Return Ins Paymenttoclient:FOROFFICEUSE:
YesNo ICD-10
Diagnosis:______CPT code______
Cindy D. Ashkins, Ph.D., LCSW, LMT
121 Metairie Lawn Drive, Suite A, Metairie, LA 70001
Phone 504.606.6011- Fax: 504.834.8802
Doc4relationships.com
CLIENT INFORMATION FORM
Name:_Age:_ SocialSecurity#: _- -______
Address:______City:______Zip:______
Telephone:Office_ Cell______Email______
Dateof Birth:YearsofEducation:Gender: ______
Occupation:_Employer:_ Employer's Address Phone: _
Referred By:______
EmergencyContact:RelationshipPhone:_
Current Relationship Status:
Married______Single_Separated/Divorced_LifePartner_
Names and ages of children:
GUARANTOR:(InsuranceInformation)PleaseallowDr.Ashkinstocopyyourinsurancecardfor reimbursement.
Name:DateofBirth:SS#:_ Address: City: Phone: _
RELEASE/PAYMENT AUTHORIZATION:
I authorize the release of medical information necessary to process an insurance claim on my behalf. I agree to make payment in full at the time of services are rendered and in lieu of this, I agree to release insurance benefits to Cindy Ashkins, PhD, LCSW, LMT.
SIGNED:_Date:
Please briefly indicate the reason for seeking treatment at this time:
______
______
______
______
______
Please list current individual stressors (please check all that apply):
______Health ______Relationship
______Finances ______Career
______Parents ______Children
______Social ______School
______Fitness/Weight ______Fatigue
______Anxiety ______Depression
______Trauma/PTSD ______Divorce
______Addictive or compulsive behavior ______Self-Harm
Other (please specify) ______
______
Please list current relationship stressors (please check all that apply): ______N/A
______Lack of communication ______Anger
______Conflict ______Health
______Finances ______Intimacy
______Children ______Living Situation
______Substance Abuse ______Addiction
______Untreated Mental Health concern (please specify):
______
______Concern of/ or tendency toward violence
______Threat/Possibility of divorce
______Affair(s)
Please list any current physical illnesses or injuries:
Please list all current medications and dosages:
Current prescribing psychiatrist, NP or medical psychologist ______
______
Please list any previous mental health treatment/couples counseling or mental health
hospitalizations.
______
Please initial each statement and fully sign at the bottom:
Cancellations: Cancellations must be made 24 hours in advance to avoid being charged for the appointment time. If 24-hour notice is not given, the 1st missed appointment will be a $50.00 charge. Second (2nd) and subsequent missed sessions will be a full charge of the session. _____
Illness: I understand that if I am ill or contagious, I shall contact Dr. Ashkins to reschedule my appointment
___
Payment: The session fee (5O minutes) for individuals is $115. 00, and for couples and families
$125.00.Thereisanadditional$20.00intakefeepayableonthefirstsession. Many couples choose to book longer sessions and these are prorated for the hourly rate. Paymentisdueatthe end of each session. Credit card payments or post-dated checks are accepted. _____
Insurance: Payment is expected in full at the time of each session. This office will file insurance and the insurance carrier will pay reimbursement directly to you. _____
Legal: I understand that due to confidentiality Dr. Cindy Ashkins, Ph.D., LCSW, LMT, does not routinely to go to court for marriage/couples counseling cases and I agree not to call her as an expert in any case relating to this current counseling _____
Electronic Communication: I understand Dr. Ashkins may at times use HIPAA compliant electronic communication including electronicinsurancefiling. _
Signed_ Date.
Thank you and welcome to our practice.
Dr. Cindy Ashkins