C.A. Larson, MC, LPC
9929 N 95th Street, Suite 101
Scottsdale, AZ 85258
480.620.9651
Intake Information
Date:______Insurance ID No: ______
Name:______
Address:______Apt:______
City:______Zip:______
Date of Birth:______Social Security:______
Religion:______Education:______
Employer:______Occupation:
How do we contact you? Please include area code.
Phone: H______W______
Cell______Email______
Do you have objection to being contacted by phone, mail, or email? YES ______NO ______
Please specify:
Where do you want me to call you?______
Where do you want me to leave a message?______
Is it ok to email you if necessary?______
Who do we contact in case of an emergency?
______
Address: ______Phone ______
Your Marital Status:______
Why are you here? ______
Who referred you? ______
Prior Psychological Consultation? No Yes
When and with whom? ______
Have you ever been hospitalized for Psychiatric Reasons? No Yes
When and Where? ______
Family Members and Others Now in Household:
Name Relationship Age Marital Status
______
Occupational History:
How many hours/week are you employed?______
How long have you worked at your current job?______
Have you ever been fired or let go from a job?______
If so, please explain circumstances______
Has there been a major change in your income recently
or income stopped? Yes No
Have you ever been arrested?YesNo
Have you ever been convicted of a crime?YesNo
Are you presently on parole or probation?YesNo
If yes, please explain
Are you currently, or have been involved in a lawsuit?Yes____No
If yes, please explain: ______
Marital/Partner History—Please give year of marriage(s):
From______To ______
From______To______
How many children do you have?______
Do they live with you? YesNo
Alcohol and Drug History:
Past Psychiatric/Substance Abuse History (including hospitalizations, Recovery programs, AA,
other 12-step groups? No Yes
If yes describe______
Please show your history of substance abuse using the following scale
1-Daily 2-Weekly 3-Monthly 4-Never use
Alcohol/Drug History Current Past
Alcohol ______
Tobacco ______
Caffeine ______
Marijuana ______
Stimulants ______
Diet Pills ______
Narcotics/Pain Killers ______
Sleeping Pills ______
Other ______
Have you ever lost time from work due to drinking/drug use? ______
Have you ever been arrested for DUI or other alcohol/drug-related offenses?
No Yes
If so, how many times? ______
Have you ever chosen to quit/cut down? No Yes
Have you ever experienced withdrawal symptoms? No Yes
Have other (family, friend, spouse, MD, employee) expressed concern or anger about your
alcohol or drug use? No Yes
Has anyone in your family had a history of heavy alcohol/drug use? No Yes
If yes who? ______
Have you ever considered suicide? If so please explain ______
Have you ever experienced physical, sexual, or emotional abuse? No Yes
Current Medications: Dose/ Frequency
______
______
______
Prescribing Physician: ______
Primary Care Physician:______
Primary Care Physician office number:______
Allergies: ______
Family History: Relationship to client
Emotional Problems: Y N ______
Substance Abuse: Y N ______
Cardiovascular Disease: Y N ______
Hypertension: Y N ______
Kidney Disease: Y N ______
Respiratory Disease: Y N ______
Cancer: Y N ______
Diabetes: Y N ______
Substance Abuse: Y N ______
Personal History:
Emotional Problems Y N ______
Cardiovascular Disease: Y N ______
Diabetes: Y N ______
Thyroid Abnormalities: Y N ______
Head Injuries: Y N ______
Respiratory Disease: Y N ______
Neurological Disorders: Y N ______
Do you smoke? Y N ______
How much per day? ______For how many years?______
Substance Abuse Y N ______
Hypertension: Y N ______
Liver Disease: Y N ______
Tuberculosis: Y N ______
Cancer: Y N ______
Other: ______
NOTICE OF PRIVACY PRACTICES
(Effective April 14, 2003)
THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION IS PROTECTED AND CONFIDENTIAL. IT ALSO DESCRIBES THOSE CIRCUMSTANCES WHERE IT MAY BE USED AND DISCLOSED IN COUNSELING AND HOW YOU CAN GET ACCESS TO THIS INFORMATION IF YOU WISH TO DO SO. PLEASE REVIEW IT CAREFULLY.
UNDERSTANDING YOUR PROTECTED HEALTH INFORMATION (PHI)
Except in the instances described in this Notice, the information you share with those of us in this office is confidential to this office only. It is our objective to follow, at all times, the Federal and State laws applicable to psychological and substance abuse services under the HIPPA standards or the federal Health Insurance Portability and Accountability Act, 45 CFR Part 464 (HIPAA). Toward that end, this notice addresses (a) the Use and Disclosure of Protected Health Care Information (PHI), specifically outlining in which instances your authorization is not needed, (b) Your Health Information Rights, and (c) My responsibilities to you.
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
The information you share with your counselor is completely confidential. Exceptions and limitations to client confidentiality are described later in this document under Uses and Disclosures with Neither Consent nor Authorization. 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:
oPHI: refers to information in your health record that could identify you.
oI may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained.
"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 or 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.
oTreatment, 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 counselor
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 healthcare 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 assessments and improvement activities, business-related matters such as audits and administrative services and case management and care coordination.
Use applies to activities within my office (office, practice group etc) such as sharing, employing, applying, utilizing, examining and analyzing information that identifies you. Disclosure applies to activities outside of my (office, practice group, etc) such as releasing, transferring, or providing access to information about you to other parties.
You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under thepolicy.
USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION
I may use or disclose PHI without your consent or authorization in the following circumstances. These are exceptions to and Limitations of Client Confidentiality:
1)Disclosures for threats to safety: If you communicate to me an explicit threat of imminent serious physical harm or death to a clearly identified or identifiable victim(s) and I believe you have the intent and ability to carry out such a threat, I have a duty to take reasonable precautions to prevent the harm from occurring, including disclosing information to the potential victim and the police and in order to initiate hospitalization procedures. I have a duty to warn others of a threat. If you believe there is an imminent risk that you will inflict serious harm on yourself I may disclose information in order to protect you
2)Child abuse: I am required to report PHI to the appropriate authorities when I have reasonable grounds to believe that a minor is or has been the victim of neglector physical and/or sexual abuse. A report may be made to the appropriate government authorities without our seeking authorization
3)Adult and Domestic Abuse: If I have the responsibility for the care of an incapacitated or vulnerable adult, I am required to disclose PHI when I have a reasonable basis to believe that abuse or neglect of the adult has occurred or that exploitation of the adult's property has occurred. I am required by law to report situations in which I believe elder abuse or neglect has occurred. This report may be made to the appropriate government authorities without our seeking authorization.
4)Judicial and Administrative Proceedings Court orders and Subpoenas: If you are involved in a court proceeding and a request is made for information about the professional services I provided you and/or the records thereof, such information is privileged under state law, and I will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case. The mere issuance of a subpoena does not indicate that a privileged communication is now open for discussion. I must still assert the privilege until you waive it, or unless a judge orders the privilege to be waived.
5)Health Oversight Activities: If the AZ Board of Social Work Examiners is conducting an investigation, then I am required to disclose PHI upon receipt of a subpoena from the Board.
6)Workers Compensation: I may disclose PHI as authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.
YOUR HEALTH INFORMATION RIGHTS PATIENT RIGHTS
You have the right to:
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not requires to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at alternative locations. You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address)
Right to Inspect Copy: You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is - maintained in the record. I may deny your access to PHI under certain circumstances, but in somecases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
Right To Amend: You have the right to an amendment of PHI as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.
Right To Accounting: You generally have the right to receive an accounting of disclosures of PHI. On your request, I will discuss with you the details of the accounting process.
Right to a paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you agreed to receive the notice electronically.
MY RESPONSIBILITIES TO YOU
I am required by law to:
Maintain the privacy o your PHI and provide you with notice of our legal duties and privacy practices with respect to your protected health information.
Reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
Revise my policies and procedures. If I do so, I will post notification in the office. You may receive a copy of the revision by request.
COMPLAINTS
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may in writing state the compliant. You will receive a written response in writing within 30 days.
You may also send a written complaint to the Secretary of the U.S. Department of Human and Health Services.
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on April 14, 2003.
I have read, understood and agreed to the information stated in this document.
Signature