Welcome to Pathways Forensic & Mental Health Services, PLLC

We are very happy you chose us to provide you with your clinical services. Please take the time to complete this intake packet and bring the information with you to your first session. If you need guidance on any part of our forms, please do not hesitate to contact us as we welcome your questions.

Client Information Sheet

How did you find Pathways FMHS:

______PFMHS Website

______Internet Search

______Psychology Today Website

______Physician (Name: ______)

______Probation / Parole Officer (Name: ______)

______Attorney (Name: ______)

______Insurance

______BCBS

______Aetna

______Magellan

______Medicaid

______United Behavioral Healthcare/Optum

______Tricare/Humana

______ComPsych

______PHCS Multiplan

Personal Information

Client name: ______Date:______

Address: ______

City, State: ______Zip: ______

Phone numbers with area code: Home: ( ) ______

Work: ( ) ______Cell: ( ) ______

Birth date: ______Age: ______Social Security Number: ______-_____-______

Family Information:

Marital/relationship status: ______Single ______Married ______Divorced

______Separated ______(if separated / divorced, how long) ______Widowed

Spouse/Significant other’s name: ______

Significant other’s age and sex: ______How long together? ______

Names and ages of all children: In your home?

______Age: ______yes ____ no

Employer/School Information:

Employer/School: ______

Position/Grade: ______For how long? ______

Education Level: ______

Parent Information (for clients 18 and under)

Please Complete The Following / Living or Deceased / If Deceased: Year of Passing / Good Relationship
Yes/No
Your Mother's Name:
Your Father's Name:
If raised by a stepparent, please list their names.

Medical Information:

List any allergies you have: ______None ____

Primary Care Physician: ______Address:______

City: ______State: ______ZIP: ______

Primary Care Physician’s phone number: (____) ______

Date of your most recent physical examination: ______

Please list all current medications and dosages:

Name of Medication / Dosage / Name of Prescribing Doctor / When did you start taking it?

Please list all current or past health problems, and any major operations:

Current / Past

Mental and/or Emotional Health

List all therapists you have seen, what year you saw them, and contact information if possible. ______

______

List any substance abuse treatment or inpatient psychiatric treatment you have had, and the dates: ______

______

Please indicate which of these substances you currently use:

Substance / Amount used / How often?
Cigarettes
Alcohol
Pills not prescribed for me
Marijuana
Cocaine or crack
LSD
Heroin
Other (please list):

What situation or problems do you want or need to address? ______

Please indicate if you are having any of the following problems, or if you had them in thepast:

I have I had it

this now in the past

Difficulty falling asleep or staying asleep ______

Sleeping too much ______

Change in appetite, weight loss, or weight gain ______

Frequent crying ______

Panic attacks or anxiety attacks ______

Thoughts of killing or hurting myself ______

Attempts to kill or hurt myself ______

Problems concentrating ______

Problems remembering things ______

Periods of daily sadness lasting more than two weeks ______

I startle easily ______

Can’t stop remembering upsetting past events ______

Difficulty controlling my temper ______

I physically hurt other people ______

I break things sometimes ______

I worry a lot ______

Little or no interest in sex ______

I feel tired almost every day ______

Feelings of unreality ______

Made myself throw up in order to lose weight ______

Used laxatives or exercised excessively to lose weight _____

I often feel like I am an outsider ______

Sexual problems ______

Worry that something is wrong with my body ______

Frequent arguments with the people I live with ______

I hear voices inside my head ______

I cause physical injury to myself ______

Other (please list):

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Is your counseling court-related? ______YES ______NO

(If no, please skip the next section)

COURT-RELATED CLIENTS:

Please indicate which of the following applies to you: I am currently involved in:

______pre-Trial Criminal Case Charge: ______

______pre-Sentence Status Charge: ______

______Post Conviction Criminal Case: Charge: ______

______Family Law Litigation Pending Court Action: ______

List the charge(s) for which you are on probation, parole, or any charges still pending in the Court / Date of arrest / Probation
Officer

Please provide details below:

______

I hereby consent for Pathways FMHS to provide evaluation and treatment to me or my child.

Client or ParentDate

Parent of minor childDate

Continue to next page for final consents

GENERAL CONSENT FOR USE OF ELECTRONIC MEDIA:

My email address: ______

May we email you at this address: _____ YES _____ NO

My Home Phone Number: ______

May we leave messages at this number? ____ YES ____NO

My Cell Phone Number: ______

May we leave messages on this number? ____ YES ____NO

May we text you at this number? ____ YES _____NO

By my signature, I am acknowledging that I have been made aware that Pathways Forensic & Mental Health Services is not using a private / encrypted server for the exchange of email; therefore, any use of email on my part to Pathways FMHS, or that of the therapist regarding my treatment, may be transmitted through a server that is not secure; therefore, may not be confidential. If you answer “Yes” to communicate by email, and/or text, you must sign this acknowledgement and consent.

With my signature, I am acknowledging that I have read and understand this disclosure and do, hereby, authorize Pathways to contact me in the manners designated above.

______Date: ______

Client (or Parent/Guardian of Minor)

Acknowledgement of Receipt of Notice of Privacy Practices & Policies & Procedures of Pathways Forensic & Mental Health Services, PLLC

Client Name: ______

I hereby acknowledge that I have received a copy of Pathways Forensic & Mental Health Services, PLLC Notice of Privacy Practices. I understand that I have the right to refuse to sign this acknowledgement if I so choose.

______

Signature of Patient or Legal RepresentativeDate

______

Printed Name of Patient’s Representative (if applicable)

Relationship to Patient (if applicable)

Parent or guardian of un-emancipated minor

Court appointed guardian

Executor or administrator of decedent's estate

Power of Attorney

------

FOR OFFICE USE ONLY

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices on the following date, ______.

Acknowledgment could not be obtained due to the following reason:

Patient/representative refused to sign

Emergency situation prevented us from obtaining acknowledgement at this time (will attempt again at a later date)

Communication barriers prohibited obtaining acknowledgement (Explain)

______

Other (Specify)

______

NOTICE OF Pathways Forensic & Mental Health Services, PLLC

PRIVACY PRACTICES

This notice tells you how Pathways FMHS makes use of your health information, how your health information may be disclosed to others, and how you can get access to the same information. Please review this notice carefully and feel free to ask for clarification about anything in this material. The privacy of your health information is very important and this agency will do everything possible to protect that privacy.

We have a legal responsibility under the laws of the United States and the state of Texas to keep your health information private. Part of our responsibility is to give YOU this notice about our privacy practices. Another part of our responsibility is to follow the practices in this notice, which took effect June 1, 2012, and will be in effect indefinitely or until such laws change that it should be replaced by this agency.

Pathways FMHS has the right to change any of these privacy practices as long as those changes are permitted, or required by law. Any changes in our privacy practices will affect how we protect the privacy of your health information. This includes health information we will receive about you or that we create here at the Pathways Forensic & Mental Health Services, PLLC, Lufkin, Texas or any other location wherein a representative of Pathways FMHS may be providing health-related services. These changes could also affect how we protect the privacy of any of your health information we had before the changes.

When changes are made, those changes will be reflected in an updated notice and you will be given a copy of the new notice. When you finish reading this notice, you may request a copy of the notice at no charge to you. If you request a copy of this notice at any time in the future, Pathways FMHS will gladly give you copy at no charge. If you have any questions or concerns about the material in this document, please ask us for assistance, which we will provide at no charge to you.

______

Here are some examples of how Pathways Forensic & Mental Health Services, PLLC, (PFMSH) may use and/or disclose information about your health information

Pathways FMHS may use or disclose your health information:

To your physician or other healthcare provider who is also treating you.

To anyone on PFMHS staff involved in your treatment program.

To any person required by federal, state, or local laws to have lawful access to your treatment program such as State, Federal, or International law enforcement or supervision agencies, or any other official associated with your treatment.

To receive payment from a third party payer for services provided by PFMHS for you.

To PFMHS staff in connection with standard business operations to include but not limited to: evaluating the effectiveness of staff, supervising staff, improving the quality of services, and in connection with licensing, clerical operations such as filing and file organization, banking and insurance-related matters, credentialing or certification activities.

To anyone you give written authorization to have your health information, for any reason you want. You may revoke this authorization in writing at any time you choose unless the authorization is designated to allow exchange of information with a third-party person required by federal, state, or local laws to have lawful access to your treatment program such as State, Federal, or International law enforcement or supervision agencies, or any other official associated with your treatment. When you revoke an authorization, it will only affect your health information from that point on and will not be retroactive.

To a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, you will be given an opportunity to object. If you object, are not present, or are not capable of responding, Pathways staff will use professional judgment in light of the nature of the emergency, to go ahead and use or disclose your health information in your best interest at that time. In so doing, we will only use or disclose the aspects of your health information that are necessary to respond to the emergency.

To report alleged abuse of children and at-risk adults or domestic violence to the Texas Department of Protective and Regulatory Services or law enforcement official in the jurisdiction in which the alleged crime occurred.

To report in response to law enforcement requests for information about victims of crimes.

To report crime on the Pathways Forensic & Mental Health Services, PLLC premises to the law enforcement official in the jurisdiction in which the alleged crime occurred.

To avert serious threats to health or safety.

If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court subpoena or court order. We may disclose health information about you in response to a notary or attorney subpoena, discovery request, or other lawful process by someone else involved in the dispute.

We may disclose health information if asked to do so by law enforcement officials in response to a court order, subpoena, warrant, summons or similar process.

We will not use your health information in any marketing, development, public relations, or related activities without your written authorization.

We: cannot use or disclose your health information in any ways other than those described in this notice unless you give us written permission.

As a client of the Pathways Forensic & Mental Health Services, PLLC you have these important rights:

With limited exceptions, you can make a written request to inspect your health information that is maintained by PFMHS for clinical and administrative purposes.

You can ask us for photocopies of the information in part “A” above.

We will charge you 15 cents per page for making these photocopies.

You have a right to a copy of this notice at no charge.

You can make a written request to have us communicate with you about your health information by alternative means, at an alternative location. (An example would be if your primary-language is not spoken at PFMHS, and we are treating a child of whom you have lawful custody.) Your written request must specify the alternative means and location.

You can make a written request that other restrictions be placed on the ways your health information is used or disclosed. Pathways FMHS reserves the right to deny any and all of your requested restrictions. If Pathways FMHS agrees to these restrictions, we will abide by them in all situations except those that professional judgment deems it appropriate that the situation constitutes emergency.

You can make a written request that we amend the information in part “A” above.

If we approve your written amendment, we will change our records accordingly. We will also notify anyone else who may have received this information, and anyone else of your choosing.

If we deny your amendment, you can place a written statement in our records disagreeing with our denial of your request.

You may make a written request that we provide you with a list of those occasions where Pathways FMHS or its associates disclosed your health information for purposes other than treatment, payment, or our standard operations. This can go back as far as June 1, 2012.

If you request the accounting in above more than once in a 12-month period we may charge you a fee based on our actual costs of tabulating these disclosures.

If you believe we have violated any of your privacy rights, or you disagree with a decision we have made about any of your rights in this notice you may complain to us in writing to the following person:

Compliance Officer: Jean Stanley

Address:Pathways Forensic & Mental Health Services, PLLC

602 S. John Redditt Drive

Lufkin, TX 75904

You may also submit a written complaint to the United States Department of Health & Human Services.

*****Please acknowledge with your signature on the top sheet that you have received a copy of the NOTICE OF THE PATHWAYS FORENSIC & MENTAL HEALTH SERVICES OF LUFKIN, PLLC, TEXAS’ PRIVACY PRACTICES.

*****THIS NOTICE IS YOURS TO KEEP. PLEASE DO NOT LEAVE THE NOTICE WHEN YOU COMPLETE YOUR INTAKE SESSION.

Financial Agreement & Disclosures

You have been referred to; or you have initiated receiving services from Pathways Forensic & Mental Health Services, PLLC (Pathways FMHS). As such, it is the policy of our agency to provide disclosure of policies related to your services, including you financial responsibilities/agreement. By initialing each section in this disclosure form, and by your signature on page 4, you (a) acknowledge understanding of each;(b) agree to pay for services at the following rates; and (c) to abide by the terms outlined in this contract.

Please initial each section stating you have read and understand the terms of this agreement.

_____ Files: As a client with Pathways FMHS, we will store you intake forms in a hard copy file. Your intake informs will then be scanned into an e-file, where these and all other information about you will be electronically entered and stored over the course of your treatment in a HIPPA compliant database to ensure confidentiality. Your hard copy folder will be maintained in a safe and secured area of Pathways FMHS in Lufkin, Texas. Upon termination, your file will be moved to a secure area containing all inactive records. After a seven-year period, all aspects of the case will be destroyed, per State mandates.

_____ Appointments represent the advance purchase of time from Pathways FMHS. Appointments range from 50-60 minutes and are billed on a per session basis. Sessions may be scheduled for a longer period of time and in such instances are billed on a prorated basis. Payment is due at the time services are rendered unless your services are funded by a third party agency such as Federal or State probation, or a private attorney, etc. If you call to cancel your scheduled appointment at least 48 hours in advance you will not be charged. If you provide less than 48 hours’ notice, a missed appointment fee equal to the full fee for the time purchased will be due, emergency situations notwithstanding. Each such circumstance shall be evaluated and a determination as to the charge will be made at that time.

_____ Phone Sessions & Professional Conferences: Clients will not be billed for brief, miscellaneous emails or concise phone calls regarding scheduling or other questions. However, we reserve the right to bill for excessive out-of-session communications or communications with other professionals if significant out-of-session time is expended in your case. However, prior to billing, we will discuss the matter with you. Any telephone conference with you or other professionals that requires formal scheduling on our calendar will be billed at your hourly rate with a minimum of billable hour. Personal consultations by your attorney in regard to your case will also be billed. If conferences of any kind exceeds one hour, an additional one-hour fee will be assessed. Payment for conferences for which you are assessed the cost will be made using your pre-authorized card on file immediately upon completion of the conference unless other payment arrangements have been made prior to the conference.

_____ CancellationPolicy: Cancellations of any appointment with less than 48 weekday (Monday through Friday, excluding holidays) hours’ notice will result in the canceling party being billed the entire service fee, emergency situations notwithstanding. You must cancel your appointment directly by phone or by email at If cancelled online, the cancellation must still be within 48 hours, otherwise, any and all cancellation conditions apply. Failure on the part of technology to deliver a message does not constitute an excusal for missed appointment.

_____ Missed Appointment Policy: Per the Pathways FMHS missed appointment policy, if you do not show up for your appointment, there will be a missed appointment fee assessed at the amount equal to the full cost of the time you purchased (therapist full hourly rate), regardless of insurance co-pay (if applicable). Missed appointment fees will be assessed to the responsible party. They will be deducted from any existing retainer, or paid using your authorized credit/debit card on file. All missed appointment fees must be paid prior to your next session. If you accumulate two consecutive missed appointment fees, Pathways FMHS will not reschedule a third appointment until the balance of your missed appointment fees is paid in full.