advice

Business & Professions Code #2086

This chapter shall not be construed to prohibit any person from providing nutritional advice or giving advice concerning proper nutrition. However, this section confers not authority to practice medicine or surgery or to undertake the prevention, treatment, or cure of disease, pain, injury, deformity, or physical or mental conditions or to state that any product might cure any disease, disorder, or condition in violation of any provision law.

For purposes of this section the terms “providing nutritional advice or giving advice concerning proper nutrition” means the giving of information as to the use and role of food and food ingredients, including dietary supplements.

Any person in commercial practice providing nutritional advice or giving advice concerning proper nutrition shall post in an easily visible and prominent place the following statement in his or her place of business:

“Notice”

“State law allows any person to provide nutritional advice or give advice concerning proper nutrition—which is the giving of advice as to the role of food and food ingredients, including dietary supplements. This state law does NOT confer authority to practice medicine or to undertake the diagnosis, prevention, treatment, or cure of any disease, pain, deformity, injury, or physical or mental condition and specifically does not authorize any person other than the one who is a licensed health practitioner to state that any product might cure any disease, disorder, or condition.”

If you would like a copy of this notice please ask Rachel, in the business office. You may request a copy by phone at (714) 256-2807. By signing below, you acknowledge that you have read and understand this notice.

Signature:Date:

(Patients Name)

Signature:Date:

(Parent/Guardian, if patient under 18 years of age)

Henslin & Associates714-256-4673 Office

745 S. Brea Blvd., Suite 23 714-256-0937 Fax

Brea, CA 92821

Confidential Staffing Option:

One of the advantages of having psychological treatment at Henslin & Associates is our weekly staffing; we need your written consent by signing on the line provided below this section explaining our confidential staffing. You may revoke this consent at any time. Please note, if you do not desire to have your case discussed in staffing, please do not sign on the line provided for this confidential staffing option.

I, , give my permission to my

(Print patient name here)

therapist,

(Print the name of your therapist at Henslin & Associates)

to discuss my case in the weekly Henslin & Associates staff meeting.

Signature:

(Patients Name)

Signature:

(Parent/Guardian, if patient under 18 years of age)

Date of Consent: //

Date revoked consent (if applicable): //

Henslin & Associates714-256-4673 Office

745 S. Brea Blvd., Suite 23 714-256-0937 Fax

Brea, CA 92821

We ask that the following form be fill out. It is for billing purposes only. Any balance at the end of each month will be charged to the credit card listed below. You may revoke your consent in writing and submitting it to the business office of Henslin & Associates at 745 S. Brea Blvd., Suite 23, Brea, CA92821.

Name as it appears on Credit Card: ______

Credit Card Number: ______

Expiration Date: ______

Credit Card Billing Address: ______

______

______

Signature of Card Holder: ______
Henslin & Associates714-256-4673 Office

745 S. Brea Blvd., Suite 23 714-256-0937 Fax

Brea, CA 92821

Office Policies

The following are office policies of Henslin & Associates:

  1. Appointment Time: The standard psychological appointment time is 45 minutes. If you would like to have a longer session time, please discuss this with your therapist.
  2. Missed Appointments and/or Late Cancellation Charges: The time reserved for your therapy session is your time. If you choose not to attend without giving at least 24 hours notice to your therapist, your full appointment rate will be charged.
  3. Payment: You are expected to pay for each session at the time of your appointment. Please make all checks payable to Henslin & Associates. We also accept Visa, Master Card, American Express, and Discover Card. If payment is not made at the time of your visit, please discuss insurance or payment schedules during your initial visit. When you give your payment to your therapist, you will be provided with a statement, which is complete for filing an insurance claim if your insurance reimburses for therapy. If you are unsure please contact your insurance carrier. Clients who carry insurance should remember that we look to the client for payment. We cannot assume that our charges will be paid by an Insurance Company. Any balance remaining on your account for 31 days is subject to be turned over to an outside collections agency.
  4. Records: You have the right to obtain a summary or a copy of your records or to inspect your records. You must make this request in writing and submit it to your therapist or to the business office. The typical fee for making a copy of your record is $35.00. This fee must be paid before or at the time of delivery of your records. We will make your records available within 15 working days of receiving a written request for a copy of your records. If you are requesting a summary, the summary will be available within 10-30 working days.
  5. Phone calls: Most therapists charge for phone calls outside of sessions that relate to therapeutic issues. Generally, the fee is in proportion to the therapist’s hourly charge.
  6. Emails: If your therapist provides this option for contact, charges may be applicable. Generally, the fee is in proportion to the therapist hourly charge.
  7. Other Charges: In applicable cases, it may be necessary to charge you for services provided by your therapist or our office such as court appearances, psychological testing, preparing a professional report, writing letters concerning your case, collateral phone calls, faxing documents, or for materials such as books, videos, or cassette tapes. You will be notified of any charges.
  8. Insurance Billing: Each therapist has his or her own policy for billing insurance. We cannot assume that an insurance company will pay our charges therefore the client is responsible for all charges to their account. Most of our therapists do not bill insurance; we leave it up to the client to handle directly with their insurance company. Please check with your therapist to find out their policy on insurance claims.
  9. Returned Checks: There is a $25.00 fee for all returned checks. This $25.00 fee must be paid separately from any other payment, and made out to Henslin & Associates. After a second returned check on any account, we will go to a cash only basis.
  10. Collections: Any balance remaining on your account for 31 days is subject to be turned over to our collections agency.
  11. Medication: We do not provide any medication. If medication seems indicated, we maintain close working relationships with a number of physicians and psychiatrists and will gladly refer you to these practitioners. Any discussion of medication with a therapist is for informational purposes only. It is never a substitute for discussing medication with your physician.
  12. Treatment of Minors: In relation to treating minor(s) (children underage 18) it is our office policy to have written consent from all parties with legal custody of the minor(s). If you have sole custody of your child please provide a copy of the custody order to your therapist before or during the first session.
  13. Childcare Policy: We do not have staff available for childcare of minor children (under 17 years of age). Please do not leave your children unsupervised at any time in our waiting area. It is the parent or patient’s responsibility to either supervise or provide childcare for their children while they are here for an appointment. ______Initial
  14. Risks: Unfortunately, there are no guarantees and there are potential risks to psychotherapeutic treatment. Risks may include experiencing uncomfortable levels of feelings like sadness, anxiety, anger, frustration, etc. and may include recalling unpleasant aspects of their personal history. People sometimes report feeling worse before feeling better. On occasion, as people make positive changes and become stronger; they may change in such a way as to grow apart from important people in their life or may grow closer. Our preference is for relationships to grow stronger, but it takes two to build a positive relationship. You have the right to ask questions about procedures used during therapy. You also have the right to prevent the use of certain therapeutic techniques. Your therapist will inform you of any intention to use any unusual procedures and shall describe any risks involved.
  15. Termination: At any time during our work together, you have the right to decide to end treatment, and there is no moral, legal, or financial obligation other than to pay for the services already rendered or cancellation charges accrued. You are encouraged to discuss with your therapist any thoughts about ending and if you wish, names of other therapists will be provided. During the first couple of meetings your therapist will assess if he or she can be of benefit to you. The therapists at Henslin & Associates do not accept clients who, in their opinion they do not feel they can help. If this is the case, the therapists will provide you with a referral. If at any point during treatment the therapist assesses that he or she is not effective in helping you reach the therapeutic goals and if appropriate treatment may be terminated. In such a case the therapist will provide you with referrals. If you request it and authorize it in writing, your therapist will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, your therapist at Henslin & Associates will assist you in finding someone qualified, and if your therapist at Henslin & Associates has your written consent, your therapist will provide the essential information needed to the new therapist.

Please feel free to discuss any questions or concerns about your Patient Registration Agreement, Therapy Sessions or services provided with your therapist.

I have taken time to read, understand, and asked any questions about the foregoing statements, and I agree to follow the policies of Henslin & Associates. The information I have given is accurate to the best of my knowledge. I have been offered a copy of this paperwork.

Date: //

Patient Signature:

Date: //

Parent/Guardian Signature (if patient is under 18 years of age):

Date: //

Parent/Guardian Signature (if patient is under 18 years of age):

If joint legal custody 2 signatures required.

Date: //

Therapist Signature:
Amen Adult General Symptom Checklist

Copyright 1997 Daniel G. Amen, MD

Please rate yourself on each of the symptoms listed below using the following scale. If possible, to give us the most complete picture, have another person who knows you well (such as a spouse, partner or parent) rate you as well. List other person______

0 1 2 3 4NA

NeverRarely OccasionallyFrequentlyVery Frequently Not Applicable/Not Known

Other Self

______1. Feeling depressed or being in a sad mood

______2. Having a decreased interest in things that are usually fun, including sex

______3. Experiencing a significant change in weight or appetite, increased or decreased

______4. Having recurrent thoughts of death or suicide

______5. Experiencing sleep changes, such as a lack of sleep or a marked increase in sleep

______6. Feeling physically agitated or of being "slowed down"

______7. Having feelings of low energy or tiredness

______8. Having feelings of worthlessness, helplessness, hopelessness or guilt

______9. Experiencing decreased concentration or memory

______10. Having periods of an elevated, high or irritable mood

______11. Having periods of a very high self-esteem or grandiose thinking

______12. Having periods of decreased need for sleep without feeling tired

______13. Being more talkative than usual or feeling pressure to keep talking

______14. Having racing thoughts or frequently jumping from one subject to another

______15. Being easily distracted by irrelevant things

______16. Having a marked increase in activity level

______17. Excessive involvement in pleasurable activities that have the potential for painful

consequences (e.g., spending money, sexual indiscretions, gambling, foolish business ventures)

______18. Experiencing panic attacks, which are periods of intense, unexpected fear or emotional discomfort (list number per month ____)

______19. Having periods of trouble breathing of feeling smothered

______20. Having periods of feeling dizzy, faint or unsteady on your feet

______21. Having periods of heart pounding or rapid heart rate

______22. Having periods of trembling or shaking

______23. Having periods of sweating

______24. Having periods of choking

______25. Having periods of nausea or abdominal discomfort/trouble

______26. Having feelings of a situation "not being real"

______27. Experiencing numbness or tingling sensations

______28. Experiencing hot or cold flashes

______29. Having periods of chest pain or discomfort

______30. Fearing death

______31. Fearing going crazy or doing something out-of-control

______32. Avoiding everyday places for 1) fear of having a panic attack or 2) needing to go with other people in order to feel comfortable

______33. Excessive fearing of being judged by others, which causes you to avoid or get anxious in

situations

______34. Experiencing persistent, excessive phobia (heights, closed spaces, specific animals, etc.) please list ______