Patient Information new

  • 2265 Teton Plaza * Idaho Falls, Idaho 83404

    (208) 403-0135 Fax: (208) 209-8454

    PATIENT INFORMATION

  • RESPONSIBLE PARTY

  • PRIMARY INSURANCE

  • ADDITIONAL INSURANCE



  • 2265 Teton Plaza * Idaho Falls, Idaho 83404 * Office: (208) 403-0135 * Fax: (208) 209-8454

    FINANCIAL POLICY AND CONTRACT FOR SERVICES

    We are dedicated to providing you with the best possible care and service, and regard your understanding of our financial policies as an essential element of your care and treatment. To assist you, we have the following financial policy. If you have any questions, please feel free to discuss them with Kristopher or his staff.

    Kristopher L. Walton & Associates, LLC does NOT accept Medicaid or Medicare.

    I am responsible for all charges at the time of service, regardless of insurance coverage. My health care provider may submit insurance information to my insurance company for processing but does so only as a courtesy for me. I am responsible to pay all charges before my insurance company pays or determines the amount I owe after insurance regardless of any billing mistakes or disputes. Payment is expected at the time of service unless prior financial arrangements have been made in advance. All co-payments, deductibles, or private pay fees will be collected when you arrive for your appointment. As a courtesy to you, we prepare and forward your insurance claim forms. We are willing to work with you regarding payments for the services provided. If arrangements need to be made, please talk to Kristopher or his staff. We do require a minimum monthly payment of$25.00. We do charge an interest fee of 1.5% (18% annual rate) for all accounts over 90-days-past-due. If payments are not received on a monthly basis for the amounts agreed upon, the account can and will be placed with an outside collection agency. If this account is assigned to an outside agency for collection, collection costs will be an additional 1/2 of your balance if sent to collections and no court costs. It will be an additional 1/2 of your account balance if balance is collected through the court system. I agree to pay all attorney's fees, court costs, and charges or commissions of 50% that may be assessed to us by the collection agency retained to pursue this matter, with or without suit.

    MINOR CLIENTS:: For all services rendered to minor client, the adult accompanying the client is responsible for payment. If your child comes in alone, please send payment for services with them. I authorize all employees of Kristopher L. Walton & Associates, LLC to receive assignment of insurance payments. Employees of Kristopher L. Walton & associates, LLC are hereby authorized to release medical information to my health insurance company that may be necessary for processing of this claim. I have read and understand the financial policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by the practice.

  • 2265 Teton Plaza * Idaho Falls, Idaho 83404 * Office: (208) 403-0135 * Fax: (208) 209-845

    CONSTENT FOR USE OF EMAIL AND/OR TEXT REMINDERS

  • We can send you an appointment reminder by email or text. The appointment reminder will include only the date and time of your appointment and your service provider's name. We will not encrypt the messages. Health care information sent by regular email/text could be lost, delayed, intercepted, delivered to the wrong address, or arrive incomplete or corupted. If you understand these risks and would like to receive an appointment reminder by email/text, then confirm you accept responsibility for these risks, and will not hold us responsible for any event that occurs after we send the message.

  • I give consent to receive promotions and offers from KLWA by email and or text. (Initials)
    I understand the above statement and agree to these terms.

  • 2265 Teton Plaza * Idaho Falls, Idaho 83404 *
    (208) 403-0135 * Fax: (208) 209-8454

    Confidentiality from Third Parties

    Psychotherapy is confidential from parties other than parents with important exceptions:

    1. Information may be released to designated parties by written authorization of clients, parents, or legal guardians.

    2. When clients seek reimbursement for psychotherapy from insurance companies or other third parties- information, including psychological diagnoses, and in many cases, explanations of symptoms and treatment plans, and in rare cases- entire client records, must be provided to the third party. If health coverage is provided by the employer, the employer may have access to such information. Insurance companies usually claim to keep psychological diagnoses confidential, but may enter this information into national medical information databanks, where it may be accessed by employer, other insurance companies, etc., and may limit future access to disability insurance. life insurance, jobs, etc. Your therapist will provide you with copies of reports submitted to insurance companies at your request.

    3.Psychotherapist are required to release information obtained from you or from collateral sources (other individuals involved in a client's psychotherapy, such as parents, guardians, spouses) to appropriate authorities to the extent to which such disclosure may help to avert danger to a psychotherapy client or to others, e.g., imminent risk of suicide, homicide, or destruction of property that could endanger others.

    4.Psychotherapists are required to report suspected past or present abuse or neglect of children, adults, and elders, including children being exposed to domestic violence. to the authorities, including Child Protection and law enforcement, based on information provided by the client or collateral sources.

    5. If clients participate in psychotherapy in compliance with a court order, psychotherapists are required to release information to the relevant court, social service, or probation departments.

    6.Your psychotherapist must release information, which may include all notes on your psychotherapy and contact with collateral sources, in response to a court order, and may also be required to do so in response to a legitimate subpoena.

    7.Psvchotherapists reserve the right to release financial information to a collection agency attorney, or small claims court, if you are delinquent in paying your bill.

    8.Cell phone and e-mail communication can be intercepted by third parties. These forms of communication are reserved for urgent or time-sensitive matters. Psychotherapists are required to make a record of each client contact- E-mail communication are printed in full and become pan of a client's file.

  • 9.Psychotherapists often consult with other professional on cases, and teach or write about the psychotherapy process. but disguise identifying information when doing so. Please indicate to your therapist if you wish to place restrictions on consultation. teaching or writing related to your case.

  • Professional Records

    Psychotherapy laws and ethics require that Idaho licensed psychotherapists keep treatment records. Professional records can be misinterpreted and/or upsetting to untrained readers- You are entitled to receive a copy of these records unless your therapist believes that seeing them would be emotionally damaging to you, in which case your therapist will review them together with you, or will send them to a mental health professional of your choice, to allow you to discuss the contents. Client be charged copying costs plus $150.00-perhour for professional time spent responding to information requests. Your record includes a copy of the signed informed consent form, acknowledgement of receipt of privacy policy and practices, progress notes, any release of protected health information, and copies of your super bill. Records are kept in a locked file cabinet.

  • 2265 Teton Plaza * Idaho Falls, Idaho 83404 * Office: (208) 403-0135 * Fax: (208) 209-8454

    Fees for Psychotherapy

    Psychotherapy sessions and collateral contact:

    $200 for initial intake evaluation, $200 per 45-50 minutes, including any time missed by being late. Payment is due at each session-

    Phone calls/Crisis calls:

    $50.00 per 15 min conversation This service IS NOT billable to insurance and 100% the responsibility of the client or responsible party.

    Letters and reports:

    $200.00-per-hour.

    Attendance and Participation in school IEP meeting:

    $200.00-per-hour. Travel time is charged at hourly rate as well. but adjusted if travel is less than one hour. I understand that payment is due at the end of each session. I agree to cooperate with procedures required to collect from third-party payers. If I receive a third-party payment, I agree to turn it over to my therapist as soon as possible.

  • Appointments

    Office visits are by appointment only Monday thru Friday from gam to 6pm. Office visits take approximately 45-50 minutes. When you call for an initial appointment, you will be asked few questions regarding the nature and urgency of your concern or problem.

  • Cancellations

    I understand that my psychotherapist reserves an appointment time for me. I agree to call 24-hours in advance if I must cancel a session in order to allow my therapist to reschedule his time. If I provide less than 24 hours' notice of a cancellation, tm less a sudden emergency has occurred, I pay the fee of $50.00 for the first missed session and $200.00-per-missed-session following.

  • Emergencies

    My therapist agrees to furnish me with their emergency contact number. My therapist is not always immediately available by phone and may not be available until the late evening. If unavailable, my therapist will return my call as soon as possible. If I cannot reach my therapist, I can call the 24-hour Crisis Team at Eastern Idaho Regional Medical Center; Behavioral Health Unit at (208) 227-2100, or Region VII Mental Health Office at (208) 528-5717, or call 911- When my therapist is out of town, and if I am not also seeing another mental health professional, such as a psychiatrist, my therapist will provide me with phone numbers of alternate sources of help.

  • Length of Psychotherapy

    Some psychological problems can be alleviated in a few sessions, while others require more time. It is often difficult to predict the length of therapy needed. Talk to your therapist if you have any questions. Some disorders cannot be properly treated with the limitations of some health insurance policies. Generally, hospitalization should be as brief as possible to limit disruptions to a client's life. The decision to terminate therapy belongs to the client. Terminating therapy with a client should be done over a number of sessions. particularly in cases of a long-term therapeutic relationship. Should you decide to terminate therapy prior to the therapist's recommendation- it is important that you have a final meeting with your therapist. If your therapist believes you are terminating your therapy before adequate treatment has been received for your psychological problems, your therapist will provide you with referrals for Other therapist or you may choose to continue therapy your current therapist. Some managed health care plans provide benefits for only a time-limited course of psychotherapy. Some companies have contracts with therapists that prohibit clients to remain in therapy with a therapist beyond the designated time-frame. If your therapist believes you need further psychotherapy after this period, your therapist will provide referrals to other therapists with whom you can continue treatment.

  • 2265 Teton Plaza * Idaho Falls, Idaho 83404 * Office: (208) 403-0135 * Fax: (208) 209-8454

    Termination

    Your therapist has the right to close your case after trying to contact you by phone two (2) times if you do not return to therapy

  • Alternative Treatments

    Other treatment approaches are available as an alternative, or as an adjunct, to individual psychotherapy. These include family therapy, couples therapy, and group therapy.

  • E-mailing

    E-mail correspondence will be allowed and billed at the private rate on the quarter-hour. Insurance does not pay for email, thus you are responsible for all incurred expenses. Any correspondence will be added to your medical record.

    Do NOT email to schedule an appointment, notify your therapist of threats of self-harming or harm to others plans or behaviors.

  • Text Messaging

    Text messaging is allowable to adjust scheduling only

    Do NOT text message threats of self-harming or harm to others thoughts or plans

  • Psychotherapy Contract for Client Receiving Therapy

    I have read the above information. have asked questions as needed, and understand the issues related to risks and benefits of psychotherapy, medical concerns. assessment- the need for confidential psychotherapy, collateral contacts with others, treating separated or divorced families, professional records, confidentiality from third parties, alternative treatments, my diagnoses, and treatment plan, length of psychotherapy, fee for psychotherapy, emergencies, and cancellations

  • I agree to treatment for myself based on my informed consent to proceed with psychotherapy with Kristopher L. Walton & Associates, LLC.

  • 2265 Teton Plaza * Idaho Falls, Idaho 83404 * Office: (208) 403-0135 * Fax: (208) 209-8454

    NOTICE OF PRIVACY PRACTICES

    Health Insurance Portability and Accountability Act of 1996 (HIPAA) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT CAREFULLY.

    PURPOSE OF THIS NOTICE

    In the course of doing business, we gather and retain personal information about you. We respect the privacy of your personal information and understand the importance of keeping this information confidential and secure This Notice describes how we protect the confidentiality of your personal information that we receive- We have implemented policies and procedures in accordance with Federal and State confidentiality and privacy laws to protect your privacy. We are obligated to maintain the privacy and confidentiality of your personal information. We are also obligated to provide you with notice of its legal obligations to maintain the privacy of your personal information and to provide you notice of its policies and procedures about privacy and confidentiality. We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you. This information is called "protected health information" or "PHI". This notice describes your right and our obligations regarding the use and disclosure of that information. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU Federal law allows us to use and disclose your personal information in order to provide treatment, payment, or operations as described below:

    For Treatment We may use PHI about you to provide you with medical treatment or services. We may disclose PHI about you to doctors, nurses. technicians, office staff or other personnel who are involved in taking care of you and your health- Different personnel in our office may share information about you and disclose information to people who do not work in our office, in order to coordinate your care. such as phoning in prescriptions to your pharmacy, scheduling lab work and counseling sessions, coordinating care with counselors, behavioral or developmental support agencies, and school psychologists. Family members and other health care providers may be part of your medical care outside of this office and may require information about you.

    For Payment We may use and disclose PHI about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or a third party- For example, we may need to give your health plan information about a service you received here so your health plan will pay us or reimburse you for the service. We may also inform your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will cover the treatment

    For Healthcare Operations We may use and disclose PHI about you in order to run the office and make sure that you and our other patients receive quality care. For example, we may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice.

    Appointment Reminders Our practice may use your PHI to contact you and remind you of an appointment.

    Release of Information Our practice may release your PHI to friends. family members- or anyone else that is involved in your care, or who assists in taking care of you. However, you must be provided with an opportunity to object prior to the disclosure.

    Special Situations We are also allowed by law to use and disclose your PHI without your consent or authorization for the following purposes:

  • 2265 Teton Plaza * Idaho Falls, Idaho 83404 * Office: (208) 403-0135 * Fax: (208) 209-8454

    1. When required by law 2. For public health such as reports about communicable diseases or work-related health issues 3_ In reports about child abuse, domestic violence, or neglect 4.For health oversight activities, such as reports to governmental agencies that are responsible for licensing physicians or other health care providers 5.In connection with court proceedings or proceedings before administrative agencies 6.For law enforcement purposes, such as responding to a court order or subpoena 7.In reports to coroners, medical examiners, or funeral directors 8.For tissue or organ donation 9.For research, with the approval of certain oversight entities; otherwise, use and disclosure of your PHI requires for research requires your authorization 10. To avert a serious threat to the health or safety of a person or of the public 11.For national security and intelligence activities, including the protection of the President 12.In connection with services provided under workers' compensation laws

    Other uses and disclosures of Health Information All other uses and disclosures of your PHI will be made by us only with your written authorization. If you give us authorization to use or disclose PHI about you. you may revoke that authorization, in written, at any time. If you revoke your authorization, we no longer use or disclose information about you for the reasons covered by your written authorization, but we cannot take back any uses or disclosures already made with your permission.

    How we protect personal information We restrict access to your PHI to those employees who need access in order to provide services to our patients. We have established and maintain appropriate physical, electronic and procedural safeguards to protect your PHI against unauthorized use or disclosure. We have established a training program that our employees must complete and update annually. We have also established a Privacy Officer. who has overall responsibility for developing, training and overseeing the implementation and enforcement of policies and procedures to safeguard your PHI against inappropriate access, use and disclosure, consistent with applicable state and federal law.

    Psychotherapy Notes In the course of your care with our practice, you will receive treatment from a mental health professional (such as a psychiatrist) who keeps separate notes during the course of your therapy sessions about your conversations. These notes, known as "psychotherapy notes", are kept apart from the rest of your medical record, and do not include basic information such as your medication treatment record, counseling session start and stop times- the types and frequencies of treatment you receive, or your test results. They also do not include any summary of your diagnosis, condition, treatment plan, symptoms, prognosis, or treatment progress. Psychotherapy notes may be disclosed by our practice only after you have given written authorization to do so. (Limited exceptions exist, e.g. in order for our practice to prevent harm to yourself or others, and to report child abuse/neglect). You cannot be required to authorize the release of your psychotherapy notes in order to obtain health-insurance benefits for your treatment, or enroll in a health plan. Psychotherapy notes are also not among the records that you may request to review or copy (see discussion of your rights below). If you have any questions_ feel free to discuss this subject with our practice.

    YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

    Right to Inspect and Copy You have the right to inspect and copy your PHI, such as medical and billing records, that we use to make decisions about your care (except psychotherapy notes). In order to do so, you must submit a written request to our office on a form that will be provided to you. If you request a copy of the information, wc will charge a fee for the cost of copying, mailing or other associated supplies. We may deny your request to inspect and/or copy in certain limited circumstances. Ifyou are denied access to your PHI, you may ask that the denial be reviewed in writing. If such a review is required by law, we will select a licensed healthcare professional to review your request and our denial. The person conducting the review will not be the person who denied your request, and we will comply with the outcome of the review

  • 2265 Teton Plaza * Idaho Falls, Idaho 83404 * Office: (208) 403-0135 * Fax: (208) 209-8454

    Right to Amend Personal Information If you believe PHI we have about you is incorrect or incomplete. You may ask us to amend the information. You have the right to request an amendment as long as the information is kept by this office. To make this request, you must submit a written request on a form that will be to you. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition. we may deny your request if you ask us to amend information that:

    • We did not create, unless the person or entity that created the information is no longer available to make the amendment
    • Is not part of the PHI that we keep
    • You would not be permitted to inspect and copy
    • Is accurate and complete

    Right to Receive an Accounting of Disclosures You the right to request an accounting of all disclosures of your PHI made by us that are not directly related to your treatment, payment for your treatment, or health care operations as outlined above- To obtain this list, you must submit a written request on a form that will be provided to you. We will provide this accounting to you within a reasonable period of time after your request and in accordance with the policies and procedures established by our office. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. There may be a cost involved in obtaining this list. We will notify you of the cost involved and you may choose to withdraw you request.

    Right to Request Restriction on Disclosure of Personal Information You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, or healthcare operations. You also have the right to request a limit on the PHI we disclose about you to someone who is involved in your care or the payment for it, such as a family member or friend. For example, you could ask that we not use or disclose information about a diagnosis with a family member. To make this request, you must submit a written request on a form that will be provided to you.

    Right to Confidential Communications You have the right to request that we provide your PHI to you in a confidential manner. For example, you may request that we send your PHI by alternate means or to an alternate address, such as by telephone to a different telephone number or to an office address rather than your home address. Also you may, for example, request that your PHI be sent in a sealed envelope rather than on a postcard.

    Right to receive this notice You have the right to request and receive a copy of this Notice in written or electronic form. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. To obtain a copy, provided to you at no charge, contact our office.

    Changes to this notice We reserve the right to change this notice, and to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a summary of the current notice in the office with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.

    Right to complain We are obligated to comply with the privacy practices set forth in this Notice. If you believe that we have violated this privacy policy, you have the right to file a complaint with our office, your Health Plan, or the United States Department of Health and Human Service, Office of Civil Rights. You not be penalized for filing a complaint.

    Contacting us regarding your rights If you should have any questions regarding your rights or wish to make any of the above requests or complaints, you should direct your inquiries to our Privacy Officer, Kristopher Walton at the address above.

    Effective Date The effective date of this Notice is October 1, 2009.

  • 2265 Teton Plaza * Idaho Falls, Idaho 83404 * Office: (208) 403-0135 * Fax: (208) 209-8454

    NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT

    I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

    • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
    • Obtain payment from third-party payers.
    • Conduct normal healthcare operation such as quality assessments and physician certification.

    I have received, and read and understand your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I understand that his organization has the right to change its NOTICE OF PRIVACY PRACTICES from time to time and that I may contact this organization at any time the address above to obtain a current copy of the NOTICE OF PRIVACY PRACTICES. I understand that I may request in written that you restrict how my private information is used or disclosed to carry out treatment. payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions-

  • FOR OFFICE USE ONLY

    We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices Acknowledgment, but we unable to do so as documented below.

  • 2265 Teton Plaza, ID 83404
    Phone:(208)403-0135 Fax:(208)441-7294

    Protected Health Information: Release of Information

    Section A: This section must be completed for all requests.

  • I understand that: 1. I may refuse to sign this authorization and that it is strictly voluntary. 2. My treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization. 3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on my actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices. 4. If the requestor or receiver is nota health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be redisclosed. 5. I understand that I may see and obtain a copy of the infomation described on this form, for a reasonable copy fee, if I ask for it. 6. I can a of this for after I s- n it, if I request it.

  • This authorization will expire on the followinq: (Fill in the date or the Event, but not both, NOT to exceed one year )

  • Purpose of Disclosure: (Description of Information to be used or disclosed)

  • NOTE: In the event we are unable to accommodate an electronic delivery as requested, a paper copy will be provided

    Section C: Signatures

    I have read the above and authorize the disclosure of the rotected health information as stated.

  • To verify the identity of the requestor, a photocopy of a government issued picture ID must accompany this request.

  • Kristopher L. Walton & Associates, LLC

    2265 Teton Plaza
    Idaho Falls, Idaho 83404
    Office: 208-403-0135
    Fax: 208-209-8454

    Comprehensive Diagnostic Assessment

  • Environment

    Who lives in your home (parents, siblings, roommates, etc.) and how do you get along with them?
  • Presenting Problem

    Please describe what the current concerns are that brought you in today.
  • Please describe any additional life stressors.
  • Psychiatric Problems

  • Depression - Have you had a period of time during which you felt unhappy, depressed, and irritable and felt no interest in life consistently for at least two to four weeks?
  • High Periods or Mania - Have you had moods that lasted one week or more in which you had so much energy you did not sleep for several nights, or felt you could accomplish many difficult tasks easily?
  • Were you feeling so good that others commented on your elevated mood?
  • Chronic Feelings of Unhappiness - Have you felt mildly unhappy, or unable to enjoy life, for many years, for no apparent reason?
  • Suicide Attempts - Have you ever attempted suicide?
  • Self-harm - Besides attempting suicide have you ever attempted to do physical harm to yourself in other ways such as cutting or burning yourself?
  • Chronic Tension and Anxiety - Have you ever had problems with chronic anxiety, tension, nervousness, or constant worrying?
  • Do you worry about minor concerns? (Not connected to anxiety attacks)?
  • Panic Attacks - Have you had brief anxiety attacks during which you felt like you were going to die, lose control, were very frightened, extremely anxious, or uncomfortable?
  • Panic Associated Fears - Have you ever been afraid of going out of the house alone, going to the grocery store, driving, or using public transportation because of fear of having a panic attack?
  • Obsessive/Compulsive Symptoms - Have you had compulsions to repeat tasks such as checking things, washing hands, counting, or obsessions (ideas that make no sense by keep repeating in your mind)?
  • Social Fears or Phobias - Have you been fearful in specific social situation, or felt uncomfortable doing things in front of other people?
  • Do you worry excessively about being embarrassed, or humiliated in social situation?
  • Phobias - Have you had significant phobias such as heights, flight, closed spaces, insects, etc. that interfere with your life?
  • Posttraumatic Symptoms - Have you ever experienced a very traumatic event that has continued to bother you or cause emotional problems later in life, such as nightmares or flashbacks of the event?
  • Hyperactivity/Inattentions - Were you considered hyperactive and/or inattentive, or have you been treated with Ritalin or another stimulant, or been diagnosed with ADHD?
  • Psychotic Symptoms - Have you ever had hallucinations, hear voices, felt that you had special powers or were receiving special messages, felt inappropriately suspicious that people were trying to hurt you?
  • Chronic Physical Symptoms - Have you had a period of time during which you felt physically sick or worried about your health when no physical cause could be found?
  • Chronic Pain - Have you had problems with chronic pain such as stomachaches or headaches?
  • Sleep Problems - Have you experienced sleep problems such as insomnia, oversleeping, frequent nightmares, or sleepwalking?
  • Anorexia - Have you ever been anorexic or purposely lost weight to obtain a weight below normal?
  • Binge Eating or Bulimia - Have you had eating binges associated with inducing vomiting using laxatives, or exercising to the extreme?
  • Compulsive Behaviors - Have you had problems with compulsive behaviors such as gambling, spending, work, sex, pornography, or other problematic compulsion?
  • Dissociative Symptoms - Have you had periods of time during which you feel “out of touch,” removed from the world around you, or lost large amounts of time that you cannot account for?
  • Psychiatric History

    Are you currently receiving services from a mental health provider? (Therapy, PSR, Service Coordination, Medication, etc.) If so, which providers?
  • Have you had mental health services in the past? (Therapy, PSR, Service Coordination, Medication, etc.) If so, which providers?
  • Have you ever been admitted to residential treatment program or psychiatric hospital?
  • Substance Use/Abuse

    Do you drink alcohol?
  • How often and how much?
  • Do you, or those who you associate with believe you have a drinking problem?
  • Drug Abuse - Have you ever abused “street” or prescription drugs?
  • Which ones and what age were you?
  • Do you smoke or use tobacco products?
  • Do you regularly consume caffeinated beverages? (Soda, tea, coffee, energy drinks, etc.)
  • Family Psychiatric History

    Please share any psychiatric problems in your biological relatives. Consider problems such as depressions, bipolar disorder, anxiety disorders (OCD, panic disorder, PTSD), schizophrenia, ADHD, alcohol or drug abuse, anger or criminal problems, suicides, etc.
  • Medical History and Functioning

    How is your overall health?
  • Do you have any major health concerns? (High blood pressure, headaches, seizures, heart problems, etc.)
  • Do you have any contagious diseases?
  • Do you have any disabilities or handicaps?
  • Do you have any major allergies?
  • Have you had any major accidents, illnesses, or injuries?
  • Family History and Functioning

    What is your current relationship status?
  • What is your sexual orientation?
  • If you have ever been married, when was it, how long did it last, and did you have any children?
  • Are you currently in a romantic relationship?
  • How do you feel about your current relationship?
  • What are your major conflicts about?
  • Any children living outside of the home?
  • What resources and supports do you feel you and your family have?
  • What are your strengths in the family setting?
  • Where were you born?
  • Were you adopted?
  • How old were your parents when you were born?
  • Were they married?
  • Where did you grow up?
  • Are your parents still living?
  • What do they do for an occupation? Please describe your relationship with your father. Please describe your relationship with your mother.
  • What siblings do you have? Please explain your family’s cultural, and/or religious background.
  • Were you ever physically or sexually abused, assaulted, or molested?
  • Social History and Functioning

    How would you describe your friendships? (No friends, acquaintances, acquaintances and friends)
  • How would you describe and comfort level in social situations?
  • What are your social talents or strengths?
  • Vocational/Educational History and Functioning

    What is the highest level of education that you have achieved?
  • Please describe how you did in school academically.
  • Please describe how you did in school behaviorally.
  • Please describe how you did in school socially.
  • Were you ever in a specialized class setting or receive special education?
  • Do you have any educational goals at this time?
  • Are you currently employed?
  • How long have you worked there and are you satisfied with this job?
  • Have you ever been reprimanded, fired, or participated in a work program?
  • What are your employment goals?
  • Have you ever been in the military?
  • Were you honorably discharged?
  • Financial History and Functioning

    Please describe the family’s source of income.
  • Do you or your children receive support from state or federal programs?
  • Do you have a history of financial problems?
  • Basic Living Skills History and Functioning

    Do you have any concerns about your ability to maintain your basic living tasks (cooking, chores, safety, etc.)?
  • Housing History and Functioning

    What are your current living arrangements? (rent, own, live with family, etc.)
  • Is this living arrangement what you would consider healthy and safe?
  • Community/Legal History and Functioning

    Do you have any current or past involvement with the legal/court system?
  • Mental Status Exam - Clinician Use Only

    Suicidality/Homicidality:

    Does client have any suicidal or homicidal thoughts, feelings, gestures, intentions, or plans?
  • Does client have a history of suicidal or homicidal thoughts feelings, gestures, intentions, or plans?
  • Is immediate intervention required to keep client or others safe?
    Referral:
  • Mental Status

    General Behavior: cooperative, passive, withdrawn, dramatic, restless, hostile, anxious, other:
    Attire: appropriate, seductive, untidy, loud, meticulous, other:
    Gait: normal, erect, stooped, ataxic, rigid, shuffling, manneristic, other:
    Motor Activity: normal, agitated, retarded, tremor, tic, mannerism, other:
    Productive of Thought: spontaneous, verbose, pressured, speech, unproductive, other:
    Mood: normal, indifferent, fearful, angry, euphoric, labile, shallow, blunted, flat, composed, anxious, sad, tearful, depressed, other:
    Affect: appropriate, inappropriate, flat, other:
    Perception: normal, auditory hallucination, visual hallucination, illusions, depersonalization, hypochondriasis, other:
    Orientation: normal, disoriented to time, place, person
    Memory: normal, defective (remote, recent, immediate), other:
    General Knowledge: consistent with education, inconsistent, able to abstract, concrete, other:
    Insight: absent, good, fair, minimal
    Judgment: good, fair, poor
  • Diagnosis
    Axis I (p)
    Axis II
    Axis III
    Axis IV
    Axis V GAF
  • Treatment Recommendations:
  • Clinical Therapy Hrs per week: Duration:
    Group Therapy Hrs per week: Duration:
    Navigating Your Life Coaching:
  • Interdisciplinary Team: (list any people involved in client care and place an “x” if we have a ROI on file)
  • - Client:
    - Parent/Guardian:
    - Previous Therapist:
    - Psychiatrist:
    - General Practitioner:
    - Bishop:
    - School:
  • CDA Completed By:
    Date: