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Screening Information
SCREENING INFORMATION
Please Print Clearly THIS SHEET MUST BE FILLED IN COMPLETELY Readmit: Yes No
Date Client’s Social Security # Case #
Client’s First Name Last Name MI Address City State Zip
Telephone (Home) (Work)
Birthdate / / Age Gender F M Race
Name of Spouse/Guardian Phone
Address City State Zip
Person Responsible for Payment Soc. Sec. #
Signature of Person Responsible for Payment X (Must be signed for services to begin)Emergency Information
In case of emergency, contact:
Name (1) Relationship Phone Work
Address City State Zip
Name (2) Relationship Phone Work
Address City State Zip
Physician Phone
Address City State Zip
Psychiatrist Phone
Address City State Zip
Other Physicians Phone
Current Medications
Allergies
Employment Information (If client is a child, use parent’s employment)
Consent to Treatment and Recipient’s Rights
Client_____________________________________________ Chart #___________________________
I, ____________________________________________________, the undersigned, hereby attest that I have voluntarily
entered into treatment, or give my consent for the minor or person under my legal guardianship mentioned above, at
(name of clinic) , hereby referred as the Center. Further, I consent to have treatment provided by a psychiatrist, psychologist, social worker, counselor, or intern in collaboration with his/her supervisor. The rights, risks and benefits associated with the treatment have been explained to me. I understand that the therapy may be discontinued at any time by either party. The clinic encourages that this decision be discussed with the treating psychotherapist. This will help facilitate a more appropriate plan for discharge.
Recipient’s Rights: I certify that I have received the Recipient’s Rights pamphlet and certify that I have read and understand its content. I understand that as a recipient of services, I may get more information from the Recipient’s Rights Advisor.
Non-Voluntary Discharge from Treatment: A client may be terminated from the Center non-voluntarily, if: A) the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts at the clinic, and/or B) the client refuses to comply with stipulated program rules, refuses to comply with treatment recommendations, or does not make payment or payment arrangements in a timely manner. The client will be notified of the non-voluntary discharge by letter. The client may appeal this decision with the Clinic Director or request to re-apply for services at a later date.
Client Notice of Confidentiality: The confidentiality of patient records maintained by the Center is protected by Federal and/or State law and regulations. Generally, the Center may not say to a person outside the Center that a patient attends the program or disclose any information identifying a patient as an alcohol or drug abuser unless: 1) the patient consents in writing, 2) the disclosure is allowed by a court order, or 3) the disclosure is made to medical personnel in a medical emergency, or to qualified personnel for research, audit, or program evaluation.
Violation of Federal and/or State law and regulations by a treatment facility or provider is a crime. Suspected violations may be reported to appropriate authorities. Federal and/or State law and regulations do not protect any information about a crime committed by a patient either at the Center, against any person who works for the program, or about any threat to commit such a crime. Federal law and regulations do not protect any information about suspected child (or vulnerable adult) abuse or neglect, or adult abuse from being reported under Federal and/or State law to appropriate State or Local authorities. Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful. It is the Center’s duty to warn any potential victim, when a significant threat of harm has been made. In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s records. Professional misconduct by a health care professional must be reported by other health care professionals, in which related client records may be released to substantiate disciplinary concerns. Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records. When fees are not paid in a timely manner, a collection agency will be given appropriate billing and financial information about client, not clinical information. My signature below indicates that I have been given a copy of my rights regarding confidentiality. I permit a copy of this authorization to be used in place of the original. Client data of clinical outcomes may be used for program evaluation purposes, but individual results will not be disclosed to outside sources.
I consent to treatment and agree to abide by the above stated policies and agreements with (name of clinic) .
____________________________________________________ _________________
Signature of Client/Legal Guardian Date
(In a case where a client is under 18 years of age, a legally responsible adult acting on his/her behalf)
_____________________________________________________ _________________
Witness Date
Initial Client InformationName: Intake date: Time:
Address: Therapist requested: ___ Y ___ N
Therapist: Office:
Source of referral: Type(s) of service:
Phone number: Work phone: Date of birth: / /
(___) Primary insurance company:
Address: City: State: Zip:
Phone number: Persons covered:
Contact person: M&F covered:
Policy holder: Policy number:
Employer/Group: SS number:
PROVISIONS: Client pays $ Deductible amount Amount satisfied: $
Insurance pays % for visits ___ - ___ and % for visits ___ - ___
Type(s) of providers covered: Supervision:
Prior authorization needed:
Effective date: Policy anniversary:
Coverage for testing: Annual limit:
Other third-party coverage:
Address: City: State: Zip:
Phone number: Persons covered:
Contact person: M&F covered:
Policy holder: Policy number:
Other provisions:
(___) Personal payment amount: $ Terms:
Payment method (Insurance and cash clients; deductibles, co-payments, etc.)
___ Check ___ Cash ___ Charge card (type) Number:
Cardholder’s name: Expires:
Completed procedures: ___ Entered system Date:
___ Confirmed insurance Date:
___ Confirmed with client Date:
