Associates in Mental Health

1715 C Street Bellingham, WA 98225
Phone: 360-715-2488
Fax: 360-671-1842
Email: associatesinmentalhealth@yahoo.com

ADULT FORMS

If you are an adult seeking treatment for yourself, please fill out and print the following three forms and bring them with you to your first appointment.

If you are a minor or an adult seeking treatment for your minor child, please fill out the forms located on the Child Forms page.

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Associates in Mental Health
1715 C Street
Bellingham, WA 98225

Adult Intake Form

Date: Form Completed by: Self Parent Guardian Spouse Other

CLIENT INFORMATION

Client Name:    Referred by:
Date of Birth:     Primary Care Physician:
Social Security Number:
Street Address:
City:     Zip code:
Phone:   Home    Work    Cell

Check box next to number if it is NOT okay to call and/or leave a message

Marital Status: Single Married Divorced Widowed Other

Education: Highest grade completed: Degree(s) earned:

Employer: Occupation:

Full-time Part-time Retired

Emergency Contact Name: Relationship:

Contact Phone: Home Work Cell

If client is a Student: Grade: School:
Teacher: School Counselor:

Please list any other people residing in the home:

Name:     Age:     Relationship:
Name:     Age:     Relationship:
Name:     Age:     Relationship:
Name:     Age:     Relationship:
Name:     Age:     Relationship:

If client is a minor, list any parents or siblings not residing with client:

Name:     Age:     Relationship:
Name:     Age:     Relationship:
Name:     Age:     Relationship:

THERAPIST USE ONLY DSM-IV:

INSURANCE/BILLING INFORMATION

Client Name:

Person responsible for copayments, coinsurance, deductibles, and/or payment in full:

Name:     Relationship:
Social Security Number:     Date of Birth:
Phone Number:      Employer:
Address (if different from client's):

NOTE: Please provide insurance card(s) at first appointment

Primary Insurance Company:
Subscriber Name:     Date of Birth:
Social Security Number:     Employer:
Address (if different from client's):

Secondary Insurance Company:
Subscriber Name:     Date of Birth:
Social Security Number:     Employer:
Address (if different from client's):

Payment and Insurance Billing:
I, the undersigned, authorize the release of any medical or other information necessary to process this claim through any insurance company previously noted. I authorize payment to the providing clinician for services rendered as stated on claims submitted by him/her to my insurance company.

I also understand that it is my responsibility to reimburse my therapist for any services provided on my behalf. In the event that my insurance does not cover costs for services rendered or I do not have insurance coverage at this time, I agree to pay any and all costs of counseling. Costs may include any missed appointments, fees for written reports, phone calls on my behalf, or any other costs of providing services on my behalf.

Client or Authorized Person's Signature:
Relationship to Client:

For Your Information: Your insurance company may require your therapist to exchange information with your referring and/or primary care physician. They may also require your therapist to provide copies of confidential chart notes in order to process your claim(s). You have the right to notify your therapist in writing to limit communication with your physician(s). You may also make arrangements to pay for therapy privately to avoid confidential information being released to your insurance company. Please discuss these options with your therapist.

Associates in Mental Health
1715 C Street
Bellingham, WA 98225

Adult Medical History Form

Client Name:      Date Completed:

Client DOB:   Form completed by:

Client Primary Care Physician:

List all doctors or medical specialists client sees now or has seen in the past year:
1.
2.
3.

Date of last physical exam:    Name of examiner:

Describe any current medical problems or recent changes in client's physical condition:

What is client's height?
What is client's weight?
Is client gaining weight?  yes  no
Is client losing weight?    yes  no
If yes, amount of gain/loss:

List any hospitalizations:
1.
2.

List all medications client is taking.  Include non-prescription drugs and health supplements:
1. Drug Name   Dosage:   # Per Day:
2. Drug Name   Dosage:   # Per Day:
3. Drug Name   Dosage:   # Per Day:
4. Drug Name   Dosage:   # Per Day:
5. Drug Name   Dosage:   # Per Day:
6. Drug Name   Dosage:   # Per Day:
7. Drug Name   Dosage:   # Per Day:
8. Drug Name   Dosage:   # Per Day:
Any medication allergies?  yes no   If yes, list:

Check any of the following which you use now or have used in the past:

Substance	Used in past	Use now	How often/How much	Is it a problem?
Hard Liquor				Yes No
Beer/Wine				Yes No
Marijuana				Yes No
Speed/Meth				Yes No
Heroin				Yes No
LSD				Yes No
Barbiturates				Yes No
Cocaine				Yes No
Tobacco				Yes No
Coffee				Yes No
Soft Drinks				Yes No
Other				Yes No

Any further comments on alcohol or drug use:

Has client had any previous mental health treatment or counseling? yes no If yes, describe below:
Date Location or therapist Reason for seeing therapist

Further comments on mental health care results and/or reasons for termination:

Check any of the following symptoms the client has had in the past three months:

Vision problems	Weakness in arms/legs	Constipation	Chronic pain
Hearing loss	Convulsion/seizures	Diarrhea	Back pain
Headaches	Nausea or vomiting	Stomach aches	Menstrual irregularities
Fainting	Shortness of breath	Unusual bleeding
Dizziness	Chest pains/tightness	Abnormal growth/lump
Head injury	Loss of consciousness	Memory loss

Check any of the following conditions the client has had and give the date of onset:

Allergies	Fibromyalgia	Liver problems
Anemia	Glaucoma	Low Blood Pressure
Angina	Gonorrhea	Lung condition
Arthritis	Gout	Migraines
Asthma	Head trauma	Multiple Sclerosis
ADHD	Heart Disease	Obesity
Autism	Hepatitis	Parkinson’s Disease
Birth defects	High Blood Pressure	Polio
Bladder problems	Huntington’s	Rheumatic Fever
Bowel problems	Hyperactivity	Stomach ulcers
Cancer	Hypoglycemia	Stroke
Cerebral Palsy	Hysterectomy	Syphilis
Chronic Fatigue	Jaundice	Thyroid Disease
Circulation problems	Kidney problems	Tuberculosis
Diabetes	Learning Disability	AIDS/HIV +
Epilepsy	Leukemia	Other

If any of the client's blood relatives (mother, father, grandparent, sibling, etc.) have had any of the above conditions, please indicate who and what:

Indicate if any of client's blood relatives have had the following conditions and who:

Alcohol/drug abuse	Nervous breakdown
Anxiety/Panic	Obsessive Compulsive
Attention Deficit	Psychiatric hospitalization
Bipolar Disorder	Schizophrenia
Depression	Seizure Disorder
Dementia	Suicide

Any additional comments on client’s health or client’s family health history:

Associates in Mental Health
1715 C Street
Bellingham, WA 98225

Adult Treatment Goals

Date:

Client Name: Therapist:

I. Please list issues to discuss in therapy which are of primary concern to you at present:

1.
2.
3.
4.
5.

II. Please list any specific goals or changes you would like to accomplish:

1.
2.
3.
4.
5.

Associates in Mental Health
1715 C Street
Bellingham, WA 98225

Health Insurance Portability and Accountability Act (HIPAA)

THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY AND SIGN AT THE BOTTOM.

I. Examples of Uses and Disclosures of Protected Health Information for Payment and Health Care Operations

The providers of Associates in Mental Health may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

• "PHI" refers to information in your health record that could identify you.

• "Treatment, Payment and Health Care Operations"

Treatment is when a provider provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when a provider consults with another health care provider, such as your family physician or another mental health provider.

Payment is when provider obtains reimbursement for your healthcare. Examples of payment are when provider discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of provider’s practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

• "Use" applies only to activities within a provider’s office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• "Disclosure" applies to activities outside of provider’s office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

Provider may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when a provider is asked for information for purposes outside of treatment, payment and health care operations, provider will obtain an authorization from you before releasing this information.

You may revoke all such authorizations of PHI at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) the provider has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with neither Consent nor Authorization

Provider may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse: If provider has reasonable cause to believe that a child has suffered abuse or neglect, provider is required by law to report it to the proper law enforcement agency or the Washington Department of Social and Health Services.

• Adult and Domestic Abuse: If provider has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, provider must immediately report the abuse to the Washington Department of Social and Health Services. If provider has reason to suspect that sexual or physical assault has occurred, provider must immediately report to the appropriate law enforcement agency and to the Department of Social and Health Services.

• Health Oversight: If the Washington Licensing Board subpoenas provider as part of its investigations, hearings or proceedings relating to the discipline, issuance or denial of licensure of state licensed providers, provider must comply with its orders. This could include disclosing your relevant mental health information.

• Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that provider has provided to you and the records thereof, such information is privileged under state law, and provider will not release information without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified and you have failed to inform provider that you are opposing the subpoena, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

• Serious Threat to Health or Safety: Provider may disclose your confidential mental health information to any person without authorization if provider reasonably believes that disclosure will avoid or minimize imminent danger to your health or safety, or the health or safety of any other individual.

• Worker’s Compensation: If you file a worker's compensation claim, with certain exceptions, provider must make available, at any stage of the proceedings, all mental health information in my possession relevant to that particular injury in the opinion of the Washington Department of Labor and Industries, to your employer, your representative, and the Department of Labor and Industries upon request.

IV. Other Uses and Disclosures of Protected Health Information

Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

V. Patient's Rights and Provider’s Duties

Patient’s Rights:

• Receive, read, and ask questions about this Notice – You have the right to request and receive a paper copy of the most current Notice of Privacy Practices for Protected Health Information ("Washington Notice Form") from your provider.

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. You must deliver this request in writing to your provider. However, your provider is not required to agree to a restriction you request but will comply with any request granted.

• Cancel prior authorizations – You have the right to cancel prior authorizations to use or disclose health information by giving written revocation to your provider. Your revocation does not affect information that has already been released. It also does not affect any action taken before your provider has your revocation. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are receiving treatment. Upon your written request, your provider will send your PHI to another address.)

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in your provider’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Your provider may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.Upon your request, your provider will discuss with you the details of the request and denial process.

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Your provider may deny your request. On your request, your provider will discuss with you the details of the amendment process. You may write a statement of disagreement if your request is denied. It will be stored in your medical record and included with any release of your records.

• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). This will not include disclosures to third-party payers. You may obtain this information without charge once every 12 months. Your provider will notify you of the cost involved if you request this information more than once in 12 months.

Provider’s Duties:

• Your provider is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.

• Your provider reserves the right to change the privacy policies and practices described in this Notice. Unless your provider notifies you of such changes, however, your provider is required to abide by the terms currently in effect.

• Your provider has the right to change his/her practices regarding the protected health information he/she maintains. If your provider make changes and you are an active patient in his/her practice, he/she will provide you with a copy of the updated Notice at your first visit after the change. You may always receive the most recent copy of this Notice by calling your provider and asking for it or by visiting your provider’s office to pick one up.

VI. To Ask for Help or Report a Grievance

If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:

Letisha Stokes, Office Manager
Associates in Mental Health
1715 C Street
Bellingham, WA 98225
360-715-2488 extension 0

If you believe your privacy rights have been violated, you may discuss your concerns with your provider or the above noted person. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

VII. Web Site

Associates in Mental Health has a Web Site that provides information about your provider. For your benefit, this Notice is on the Web Site at this address: www.amhinfo.com.

VIII. Effective Date

This notice is effective as of April 14, 2003.

_______________________________________________________________________________________________

Signature

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