New Patient Adult Registration

Patient Name:

Sanders & Associates LLC

Charles W. Sanders, Ph.D.

5555 N. Tacoma Avenue, Suite 204

Indianapolis, IN 46220

Phone: 317-257-7434

NEW PATIENT ADULT REGISTRATION

PATIENT NAME: _____

Do you prefer to be called a different name? If so, what? ______

Date of Birth: ___/___/____ Age: ____ SSN:____-____-____ Sex: Male / Female

Home
address: Work Address:

HOME PHONE: ______WORK PHONE: ______

OTHER PHONE: ______OTHER PHONE: ______

EMAIL ADDRESS: ______

PRIMARY CARE PHYSICIAN: ______PHONE: ( ) ______

ADDRESS: ______FAX: ( ) ______

______

HOW DID YOU HEAR ABOUT ME?

[ ] phone book [ ] insurance company [ ] friend [ ] Primary Care Physician

listed above

[ ] another physician: ______[ ] EAP ______[ ] other: ______

Insurance Co. ______

Policy No. ______, Group No. ______

Insurer’s Name:______, Insurer’s Birth Date:______

PERSON TO CONTACT IN CASE OF EMERGENCY:

NAME: ______RELATIONSHIP: ______

HOME PHONE: ( ) ______OTHER PHONE: ( ) ______

Patient Rights & Responsibilities

Be treated with respect and recognition of my dignity and rights to privacy.
Receive care that is considerate and respects my personal values and belief system.
Personal privacy and confidentiality of information.
Receive information about my managed care company’s services, practitioners, clinical guidelines, quality improvement program and patient rights and responsibilities.
Reasonable access to care, regardless of my race, religion, gender, sexual orientation, ethnicity, age or disability.
Participate in an informed way in the decision making process regarding my treatment planning.
Discuss with my treating professionals appropriate or medically necessary treatment options for my condition regardless of cost or benefit coverage.
Have family members participate in treatment planning and if I am over the age of 12 to participate in such planning.
Individualized treatment, including
Adequate and humane services regardless of the source(s) of financial support.
Provision of services within the least restrictive environment possible
An individualized treatment or program plan
Periodic review of the treatment or program plan
An adequate number of competent, qualified and experienced professional clinical staff to supervise and carry out the treatment or program plan
Participate in the consideration of ethical issues that arise in the provision of care and services, including
Resolving conflict
Withholding resuscitative services
Foregoing or withdrawing life-sustaining treatment
Participating in investigational studies or clinical trials
Designate a surrogate decision maker if I am incapable of understanding a proposed treatment or procedure or am unable to communicate my wishes regarding care
Be informed, along with my family, of my rights in a language I/we understand
Voice complaints or appeals about my managed care company, provider of care of privacy practices
Make recommendations regarding my managed care company’s rights and responsibilities policies
Be informed of rules and regulations concerning my own conduct
Be informed of the reason for any utilization management adverse determination including the specific utilization review criteria or benefits provision used in the determination
Have utilization management decisions based on appropriateness of care
Request access to my Protected Health Information (PHI) or other records that are in the possession of my managed care company
Request to inspect and obtain a copy of my PHI, to amend my PHI or to restrict the use of my PHI, and to receive an accounting of disclosures of PHI

I understand that I am responsible for:

Providing (to the extent possible) my treating clinician and managed care company with information needed in order to receive appropriate care
Following plans and instructions for care that I have agreed on with my treating clinician
Understanding my health problems and participating, to the degree possible, in developing, with my treating clinician, mutually agreed upon treatment goals

FINANCIAL POLICY

Charles W. Sanders, Ph.D. will file claims with my primary insurance company upon my submission of proof of insurance. However, I understand that I am ultimately responsible for all charges incurred with Charles W. Sanders, Ph.D. In the event that I do not provide documentation, payment is due at the time of service.

Unless my primary insurer is Medicare, Medicaid, or directly contracted with Charles W. Sanders, Ph.D., I understand that Charles W. Sanders, Ph.D. will be unable to file my secondary insurance claims.

I understand that it is my responsibility to confirm that any/all providers with whom I am scheduled are participating in my insurance network and I further understand that I will be responsible for charges incurred as a result of services rendered with an out-of-network provider.

ALL CO-PAYMENTS AND DEDUCTIBLES ARE DUE AT THE TIME OF SERVICE. Acceptable methods of payment include cash or checks. I understand that I will be unable to reschedule appointments if I am 3 or more co-payments past due.

Payment from statement is due upon receipt. Non-compliance may result in preparation of account for credit bureau reporting and possible discharge from the practice. I understand that I am responsible for reasonable attorney’s fees and costs of collection in the event of default. I further understand that if a payment becomes 85 days past due, delinquency of the lesser of the annual rate of 18%, or the maximum allowable rate, will be due on delinquent amounts from the date the payment was due.

WE REQUIRE 24 HOURS ADVANCE NOTICE FOR ALL CANCELLATIONS

IF YOU FAIL TO SHOW UP OR DO NOT CANCEL AT LEAST 24 HOURS IN ADVANCE

YOU WILL BE CHARGED FOR THE APPOINTMENT

I understand that I am financially responsible for any service that my insurance company deems as a non-covered service including medical records, prescription refill charges, missed and/or late cancelled appointments.

BY MY SIGNATURE BELOW:

I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY OF CHARLES W. SANDERS, PH.D.
I HAVE READ AND UNDERSTAND THE PATIENT RIGHTS & RESPONSIBILITIES.
I AUTHORIZE MY PROVIDER TO RELEASE ANY INFORMATION REQUIRED TO PROCESS MY CLAIM TO MY INSURANCE COMPANY AND TO RECEIVE PAYMENT FROM MY INSURANCE COMPANY FOR SERVICES RENDERED BY CHARLES W. SANDERS, PH.D.
I AGREE AND CONSENT TO PARTICIPATE IN THE MENTAL HEALTH SERVICES OFFERED AND PROVIDED BY CHARLES W. SANDERS, PH.D., A MENTAL HEALTH PROVIDER AS DEFINED IN INDIANA LAW. I UNDERSTAND THAT I AM CONSENTING AND AGREEING ONLY TO THOSE SERVICES THAT THE ABOVE NAMED PROVIDER IS QUALIFIED TO PROVIDE WITHIN: (1) THE SCOPE OF THE PROVIDER’S LICENSE, CERTIFICATION, AND TRAINING; (2) THE SCOPE OF THE LICENSE, CERTIFICATION, AND TRAINING OF THE MENTAL HEALTH PROVIDERS DIRECTLY SUPERVISING THE SERVICES RECEIVED BY TH E PATIENT.
I HAVE RECEIVED THE PRACTICE’S NOTIC E OF PRIVACY PRACTICES AND UNDERSTAND THAT MY PROTECTED HEALTH INFORMATION MAY BE USED BY THE PRACTICE AS DESCRIBED IN THE NOTICE.

SignatureDate

Relationship to Patient

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO PRIMARY CARE PHYSICIAN

PATIENT NAME: D.O.B.

ADDRESS: PHONE:

CITY: STATE: ZIP:

***** PLEASE CHOOSE ONE OF THE FOLLOWING OPTIONS *****

[ ] I do not want any information released to my Primary Care Physician

[ ] I authorize Charles W. Sanders, Ph.D. to release my protected health information to

my PCP: Dr.

Address:

City: State: Zip:

Phone: Fax:

I understand that this request will be valid for one hundred eighty (180) days from the date written below. At that time the request will be void and no further information will be furnished pursuant to it.

I understand that I have the right to revoke this authorization, in writing, at any time by sending written notification to Charles W. Sanders, Ph.D. I understand that a revocation is not effective to the extent that Charles W. Sanders, Ph.D. has relied on the use or disclosure of the protected health information.

This release prohibits redisclosure except in accordance with 42 C.F.R. 21, et seq., which is a federal regulation governing release and use of patient record information pertaining to treatment for alcohol and drug abuse.

Charles W. Sanders will not condition my treatment whether I provide authorization for the requested use or disclosure.

I agree to pay Charles W. Sanders an actual cost incurred in preparing and delivering the information requested therein.

A copy of this authorization shall be as valid as the original.

I understand that I have the right to:

Inspect or copy the protected health information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights).
Refuse to sign this authorization.
Receive a signed copy of this authorization.

Signature of Patient or Personal RepresentativeDate

Name of Patient or Personal RepresentativeDescription of Personal Representative’s

Authority

********************************For Internal Use Only ********************************

[ ] MAILED [ ] FAXED record to PCP on ______

AUDIO AND VISUAL RECORDING PROHIBITED

There shall be no audio or video recordings used during therapy sessions for any purpose unless there is a written and signed agreement between Sanders and Associates LLC and the patient or parent/guardian if the patient is under the age of 18.

SERVICES NOT COVERED BY EAP OR INSURANCE

Please note that only therapy sessions are covered by EAP services and/or insurance. Any testing, protocols (Conners’ Rating Scales, Autistic Rating Scales, etc.), writing of reports, writing of letters to medical personnel, or appearances in court are not covered by EAP services or insurance. Patient is responsible for the payment of these services.

WE WANT TO HELP YOU

If you have a complaint, please bring it to our attention so we can remedy the matter. Additionally, we recognize that sometimes personalities do not always work well together. If you would like to change therapists, please let us know. We have other therapists in our practice who would love to help you. FILING A FALSE COMPLAINT WITH THE INSURANCE COMPANY, MEDICAID OR EAP COMPANY WILL RESULT IN LEGAL ACTION.

Date:

Patient

PATIENT HISTORY QUESTIONNAIRE

Briefly describe the problems you are having and when they began:

MENTAL HEALTH HISTORY

Please list any psychiatrist, psychologist, or counselors you are currently in treatment with: [ ] NONE

Please list any psychiatrist/counselors you have seen in the past and response to treatment? [ ] NONE

Please list any previous psychiatric hospitalizations or intensive outpatient programs: [ ] NONE

Please list all past psychiatric medications you have taken, dates, and responses to each: [ ] NONE

Please list any family history of mental health/substance abuse problems: [ ] NONE

SYMPTOM CHECKLIST

Please check any symptoms you are experiencing

Patient Name:

[ ] Addiction to ______

[ ] Anxiety

[ ] Appetite – Increase / Decrease

[ ] Avoidance of People

[ ] Body Pains

[ ] Change in Eating Habits

[ ] Compulsions

[ ] Concentration Problems

[ ] Dizziness

[ ] Fatigue

[ ] Fear of ______

[ ] Guilt

[ ] Hallucinations

[ ] Headaches

[ ] Hopelessness

[ ] Impulsivity

[ ] Indecisiveness

[ ] Irritability

[ ] Loneliness

[ ] Memory Problems

[ ] Mood Swings

[ ] Panic Attacks

[ ] Paranoid Feelings

[ ] Racing Thoughts

[ ] Restlessness

[ ] Sexual Difficulties

[ ] Sleeping Problems

[ ] Stomach Upset

[ ] Suicidal Thoughts

[ ] Tearfulness

[ ] Trembling

[ ] Weight – Gain / Loss

Patient Name:

SUBSTANCE ABUSE HISTORY

Please describe your current and/or previous use of caffeine / alcohol / tobacco products / drugs:

[ ] NONE

TYPE
USED / CURRENT
OR
PREVIOUS / AMOUNT
USED / HOW
OFTEN / LAST
USED

GENERAL MEDICAL HISTORY

Please check any of the following that apply:

Patient Name:

{ } Head Injury

{ } Heart Disease

{ } Hepatitis

{ } Hypoglycemia

{ } Asthma

{ } High Fevers

{ }Seizures

{ } Lung Disease

{ } TB

{ } Diabetes

{ } Arthritis

{ } Meningitis

{ } Thyroid Problems

{ } Liver Disease

{ } HIV

{ } Cancer

{ } Chronic Pain

{ } Loss of Consciousness

{ } Hypertension

{ } Kidney Disease

{ } Sexually Transmitted Disease

{ } Memory Problems

{ } Headaches

{ } Fibromyalgia

Patient Name:

{ } Other ______

Please describe any checked items above, including age of onset

List all medications you are currently taking including the date started, dose & the prescribing doctor:

List the names and specialties of all the physicians who you are currently seeing:

List any allergies or medication intolerance you have:

List any hospitalizations/surgeries you have had in the past:

Date: ______Hospital: ______Reason: ______

Please list any family history of medical problems:

Women Only

First day of your last menstrual period: ______Number of days in cycle: _____

Age of first menstrual period: ______Are your periods: Regular / Irregular

Total number of: Pregnancies: ______Children delivered: ______Miscarriages/Abortions: _____

Do you currently use birth control: Yes / NoMethod Used:

RELATIONSHIP HISTORY

Marital Status: never married marriedseparated divorcedremarried widowed

Please describe your current relationship, including any stressors:

If married, length of marriage: ______Spouse’s name:

Number of previous marriages: _____Number of previous long-term relationships:

Describe prior marriages/long-term relationships and the reason for the divorce or break up:

List all people that are currently residing in your home and their relationship to you:

FAMILY/SOCIAL HISTORY

Where did you grow up? ______Did your family move around? YES / NO

If yes, please describe:

How many siblings do you have? _____ Half-siblings? ______Step-Siblings? ______

Which family member are you close to?

Describe your childhood:

Were you ever abused (physical, sexual, emotional)?

Have there been major losses, changes, or crisis in your life? YES / NO

If yes, please describe:

EDUCATIONAL HISTORY

What is the highest grade you completed?

Did you receive any special education services?YES / NO

Did you have any discipline problems at school? YES / NO

How did you get along with your teachers and peers?

MILITARY HISTORY

Have you ever served in the military? YES / NO If so, which branch?

Date of entry: ______Date of exit: ______Highest rank achieved: ______

Were you stationed in a combat or other high-risk zone?

List any disciplinary action taken against you:

Type of discharge:

OCCUPATIONAL HISTORY

Are you currently employed? YES / NO If yes: FULL-TIME / PART-TIME

If yes, where? ______How long have you been there? ______

Current Position: ______Do you like your job? YES / NO

Do you get along with your co-workers? YES / NO Have you ever been laid off / fired? YES / NO

If yes, explain:

Longest job previously held – where? How long? ______

Are you currently on disability? YES / NOAre you currently applying for disability? YES / NO

RELIGIOUS/SPIRITUAL HISTORY

[ ] NONE [ ] CATHOLIC [ ] JEWISH [ ] PROTESTANT [ ] OTHER: ______

I attend services: NEVER OCCASIONALLY MONTHLY WEEKLY MORE THAN ONCE A WEEK

LEGAL HISTORY

Have you ever been arrested for or convicted of a crime? YES / NO

If so, please list charges and results (probation, incarceration, fine, etc.):