1Adult History Form2Legal form3How the process works and credit card information Adult History form Please Take your time and fill in compltelyName(Required) Date of Birth(Required) MM slash DD slash YYYY Age(Required) Soc.Sec# Address City State / Province / Region ZIP / Postal Code Home Phone(Required) Work Phone(Required) Cell Phone(Required) occupational backgroundCurrent Occupation(Required) How Long(Required) Describe any dissatisfaction or problems in your present job(Required)List previous jobs and time spent working in each one(Required)educational backgroundHighest grade completed(Required) College degrees obtained(Required) Describe any academic or behavior problems you had in schoolFamily Of origin HistoryCity of birth(Required) In what city were you raised?(Required) How many times did you move prior to leaving your parent's home?(Required) How many children were in your family?(Required) which one were you?(Required) Who were you closest to in your family?(Required) most distant from?(Required) Describe your relationship with each of your parents(Required)Problems experienced during child and teen years(Required) Describe any mental illness,substance abuse or legal problems in your family of origin(Required)Current Family HistoryMarital status(check all that apply)(Required) single,never married separated divorced widowed How long?(Required) How many times have you been married?(Required) Please complete the following information about each of your childrenNameSexAgeResidenceDescribe Your Relation with each child Add RemovePsychological HistoryHave you ever considered or attempted suicide?(Required) DescribeDescribe any emotionally disturbing experiences you have had:(Required)Describe what has been stressful for you in the past year:(Required)Have you ever been arresrted?(Required) If yes,what were the charges? Have you ever been physically abused?(Required) If yes,at what ages: Have you ever been sexually abused?(Required) If yes,at what ages: Symptom Checklist 1. Please check each symptom experienced within the past two months 2. Then Circle your worst symptoms(six to eight).Symptom Checklist Depressed mood Feel worthless Hopeless or helpness Mood swings Socially withdrawn Increase crying Suicidal attempt Memory problem Temper outbursts Insomnia Thoughts of death Low self-esteem Easily startled Easily fatigued Sleeps too much Binge eating stealing Dramatic Other Problem Obsessive thoughts Compulsive behavior Nightmares Anxiety/Worry Intense fear Short attention span Hyperactivity Impulsive Perfectionist Change of appetite Poor concentration Easily distracted Avoids crowds Muscle tension Panic attacks Easily confused Makes self vomit Fire setting Avoids conflict Exposed to life threatening event Hears voices Sees things that are not there Racing thoughts Increased energy Sexual problem Stomach aches Headaches Conflicts with peers Rapid heart beat Reckless or self-abusive behavior Conflicts with others Aggressive behavior Less interested in fun activities More talkative Believe that others are plotting against you Constantly on the watch for danger Feels like things are not real Fears gaining weight Gambling problem Hair pulling Enjoys being center of attention Social HistoryDescribe your friendships as a child(Required)How many close friends do you now have?(Required) Describe your best friend(Required)What do you like do with your friends?(Required) Involvement in social oraganizations(i.e church,clubs,organizations)(Required) Health History(please fill in completely,even if some things do not seem important)(Required)Illness & HospitalizationsAgeLengthFever-Unconscious?Treatment & Aftereffects Add Removelist(Required)AccidentsAgeUnconscious?reatment & Aftereffects Add RemoveList(Required)List all medications you are now takingName of Dr.prescribingPurpose of medication Add RemoveList(Required)List all psychiatric medications you have taken in the pastName of Dr.prescribingPurpose of medication Add RemoveList all your current medical problems(Required)Name of your primary physician(Required) Physician's address and phone numberDescribe any weight loss or gain in the past year(Required)Describe how much you excercise(Required)How much do you smoke?(Required) Date of last physical exam(Required) Describe any sleep difficultiesHead injuries?(Required) ExplainHave You ever had a seizure?(Required) If yes,describeHow much alcohol do you drink on weekly basis? What other non-prescription drugs have you used?(Required) Have you ever been charged with a D.W.I or D.U.I?(Required) Ages or years(Required) ReligiousDescribe your religious upbringing(Required)Church affiliation Describe your level of participation in religious activities(Required)Describe how you would feel about discussing spiritual or religious issues as a part of your evalution or therapy(Required)Counseling & Therapy HistoryDescribe any previous psychological or psychiatric evalution(Required)Describe any previous involvement with therapy or counseling(Required)Treatment GoalsDescribe the problem that troubles you the most(Required)Why are you coming in for therapy(versus before or later)?(Required) What goals do have for therapy?(Required) Signature(Required) Date(Required) MM slash DD slash YYYY PATIENT POLICY Welcome to our practice! This agreement contains important information about our financial and office policies related to your care. Although these documents are long and sometimes complex, it is important that you read them carefully before your next session. We can discuss any questions you have about these policies procedures at that time, or you may call our office with your questions before you appointment: 612-886-6112 You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspect of your treatment and about our providers’ specific training and experience. EMERGENCY For any number of unseen reasons, if you attempt to contact your provider and you do not hear back, or we are unable to reach you, it will remain your responsibility to care for yourself, and keep yourself safe. If you feel unable to keep yourself safe, or to care for yourself, call 911 or go to your nearest emergency room. PSYCHOTHERAPY PARTNERS Some providers are employees of PTP, and other providers work as affiliates or independent contractors of PTP. Your provider may be a PTP affiliate or independent contractor, in which case you indemnify and hold harmless PTP, its officers, directors, successors, assigns and customers against any liability costs, or damages, including attorneys’ fees, relating to a claim for services provided by your provider, or any part of those services. CONFIDENTIALITY The confidentiality of all communications between a patient and a mental health provider is generally protected by law, with some exceptions, and we cannot and will not tell anyone else what you have discussed or even that you are in treatment with us without your written permission. Confidentiality and exceptions to the confidentiality law is more completely addressed in the HIPAA PRIVACY NOTICE & CONSENT form found on our website. In most situations, we only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA and addressed in HIPAA PRIVACY NOTICE & CONSENT form found on our website. CHARGES FOR MISSED APPOINTMENTS If you need to cancel or reschedule a session, it is required that you provide more than 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hours notice, you must pay our standard fee ($75) for the missed session. It is important to note that insurance companies do not provide reimbursement for cancelled or missed sessions. In addition, you are responsible for coming to your session on time and at the time scheduled. If you are late, your appointment will still end on time. Check this box to indicate that you have read & understood our Missed Appointment policy.INSURANCE We accept payment directly from insurance companies, and are participating providers with most major insurance companies. In the event that we are not a participating provider in your insurance network, our services will still be submitted to your insurance to obtain out-of-network reimbursement. We try to check your insurance upon your request for services, however you are ultimately responsible for knowing your insurance coverage, and paying for any non-reimbursable charges. Insurance companies require a formal diagnosis with their claims. If your provider believes you do not fit any diagnostic criteria, your insurance will likely not cover claims made for services, and you will be responsible for accrued fees. Check this box to indicate that you have read & understood our insurance policies. DELINQUENT ACCOUNTS Payment is required at time of service. We provide regular statements of your account balance via mail &/or email. You may pay your balance in session with your provider, online via credit/debit card through our Patient Center, and via check or cash. If a balance accrues and no payment is received, we reserve the right to seek payment by any means, including: using the credit/debit card information we have on file, retaining a collection agency, and taking legal action in court. We may be willing to work out a patient payment plan that includes a reasonable period for resolving the balance. If a patient balance remains unpaid, we receive the right to suspend services until balance is paid in part or in full. DATA SECURITYDATA SECURITY We will maintain reasonable and appropriate security methods, as required by HIPAA, to prevent unauthorized access to personal health information (PHI) protected by HIPAA and other state and federal privacy laws. Although we use encrypted and HIPAA accredited electronic health storage and email, in order to conduct business and provide you services, we may use means of electronic data transmittal which are ultimately unsecure, including but not limited to email, website transmittal, text messaging, facsimile (FAX) transmittal, insurance company portals. These electronic storage & communication methods may contain PHI. Although you can request that we not use the above methods to conduct business, we reserve the right to refuse your request. Check this box to indicate that you have read & understood our Data Security policies. I have read and understood the Patient Policies HIPAA PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMAITON. PLEASE REVIEW IT CAREFULLY. When you sign this document, it is a binding agreement. You may revoke or restrict portions of this agreement in writing at any time as provided below under “ADDITIONAL RIGHTS.” That revocation or restriction is binding on us unless we have taken action in reliance on it or if your authorization was obtained as a condition of obtaining insurance coverage or other law provides you with a right to contest a claim and you have not satisfied any financial obligations you have incurred.PROFESSIONAL RECORDS We are required to keep appropriate records of the psychological and psychiatric services that we provide. Your records are maintained in a secure electronic health record (EHR) that is HIPAA compliant and accredited. Although mental health treatment often includes discussions of sensitive and private information, normally brief records are kept noting that you have been here, what was done in session, and a mention of the topics discussed. You have the right to request that a copy of your file be made available to any other health care provider or for yourself at your written request.PSYCHOTHERAPY NOTES Psychotherapy notes require specific authorization to be released except for use of the notes for treatment, to defend PTP in a legal action or other proceeding brought by you and other specific legally permitted exceptions. The term "psychotherapy notes" means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint or family counseling session and that are separated from the rest of the individual's record. No one except PTP staff or a contracted clinical consultant covered by a business associate agreement will view or read of a session unless you give permission.THIRD PARTY RELEASE Once medical records are released to a third party, they may no longer be protected by state and federal privacy laws.CONFIDENTIALITY The confidentiality of all communications between a patient and a mental health provider is generally protected by law and we cannot and will not tell anyone else what you have discussed or even that you are in treatment with us without your written permission, unless otherwise required by law. In most situations, we only release information about your treatment to others with your written authorization. You, on the other hand, may request that information is shared with whomever you choose and you may revoke that permission in writing at any time, except that consent may not be revoked in situations in which we are required by law to disclose PHI. There are several exceptions in which we are legally bound to take action that requires revealing some information about a patient's treatment and other situations in which it is permitted to use and disclose PHI for treatment purposes. The situations in which we are permitted or required, as the case may be to reveal PHI include, but are not limited, to the following: If there is good reason to believe you are threatening serious bodily harm to yourself, or if we believe a patient is threatening serious bodily harm to another, we may be required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a patient threatens harm to themselves or another, we may be required to seek hospitalization for the patient, or to contact family members or others who can provide protection. To report suspected, or evidence of, abuse or neglect of children, disabled persons and vulnerable adults. In such a situation, we are required by law to file a report with the appropriate state agency. In response to a subpoena or other court order or where otherwise required by In situations in which it is appropriate to report to the National Instant Criminal Background Check System. To the extent necessary, to collect payment and to make a claim on a delinquent account. To the extent necessary for emergency medical care to be To discuss your care within our clinic’s treatment team, or to seek professional consultation with colleagues outside this clinic, PHI is disclosed for multidisciplinary team case consultations. Those professionals consulting on your case are also required to keep the information For health care & clinic operations, e.g., outcomes evaluation or quality assessment activities. PATIENT RIGHTS You have the following additional rights regarding PHI: The right to receive confidential communications of PHI and to make a written request to receive communications of PHI by alternative means or at alternative locations The right to inspect and receive a paper or electronic copy of PHI except for psychotherapy notes and information complied in reasonable anticipation of, or for use in a civil, criminal or administrative action or proceeding and other specific instances provided by law, such as if your PHI was obtained from someone other than your health care provider under a promise of confidentiality and access to the PHI would be reasonably likely to reveal the source of the information. The right to request amendment of PHI in writing in certain circumstances as permitted by law. The right to receive an accounting of disclosures of PHI during the six years preceding your request, except as to those not required to be disclosed by law. The right to request a paper copy of this notice from PTP, even if you have already agreed to receive notice electronically. The right to be notified if there has been a breach involving your PHI. The right to revoke consent to release of your medical records. If you want to revoke consent, it must be in writing and sent to the PTP. Your revocation does not apply to records that have already been released. EXCEPTIONS You have the right to view your PHI, with a few exceptions: If a doctor or licensed provider believes that it will be harmful to you or others. Information compiled in anticipation of, or for use in, a civil, criminal or administrative action or proceeding NOTICE PTP is required by law to maintain the privacy of PHI and to provide individuals with notice of its legal duties and privacy practices with respect to that PHI. PTP is required to abide by the terms of the notice currently in effect. PTP reserves the right to change the terms of this notice. The new notice provisions will be effective for all PHI that PTP maintains. Any revisions to the Notice will be provided to to you at your next session, via the agency website, or by having copies available at clinic sites. FILING A COMPLAINT(Required)FILING A COMPLAINT If you believe your privacy rights have been violated, you may file a complaint with Psychotherapy Partners or with the Department of Health and Human Services Office of Civil Rights (or both), without fear of retaliation by Psychotherapy Partners. For questions or complaints about data privacy or client privacy rights, you may contact your clinician. A complaint to the Office of Civil Rights may be filed in writing through fax, email, OCR Complaint Portal or by mail at: Office for Civil Rights, Regional Manager Response Center: 800-368-1019 U.S. Department of Health and Human Services 233 N. Michigan Ave., Suite 240 Chicago, IL 60601 Customer Fax: 202-619-3818 Email: ocrmail@hhs.gov I have read and understood HIPAA policy ELECTRONIC COMMUNICATION POLICY(Required)ELECTRONIC COMMUNICATION POLICY By signing this form I authorize Psychotherapy Partners, LLC to communicate with me electronically via telephone, email, faxing, the clinic website or internet patient portal, or claims filing sites. These communications will be used for scheduling, and for collecting or sending pertinent clinical, insurance information and claims, billing &/or collections information as is necessary to provide your treatment and or to correspond. I understand that communications via the means as described above, are not always secure. Although it is unlikely, there is a possibility that information you send to us, or that we send to you, may be intercepted and read by other parties besides the person to whom it is addressed. I understand that by federal law, Psychotherapy Partners, LLC may not use/disclose my healthcare information without my authorization except the information designated in my Patient-Clinician Agreement. My signature on this disclosure indicates that I am giving my permission to engage in the electronic and internet communication described above. I hereby release Psychotherapy Partners, LLC , from any and all liability that may arise from the release of electronic information. I understand that I have the right to revoke this authorization at any time. If I want to revoke this authorization I must do so in writing and address it to Psychotherapy Partners, LLC. I understand that if I revoke this authorization, it will not apply to any information previously released as a result of this authorization. I understand that I may refuse to sign this authorization. I also understand that Psychotherapy Partners, LLC cannot deny or refuse to provide treatment or billing services if I refuse to sign this authorization. I understand that once the information is disclosed pursuant to this authorization, it is possible that it will no longer be protected by the federal medical privacy law and could be disclosed by the person or agency that receives it. I have read and understood electronic communication policy TELETHERAPY CONSENT(Required)TELETHERAPY CONSENT TELETHERAPY CONSENT Confidentiality: The information disclosed during the course of my therapy is confidential, however, there are legal exceptions both mandatory, and permissible, including a child, elder, and dependent adult abuse; threats of harm to self or others, or if court-ordered. The therapist will take all precautions to ensure online therapy is confidential, but the client is informed that transmission could possibly be disturbed or distorted by technical failures, or interrupted or accessed by unauthorized persons. Appointments and Charges for Services: Patients are responsible for checking with their insurance to verify that Teletherapy Health therapy is covered. Copayment, deductible, and fees not covered by insurance are the client's responsibility and are due at the time of service. Limitations: On-line therapy plays a useful role in addressing mental health issues. It also has inherent limitations in not being physically present. For instance, body language is limited by this format and technical difficulties can have poor timing. Due to these limitations, this method is not recommended when in a state of crisis or when at high risk. When should I seek traditional mental health treatment rather than internet therapy? If you are having thoughts of harming yourself and or someone else. Please call 911. If you are in an abusive or violent relationship If you are in an abusive or violent relationship If you have serious substance abuse dependence If you are a minor (under 18 years old) Procedures should we encounter technical difficulties or disruptions in service: It is understood that when communicating by internet or other electronic means, disruptions in service or other technical difficulties will likely occur from time to time. Should a disruption occur at a time of crisis, the patient agrees to immediately phone me at 612-388-5236. I have read and understood teletherapy policy. By signing this form: I agree that I reside in the state of Minnesota I have read Patients Policies agreement I have read HIPPA notice I have read Electronic Communication Policy I have read Teletherapy Policy DISCLAIMER : By typing your name below, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this document. Clients Name (Please Print)(Required) Date(Required) MM slash DD slash YYYY Signed by: How the process work: After you complete intake form and sign legal documents/forms you will receive a link to Patient Portal. One of our licensed and credentialed therapists will contact you via phone or email to schedule your first session. The therapist will email you link to video platform you will be having session with them on During the first online session called Diagnostic Assessment the therapist will review your information you shared with them and start your therapy. You therapy process will continue for next 3 session. After that you have an option to purchase another 4 session or terminate your subscription. How do I talk to my therapist? You can talk to your therapist visa phone or email to schedule, cancel or reschedule your appointments. Your therapy will by online sessions (45 min) What if I don't like the therapist that was matched to me? You can ask to be matched to a different therapist. How much will it cost? Your therapy will be $100 per week, charged every 4 weeks. The subscription is billed and renewed every 4 weeks. It includes both the use of the secured site and the therapy service itself.How long will I use the service? As long as you need. You can cancel the subscription to the service at any time for any reason with a click of a button.Cost: Cost is $100 per week (charged every 4weeks) Currently we ore offering a 10% discount for the first 4 sessions. Your card will be charged $360 the first time and $400 ($100 per session) weekly after that. Enter payment card information to start:
