570-961-3361 570-961-3364 (fax)
Client Registration Form
Date: ______
Therapist: ______
DX Code: 1.______2. ______DX Name:______
Client Name______
Date of Birth______Age______
Address ______
Town/Zip ______
Phone: Home______Cell______
Marital Status ______Partner/ Spouse Name______
If child client: Parents Names:______/ Associates
Anthony Black, LCSW
Amy Clark, LCSW
Jeanne Decker, LSW
Kara Golden, LSW
Sara Grier, LCSW
Joanne Judge, LSW
Patricia Krenitsky, LPC
Jennifer Marzzacco, LSW
Stephen Peters, LSW
Michelle P Elliott, LPC
Keith Ripley, LPC CADC
Linda Strain, LPC
Jodi Weiskerger, LSW
Bethany Woznikaitis, LCSW
Philip Zuckerman, LCSW
Emergency contact name ______Number ______
Employer______Number ______
Do we have permission to contact you and leave a call back message at above numbers? Y or N
Please specify if there are any instructions with regards to contacting you:
______
How did you find out about us? ______
Physician ______Date of last Physical______
Permission to contact your PCP: Yes ______No ______
Major/Chronic Illness:______
Medications: ______
Previous Counseling: ______
INSURANCE INFORMATON:
Primary Insurance ______ID# ______
Name of Insured ______
DOB of Insured______Social Security of Insured ______
Secondary Insurance ______ID# ______
Name of Insured ______
DOB of Insured______Social Security of Insured ______
1011 Pennsylvania Avenue 112-1 Warren Street 1418 Main Street, Suite 103
Matamoras, PA 18336 Tunkhannock, PA 18657 Peckville, PA 18452
4101 Birney Avenue 130 Bridge Street 189 Market Street 301 West Grove St.
Moosic, PA 18517 Tunkhannock, PA 18657 Kingston, PA 18704 Clarks Summit, PA 18411
John G. Kuna, Psy.D & Associates, LLC570-961-3361 570-961-3364 (fax)
CONSENT FOR TREATMENT
I ______give permission to ______to provide mental/behavioral health therapy for myself or child ______. I will be treated with respect and honesty throughout treatment. I am expected to benefit from treatment, but there are no guarantees. Maximum benefits will occur with regular attendance. I understand that I may temporarily feel worse while in treatment. I will let my therapist know if this begins to happen. I can discuss with my therapist if my goals in treatment are / are not being met. / Associates
Anthony Black, LCSW
Amy Clark, LCSW
Jeanne Decker, LSW
Kara Golden, LSW
Sara Grier, LCSW
Joanne Judge, LSW
Patricia Krenitsky, LPC
Jennifer Marzzacco, LSW
Stephen Peters, LSW
Michelle P Elliott, LPC
Keith Ripley, LPC CADC
Linda Strain, LPC
Jodi Weiskerger, LSW
Bethany Woznikaitis, LCSW
Philip Zuckerman, LCSW
CONFIDENTIALITY
I understand the limits of confidentiality which are: While under most circumstances communication between the client and the therapist is confidential, Pennsylvania State Law mandates the reporting of actual or suspected child or elder abuse to the appropriate agency. Also, if an individual intends to take harmful or dangerous action against another, it is the therapist’s duty to warn the person or the family of the person who is likely to suffer the results of harmful behavior. . Clients who have suicidal desires are also reported and referred to the appropriate agency. Court orders may also mandate the release of confidential information.
Every reasonable effort will be made to notify the client before such a compromise.
PAYMENT FOR SERVICES
While this office will process insurance billing, I understand that payment for services insurance deductibles and co-pays are my responsibility. I understand balances over 90 days may be forwarded to an independent collection agency. By signing below I give permission for submission to my insurance company.
** Late Cancellation Fee: Please be aware that once an appointment time is scheduled, an hour is reserved for you. Absent an emergency or 24 hours notice, a $25 fee will be charged.
TERMINATING TREATMENT
I have the right to terminate the therapeutic relationship should I desire with or without explanation. I may ask my therapist for other therapist referrals.
NOTICE OF PRIVACY AND HIPPA
I understand my privacy and the “Protected Health Information” in the HIPPA information provided and available for reading in the waiting area. I understand billing information (I.E. Diagnosis) may be shared with others who need to arrange payment for my treatment by a third party payer. This office uses the professional billing services of Rose Higgins. I understand if I am concerned about shared information, I have the right to ask for further explanation.
Signed: ______Date______
Printed______
For children under 14: Consent By 2nd Legal Guardian: ______
Printed: ____________