Louisville Family & Cosmetic Dentistry

CATHERINE COURSON, LCSW

1169 EASTERN PARKWAY, STE. 411

LOUISVILLE, KY 40217

502-473-7028

Thanks for your help in making your first session a productive one. Please note that if you are not able to complete the information on the following forms we will do them together in our first session.

WHAT YOU WILL NEED FOR YOUR FIRST SESSION.

A copy of your insurance card and driver’s license.
The client’s social security.
The social security number and date of birth of the policyholder.
Please call your insurance for verification of co-pay, and deductible. You will be responsible for the deductible portion and the co-pay for your session.
Each session after please pay your co-pay before going back to your session.
Call your insurance to get an authorization number for your sessions.

AUTHORIZATION NUMBER IF NEED: ______

THINGS TO REMEMBER:

You are accountable for any session not authorized by your insurance company.
There is a missed appointment fee, and a late cancelation fee. The late cancelation fee of $50.00 is charged if I am not notified within 24 hours. This fee is not covered by insurance.
If there is a problem with making the payment, the therapist will give you an envelope for you to mail in the payment before your next session, or you can call with a credit card number before the next session.
Routines calls, such as rescheduling, are returned between 9:00 am and 5:00 pm during the week. The answering service will note the time called.

What you can expect during treatment:

We will review your demographic information, and all of the information from the enclosed forms.
We will determine the goals of treatment.
You will have the opportunity to ask questions relative to your treatment.
While in treatment you will be asked to do homework to speed your therapy along. I might ask you to read a book, journal, see your family doctor for a physical, attend AA, NA, ALON, ACOA, gamblers anonymous, overeaters anonymous, depression anonymous, or other tasks. These tasks are necessary to be successful in your treatment.
Only a portion of your treatment takes place in the office. The rest of treatment takes place with the changes you make outside of the office.
When dealing with traumas it sometimes gets worse before it gets better.

Please read and sign the next paragraph.

Emergencies are situations that could result in danger to self or others. Please go to the nearest emergency room should you experience an emergency or call 911.

Urgent calls are billable calls and are returned by me, or someone covering my calls. If for some reason you can’t reach me or I don’t return your call within a couple of hours and you need to talk to someone.

Please call the answering service and indicate that your call is urgent. (502) 473-7028

QUESTIONS IF CLIENT IS A CHILD:

Are you the legal guardian with the authority to take the child to treatment? Yes or No.

If you are a single parent I will need to see court custody papers.

Developmental History (milestones met early, late, normal): ______

______

Perinatal History (details of labor/delivery): ______

______

Prenatal History (medical problems during pregnancy, mother's use of medications): ______
Grade and school attending: ______
Childhood traumas: ______

______

Client information
Date______
Social security #______
Client name Last______
First ______
Middle______
E-MAIL: ______
Address______
City______
State______Zip______
Sex □F □M
Date of Birth______□single □married □child □partnered
Client employer/school______
Occupation______
DISABILITY (CHECK ONE): DISABLED_____, NOT DISABLED_____, PARTIAL_____
IS CONDITION RELATED TO: AUTO ACCIDENT? YES ____ NO ___
EMPLOYMENT? YES __ NO __ OTHER ACCIDENT?YES __ NO___
Partner’s name______
Partner’s employer______
Partner’s Spouse’s date of birth______
Occupation______
Employer phone #______
Contact information
(PLEASE LIST NUMBERS IN WHICH A MESSAGE CAN BE LEFT)
Home#(_____)______Work#(_____)______
Cell#(_____)______
In case of emergency, contact (someone not in your household)
Name______
Home#(_____)______Work#(_____)______
Relationship______ / Insurance information
Who is responsible for this account?______
Relationship to client______
If responsible party has different address:
______
______
Client’s insurance company:
______
Group #______
Insurance ID: ______
Subscriber’s name: ______
Subscriber’s employer:______
Subscriber’s date of birth:______
Subscriber’s social security #:______
Is the client covered by additional insurance?
□yes □no
If additional insurance-
Secondary insurance Co.______
Group #______
Subscriber’s name______
Subscriber’s employer______
Subscriber’s social security #______
I certify that I, and/or my dependent(s), have insurance coverage with ______
and assign directly to Catherine Courson, LCSW all insurance benefits, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named Therapist may use my health care information and may disclose such information to the above-named Insurance co. and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services.
Signature of Client Date
Mental Health History
Reason for today’s visit______
Former Therapist______Date of last counseling visit:______
Dates of any inpatient hospitalizations:______
Dates of previous outpatient counseling and counselor: ______
Family Mental Health or Chemical Dependency History: ______
______
Referred by  insurance  friend/family ______Website other______

Health History

Client name______Today’s date______
Physician’s Name______Date of last visit______
Please circle:
Yes No Heart trouble/disease Yes No Hepatitis type______
Yes No Heart murmur Yes No HIV/AIDS
Yes No Irregular heartbeat Yes No Anemia
Yes No Angina/chest pain disorder Yes No Stomach problems
Yes No Drug addiction
Yes No Sickle cell disorder Yes No Alcohol addiction
Yes No Hemophilia Yes No Fainting or dizziness
Yes No Blood transfusion Yes No Headaches/migraines
Yes No Tuberculosis (TB) Yes No Cortisone treatments
Yes No Heart attack/failure Yes No Liver problems
Yes No Stroke Yes No Kidney problems
Yes No Congenital heart disorder Yes No Diabetes type______
Yes No Mitral valve prolapse Yes No Cancer/chemotherapy
Yes No Rheumatic fever Yes No Radiation treatment
Yes No Artificial heart valve Yes No Skin grafts
Yes No High blood pressure Yes No Back/neck problems
Yes No High cholesterol Yes No Emphysema
Yes No Pacemaker
Yes No Asthma Yes No Nervousness
Yes No Arthritis/rheumatism Yes No Psychiatric care
Yes No Artificial joint replacement Yes No Seizure disorder
*date of surgery______ Yes No Alzheimer’s disease
Yes No Blood
Medications
List any medications you are currently taking:______
______
______
Pharmacy Name______Phone______
Allergies:
□ Codeine □ Iodine
□ Penicillin □ Local Anesthesia
□ Sulfa drugs □ Hydrocodone
□ Latex □ Metals (ie.nickel)
□ Other______

BRIEFLY STATE YOUR REASON FOR SEEKING PSYCHOTHERAPY: ______

______

HAS CLIENT EXPERIENCED ANY OF THE FOLLOWING? Circle all that apply

CHANGE IN APPETITE:IncreaseDecreaseOther (Explain) ______

CHANGE IN WEIGHT:IncreaseDecreaseOther (Explain) ______

CHANGE IN SLEEP: IncreaseDecreaseOther (Explain) ______

CHANGE IN ENERGY:IncreaseDecreaseOther (Explain) ______

CHANGE IN MOOD: IncreaseDecreaseOther (Explain) ______

SUBSTANCE ABUSE PHYSICAL ABUSE SEXUAL ABUSE FAMILYVIOLENCE FEAR

HOPELESSNESS HELPLESSNES PANIC ATTACKS LOW SELF-ESTEEM SHY WORTHLESSNESS ISOLATING SELF DEPRESSION ANXIETY GRIEF

SELF-FOCUSED IRRITABILITY SEXUAL PROBLEMS SHAME CRYING

WITHDRAWAL FREQUENT CRYING WORRYING GUILT ANGER

FATIGUE LOSS OF TIME

LEGAL ISSUES PAST OR PRESENT: ______

None Noted / Thoughts Only / Plan (describe) / Intent (describe) / Means (describe) / Attempt (describe) / Able to Contract For Safety
Suicidal Ideation
Homicidal Ideation

SUBSTANCE ABUSE HISTORY (complete if you are over age 12)

Substance / Amount / Frequency / Duration / First Use / Last Use
Caffeine
Tobacco
Alcohol
Marijuana
Opiods/ Narcotics
Amphetamines
Cocaine
Hallucinogens
Other

CONSENT: I, the undersigned, a client or parent/guardian of a client, do hereby voluntarily consent and authorize Catherine Courson, L.C.S.W., B.C.D., to administer psychotherapy.

I am aware that the practice of psychotherapy is not an exact science and I acknowledge that no guarantees have been made to me as to the result of evaluation and treatment.

I understand that Catherine Courson, L.C.S.W., B.C.D., practices under the ethical guidelines set forth by the National Association of Social Workers. I further understand that she will make the appropriate referral for me if I have a need that she is unable to address.

______/______/______

Client or Responsible Party SignatureDate

FINANCIAL AGREEMENT:Counseling fees are $125 for the first session and $100 for each additional 50-minute session. Co-pays are due prior to each session. Missed appointments or appointments cancelled without 24 hours notice will result in a $50 fee. There is a $25 returned check fee.

I understand and agree that any and all charges not covered by my insurance carrier(s) will be my responsibility and that I will make every effort to forward payment on all outstanding charges to my account in a timely manner. I further understand that not doing so may result in my delinquent account being turned over to a collection agency for further action.

I understand and agree to the above fees and responsibilities and will notify my therapist of any change in my insurance coverage.

______/______/______

Client or Responsible Party SignatureDate

UNDERSTANDING: I understand that Parkway Psychotherapy Associates, Inc. is a leasing agent to therapists who need office space and related services for the operation of their own individual private practice of psychotherapy. Under no circumstances is it to be misconstrued that any leasee nor Parkway Psychotherapy Associates, Inc. itself are a partner or an associate in the practice of psychotherapy with each other or are responsible for each other’s conduct. Each leasee of office space is solely responsible for their own private practice of psychotherapy and conduct, including but not limited to providing malpractice insurance, scheduling, billing and record keeping.

By my signature below, I hereby agree to assure the confidentiality of information received from others or obtain from my own observation regarding clients, former clients, or persons whose treatment has been sought at the facilities of Parkway Psychotherapy Associates, Inc.

______/______/______

Client or Responsible Party Signature Date

MANDATORY RELEASE OF INFORMATION: The undersigned acknowledges that Catherine A. Courson, L.C.S.W., B.C.D., is obligated by Kentucky law and by her professional regulating agency to report to the appropriate authorities any information obtained regarding the following:

Incidents of abuse or neglect upon a child, either new or old, who is currently 16 years of age or under, that has never been reported to The Cabinet For Human Services, Child Protective Services. This will result in a mandatory investigation by a social worker within 72 hours. If there is a finding of abuse, there is mandatory involvement by the Court system and a case worker from The Cabinet for Human Resources. KRS620.030
Current incidents of abuse upon an adult, either by a spouse or another person, that has never been reported to The Cabinet For Human Resources, Adult Protective Services. This will result with a mandatory contact by a social worker inquiring whether you would like their services or whether you wish to decline their services. This can be done at the time of disclosure at the office. KRS209.030
Any specific threats to cause bodily harm to any identified individual(s) including oneself, where there is a plan, available methods and the client refuses to take appropriate actions to not follow through with the threat. This will result in a mandatory contact with the Police Department. In the case of suicidal behavior, the next of kin will be notified and a mental inquest warrant may be issued, resulting in a 72-hour hold in an inpatient setting for stabilization. In the case of homicidal behavior the intended victim will also be notified. These actions may result in criminal charges.
Any breach of a Court order, specifically a restraining order, no-contact order or protective order, must be reported to the Courts.
If ordered to treatment by Court, Probation, Parole or The Department for Human Services, failure to cooperate with the treatment plan must be reported.

(sign once for each person present in the session).

SIGNATURE______DATE______

MEDICARE AUTHORIZATION:I am responsible for my coinsurance and deductible at the time of service. I direct the payment from Medicare be paid directly to Catherine A. Courson, L.C.S.W., and B.C.D. I authorize her to release any and all medical information about me to the Health Care Financing Administration and its agents to determine these benefits or the benefits payable for her services. In the case of insurance my signature also authorizes release of information to the insurer or agency I have listed. The therapist agrees to accept the charge as set by Medicare as the full charge for the services.

______/ ______/ ______

Client or Representative SignatureDATE

LIMITED CREDIT CARD AUTHORIZATION: I authorize Catherine Courson, L.C.S.W., to keep my signature on file and to charge my credit card for any fees due under the Financial Agreement and not paid by my insurance carrier.

CLIENT Name (Print) ______

Name as It Appears on CREDIT CARD (Print) ______

Credit Card Number

    Expiration Date:  Validation Code:

Month/Year Back of Card

Cardholder Signature______Date______

DATE

RECEIPT OF NOTICE OF PRIVACY PRACTICES.I affirm that Catherine A. Courson, L.C.S.W., B.C.D., or her staff has given me a copy of the Notice of Privacy Practices effective. Please take the last two papers labeled HIPPA PRIVACY NOTICE with you.

______/ ______/ ______

Client or Representative Signature Date

HIPPA PRIVACY NOTICE: PLEASE TAKE THESE HIPPA PAGES AND MAKE SURE YOU HAVE SIGNED THAT YOU RECEIVED THEM ON THE PREVIOUS:

I.THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

II.IT IS MY LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).

By law I am required to insure that your PHI is kept private. The PHI constitutes information created or noted by me that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. I am required to provide you with this Notice about my privacy procedures. This Notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally required to follow the privacy practices described in this Notice.

Note that I reserve the right to change this Notice and my privacy policies at any time. Any changes will apply to PHI already on file with me. Before I make any important changes to my policies, I will post a new copy of it in my office. You may also request a copy of this Notice from me, or you can view a copy of it in my office.

III.HOW I WILL USE AND DISCLOSE YOUR PHI.

I will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of my uses and disclosures, with some examples.

A.Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I may use and disclose your PHI without your consent for the following reasons:

1.For treatment. I may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, I may disclose your PHI to her/him in order to coordinate your care.

2.For health care operations. I may disclose your PHI to facilitate the efficient and correct operation of my practice. Examples: Quality control - I might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. I may also provide your PHI to my attorneys, accountants, consultants, and others to make sure that I am in compliance with applicable laws.

3.To obtain payment for treatment. I may use and disclose your PHI to bill and collect payment for the treatment and services I provided you. Example: I might send your PHI to your insurance company or health plan in order to get payment for the health care services that I have provided to you. I could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for my office.

4.Other disclosures. Examples: Your consent isn't required if you need emergency treatment -- provided that I attempt to get your consent after treatment is rendered. In the event that I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) but I think that you would consent to such treatment if you could, I may disclose your PHI.

B.Certain Other Uses and Disclosures Do Not Require Your Consent. I may use and/or disclose your PHI without your consent or authorization for the following reasons:

When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: I may make a disclosure to the appropriate officials when a law requires me to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.
If disclosure is compelled by a party to a proceeding before a court of an administrative agency pursuant to its lawful authority.
If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.
If disclosure is compelled by the patient or the patient’s representative pursuant to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.
To avoid harm. I may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public.
If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger.
If disclosure is mandated by the Kentucky Child Abuse and Neglect Reporting law. For example, if I have a reasonable suspicion of child abuse or neglect.
If disclosure is mandated by the Kentucky Elder/Dependent Adult Abuse Reporting law. For example, if I have a reasonable suspicion of elder abuse or dependent adult abuse.
If disclosure is compelled or permitted by the fact that you tell me of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.
For public health activities. Example: In the event of your death, if a disclosure is permitted or compelled, I may need to give the county coroner information about you.
For health oversight activities. Example: I may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization or provider.
For specific government functions. Examples: I may disclose PHI of military personnel and veterans under certain circumstances. Also, I may disclose PHI in the interests of national security, such as protecting the President of the United States or assisting with intelligence operations.
For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research.
For Workers' Compensation purposes. I may provide PHI in order to comply with Workers' Compensation laws.
Appointment reminders and health related benefits or services. Examples: I may use PHI to provide appointment reminders. I may use PHI to give you information about alternative treatment options, or other health care services or benefits I offer.
If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.
I am permitted to contact you, without your prior authorization, to provide appointment reminders or information about alternative or other health-related benefits and services that may be of interest to you.
If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law. Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess my compliance with HIPAA regulations.
If disclosure is otherwise specifically required by law.

C.Certain Uses and Disclosures require you to have the opportunity to object. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.