JOHNSTON PSYCHIATRIC ASSOCIATES

REGISTRATION INFORMATION

PATIENT INFORMATION
First Name:______MI: ______Last Name:______Social Security:______
Street Address:______City:______State:______Zip:______
Sex: M F Date of Birth: ______Age:______Marital Status: Single Married Divorced Widowed Separated
Employer and Employer’s Address: ______
Work Phone: ______Home Phone: ______Cell Phone:______
Student Status: Full Time: Part Time Name of School:______
Emergency Contact Name:______Telephone Number:______
Relationship to You: Spouse/Partner Parent Other:______Permission to Contact in Case of Emergency? Yes or No
**At which telephone number should we leave reminder calls (CHOOSE ONE)? Work Home Cell Other ______
RESPONSIBLE PARTY INFORMATION
*The responsible party is the person responsible for payment (which may or may not include insurance coverage if you are a dependent)*
Patient’s relationship to responsible party: Self If self, information below is: Same as Above (Proceed to “Insurance Information”)
Spouse Dependent If spouse or dependent, complete the following sections.
First Name:______MI: ______Last Name:______Social Security:______
Street Address:______City:______State:______Zip:______
Sex: M F Date of Birth: ______Age:______Marital Status: Single Married Divorced Widowed Separated
Employer and Employer’s Address: ______
Work Phone: ______Occupation: ______
INSURANCE INFORMATION
***(IF INSURANCE CARD NOT PROVIDED)***
(1) Insurance Company:______Phone number: ______
Claims Address: ______
Group or Policy Number:______Subscriber or I.D. Number:______
(2) Secondary Insurance Company:______Phone number: ______
Claims Address: ______
Group or Policy Number:______Subscriber or I.D. Number:______
ASSIGNMENT AND RELEASE
I hereby assign, transfer, and set over to Johnston Psychiatric Associates all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance.
Patient’s (or Responsible Party/Guardian) Signature: Date:

Johnston Psychiatric Associates

Consent For Treatment

Consent for Evaluation and/or Treatment

I request evaluation services from Johnston Psychiatric Associates. If it is determined by a qualified professional that admission to Johnston Psychiatric Associates is appropriate, I consent to services from Johnston Psychiatric Associates as prescribed by me and/or my treatment team.

If the evaluation indicates that I would benefit from services available by another agency or if the needed services are not offered by the agency, then I will be referred to an more appropriate resource for assistance.

My consent for services is voluntary and I understand that I may withdraw at any time.

Consent for Emergency Services

I give my permission for Johnston Psychiatric Associates staff to seek emergency medical services from a hospital, medical facility or physician on my behalf should it become necessary. Johnston Psychiatric Associates is not responsible for any charges incurred as a result of emergency medical services.

Psychotherapy Risks and Benefits

Participation in psychotherapy has shown to significantly benefit people who undertake it for personal growth, symptom reduction, behavioral change, self-development, skill development, improvement in relationships, increasing feelings of well-being and reduction of feelings of distress.

However, psychotherapy does carry some risks. Risks may include: uncomfortable feelings which can result from the exploration of difficult or unpleasant aspects of past or current experiences or discomfort from attempts to stretch oneself by engaging in new behaviors, relational skills and coping strategies. For children and adolescents this may manifest in behavioral reactions. The most notable risk is a lack of improvement on your areas/issues of concern.

Best outcomes of psychotherapy are typically associated with the following:

  • Consistent attendance
  • Active effort in collaboration, both on your part as the patient and on our part as the therapist/doctor.
  • A positive relationship between therapist and patient. Therefore, if at any time you feel uncomfortable or dissatisfied with our relationship or work, it is important that we discuss this so that we can make the appropriate adjustments to our work together or, if needed, we can assist you with referrals to another provider.

I understand all of the above statements. This consent shall be valid until services are terminated or sooner if I revoke consent.

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Client Signature (or responsible person) Date

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Print Name Date