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New Member Sign Up

Please review and complete both forms below

New member form

First name

Last name

Address

Birthday

Month

Day

Year

Phone Number

Occupation

Who referred you to DC&W

Policy Number

Health insurance and Group Number

Emergency Contact Name

Policyholder Name and DOB

Emergency Contact Number

What is the main concern that led you to consult DC&W

Have you had any medical illnesses in the past?

What is the date of your most recent physical examination?

Have you had any surgical operations or injuries?

Have you ever had a head injury or loss consciousness?

Have you ever had a seizure?

Have you ever had outpatient psychiatric treatment?

Have you ever been hospitalized for a psychiatric disorder? If yes, when?

List of current medications.

Have you seen a therapist in the past?

Do you drink alcohol?

Do you currently use or have you ever used recreational or illegal drugs? If yes, which drugs and how often? *

Have you felt guilty about anything resulting from your drinking

Have you ever tried to cut down on how much you drink? *

Do you smoke? If yes, what do you smoke and how often?

Do you feel better if you have a drink early in the day? *

Do you use nonsmoking forms of tobacco? If yes, which?

Has anyone in your family ever had a psychiatric disorder? (I.e. depression, mania, schizophrenia, drug or alcohol abuse, obsessive-compulsive disorder, panic disorder, phobias, suicide, etc.) Please indicate diagnosis below if know and list who.

Family Psychiatric History

What is your marital status?

If separate and/or divorced, what was your date of separation/divorce and the reason?

Family Medical History

Please list all individuals currently living in your household and their relationship to you.

Your mothers's name and age

If your mother is deceased, what was date and cause of death.

Your Father's name and age

If your Father is deceased, what was date and cause of death

Have you ever experienced any form of abuse (such as physical, sexual, or emotional), who was involved, and are you currently distressed about any aspect of your appearance related to these experiences?

EDUCATIONAL HISTORY & OCCUPATIONAL HISTORY

Please list all educational history, school location, occupational history. Please list correct dates for all.

Have you performed any military service and served during any wars? If so have you been released on honorable discharge?

Have you had any problems with the law? If yes, please explain below.

DEVELOPMENTAL/ADAPTIVE HISTORY

To the best of your knowledge, was your mother exposed to stresses, drugs, or dangerous substances while she was pregnant with you? Were there any difficulties with your birth? If yes, what were they?

Have you experienced any recent or past significant stresses? If so, please list them and describe which ones you have overcome and how you managed to overcome them.

What would you consider the best period of your life, and what personal strengths and weaknesses do you feel have contributed to your experiences

Please sign that all information is correct.

Signature

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Telehealth Services Informed Consent

Definition of Telehealth

Telehealth involves the use of electronic communications to enable professionals to connect with individuals using interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

I understand that I have the rights with respect to telehealth:

I understand privacy and the confidentiality laws apply to telehealth, and that no information obtained through the use of telehealth services will be disclosed to researchers or other entities without my written consent.
My health care provider has explained how the videoconferencing technology will be used to conduct a telehealth session, that unlike a direct patient/provider in person, I will not be in the same room as my health care provider.
I understand the potential risks to technology including interruptions, unauthorized access and technical difficulties. I understand my health care provider or I can discontinue the videoconference consult/visit if it is believed videoconferencing technologies are not adequate for the situation.
I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
I understand that no results for anticipated benefits can be guaranteed or assured by my provider.
I understand my healthcare information may be shared with other individuals for purposes of scheduling and billing. Individuals other than my healthcare provider may be present during the session in order to operate videoconferencing equipment. I further understand that I will be informed of their presence, and that such individuals will maintain confidentiality on information obtained during the session. Furthermore, I have the right to request the following:• Ask non-medical personnel to leave the telehealth examination room; and/or• Terminate the consultation at any time.
I agree certain situations — such as emergencies and crisis — are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 911 or seek help from a hospital or crisis-oriented healthcare facility in my immediate area.

Consent to The Use of Telehealth

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me.

• That I fully understand its contents including the risks and benefits of the procedure(s).

• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

Signature

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Records Release Authorization

FOR THE RELEASE OF PROTECTED MENTAL HEALTH INFORMATION

By signing this form, confidential psychological and psychiatric information can be released to and/or discussed with the people or

agencies listed below unless noted by exclusions or limitations. This form is signed voluntarily and may be revoked at any time. All

disclosures made pursuant to this form are valid as long as they were made before the date of revocation.

Authorization to Bill Insurance

I, the undersigned, hereby certify and attest that I have sought evaluation, treatment, or medical

advice from the staff at the clinic named above. I therefore authorize the medical staff and

personnel to release my or my minor child’s medical information to the insurance company

listed above for the purpose of determining and receiving benefits for medical bills.

I understand and acknowledge that the medical staff will submit my claim to the insurance

company on my behalf. I further understand that I will be held responsible for any amount of my

medical bills not covered by my insurance policy or claims, and that I will be responsible for

paying all deductibles, fees, co-payments, and co-insurance payments required.

I understand that any portion of my medical bills not covered by insurance will be billed to me

at the address I have provided above. Non-compliance or defaulting on payments may result in

denial of service and/or a legal claim against me for non-payment.

Patient Name:

Patient Date of Birth:

I authorize my provider to

RELEASE

RECEIVE psychological/psychiatric mental health information to/from the SECOND PARTY as directed below:

SECOND PARTY: Name,Address,Fax number and Phone number

TYPE OF INFORMATION TO BE DISCLOSED

I authorize disclosure of all health information, including information relating to medical, pharmacy, mental health, substance abuse, and psychotherapy

authorize only the disclosure of the following information:

Purpose

Multi choice

My health information is being disclosed at my request or at the request of my personal representative; or

My health information is being disclosed for the following purpose:

Purpose

Note any exclusions or limitations here:

I understand that treatment, payment, enrollment in a health plan, or eligibility for benefits is not dependent on

my signing this authorization. By signing below, I acknowledge that I have read and understand this document

and that I have voluntarily given my provider authorization to disclose my records. I understand that I may

revoke this authorization at any time by providing a written notice to my provider, however the revocation will

not have an effect on any actions taken prior to the date my revocation is received. I understand that my

information may be redisclosed by the authorized person/organization receiving the information, and at that

point, the information may no longer be protected under the terms of this agreement. This authorization will

expire one year following the date signed unless revoked in writing.

Authorization is given on this patient’s behalf due to being a minor or unable to sign.

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Legal Guardian/Personal Representative Signature:

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Date

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NOTICE OF PRIVACY PRACTICES

This Notice describes how medical information about you may be used and disclosed and how you can get

access to this information. Please review this notice carefully.

Your health record contains personal information about you and your health. This information about you that

may identify you and that relates to your past, present, or future physical or mental health or condition and

related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy

Practices describes how your provider may use and disclose your PHI in accordance with applicable law. It

also describes your rights regarding how you may gain access to and control your PHI.

Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), your provider is required to

maintain the privacy of PHI and to provide you with notice of his or her legal duties and privacy practices with

respect to PHI. Your provider is required to abide by the terms of this Notice of Privacy Practices. Your

provider reserves the right to change the terms of this Notice of Privacy Practices at any time. Any new Notice

of Privacy Practices will be effective for all PHI that your provider maintains at that time. Your provider will

provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon

request or by providing one to you at your next appointment.

HOW YOUR PROVIDER MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose

of providing, coordinating, or managing your healthcare treatment and related services. This includes

consultation with clinical supervisors or other treatment team members. Your provider may disclose PHI to any

other consultant only with your authorization.

For Payment: Your provider may use and disclose PHI so that he or she can receive payment for the

treatment services provided to you. Examples of payment-related activities are: making a determination of

eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing

services provided to you to determine medical necessity, or undertaking utilization review activities. If it

becomes necessary to use collection processes due to lack of payment for services, only disclose the

minimum amount of PHI necessary for purposes of collection will be disclosed.

For Health Care Operations: Your provider may use or disclose, as needed, your PHI in order to support his

or business activities including, but not limited to, quality assessment activities, licensing and conducting or

arranging other business activities. For example, your PHI may be shared with third parties that perform

various business activities provided we have a written contract with the business that requires it to safeguard

the privacy of your PHI. Your PHI may be used to contact you to provide appointment reminders or information

about treatment alternatives or other health-related benefits and services.

Required by Law: Under the law, your provider must make disclosures of your PHI to you upon your request.

In addition, disclosures must be made to the Secretary of the Department of Health and Human Services for

the purpose of investigating or determining compliance with the requirements of the Privacy Rule.

Without Authorization: Applicable law and ethical standards permit your provider to disclose information

about you without your authorization only in a limited number of other situations. The types of uses and

disclosures that may be made without your authorization are those that are:

Required by Law, such as the mandatory reporting of child abuse or neglect or elder abuse, or

mandatory government agency audits or investigations.

Required by Court Order

Necessary to prevent or lessen a serious an imminent threat to the health or safety of a person or the

public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or

persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission: Your provider may use or disclose your information to family members that are directly

involved in your treatment with your verbal permission.

With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with

your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI maintained

Right of Access to Inspect and Copy. In most cases, you have the right to inspect and copy PHI that may

be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those

situations where there is compelling evidence that access would cause serious harm to you. Your provider

may charge a reasonable, cost-based fee for copies.

Right to Amend. If you feel that the PHI your provider has about you is incorrect or incomplete, you may ask

for it to be amended, although your provider is not required to agree to the amendment.

Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures

that your provider makes of your PHI. Your provider may charge you a reasonable fee if you request more

than one accounting in any 12-month period.

Right to Request Restrictions. You have the right to request a restriction or limitation on the use or

disclosure of your PHI for treatment, payment, or healthcare operations. Your provider is not required to agree

to your request.

Right to Request Confidential Communication. You have the right to request that your provider

communicate with you about medical matters in a certain way or at a certain location.

Right to a Copy of This Notice. You may ask your provider for a paper copy of this notice at any time.

COMPLAINTS

If you believe your privacy rights have been violated, you may submit a complaint with the Federal

Government. Filing a complaint will not affect your right

Secretary of the U.S. Department of Health and Human Services

200 Independence Avenue, SW

Washington, DC 20201

(202) 619-0257

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge receipt of the Notice of Privacy Practices, which explains my rights and the limits on ways my

provider may use or disclose personal health information to provide service.

Client signature

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INFORMED CONSENT FOR ASSESSMENT AND TREATMENT

Name

DOB

Add your textI understand that I am eligible to receive a range of services from my provider. The type and extent of services that I

receive will be determined following an initial assessment and thorough discussion with me. The goal of the

assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the

course of several weeks.

I understand that I have the right to ask questions throughout the course of treatment and may request an outside

consultation. (I also understand that my provider may provide me with additional information about specific treatment

issues and treatment methods on an as-needed basis during the course of treatment and that I have the right to

consent to or refuse such treatment). I understand that I can expect regular review of treatment to determine whether

treatment goals are being met. I agree to be actively involved in the treatment and in the review process. No promises

have been made as to the results of this treatment or of any procedures utilized within it. I further understand that I

may stop treatment at any time, but agree to discuss this decision first with my provider.

I am aware that I must authorize my provider, in writing, to release information about my treatment but that

confidentiality can be broken under certain circumstances of danger to myself or others. I understand that once

information is released to insurance companies or any other third party, that my provider cannot guarantee that it will

remain confidential. When consent is provided for services, all information is kept confidential, except in the following

circumstances:

When there is risk of imminent danger to myself or to another person, my provider is ethically bound to take

necessary steps to prevent such danger.

When there is suspicion that a child or elder is being sexually or physically abused, or is at risk of such abuse, my

provider is legally required to take steps to protect the child, and to inform the proper authorities.

When a valid court order is issued for medical records, my provider is bound by law to comply with such

requests.

While this summary is designed to provide an overview of confidentiality and its limits, it is important that you read the

Notice of Privacy Practices which was provided to you for more detailed explanations, and discuss with your provider any

questions or concerns you may have.

By my signature below, I voluntarily request and consent to behavioral health assessment, care, treatment, or services

and authorize my provider to provide such care, treatment or services as are considered necessary and advisable. I

understand the practice of behavioral health treatment is not an exact science and acknowledge that no one has made

guarantees or promises as to the results that I may receive. By signing this Informed Consent to Treatment Form, I

acknowledge that I have both read and understood the terms and information contained herein. Ample opportunity has

been offered to me to ask questions and seek clarification of anything unclear to me.

Client Signature:

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Witness Signature:

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