Paper work Order Number Client Information Today’s Date * First name * Last name * Date of Birth: * Social Security: * Email: * Home #: * Work #: * Cell #: * Please indicate where we may leave a message * Home Cell Email Address: * City & State: * Zip: * Sex * Male Female Other Name of Spouse/Sig. other: * Children’s Name(s) & Age(s) & Father/Mother of Children: * Primary Care Physician: * City: * Employer: * Insured through Employer: * Yes: No: Medical Insurance Co: * Member/Subscriber ID#: * Primary Insured’s Name & Date of Birth: Emergency Contact Name: * Home Phone: * Address: * Relationship: * Health Information Please rate your health: * Very Good Good Poor Average Declining Please rate your Weight: * Lost Gained About the same Date of Last physical exam: * Report from most recent exam: * List all important past or present injuries, illnesses or disabilities: * Are you currently taking any medication? * Yes No Prescribed by: * If yes, please list them with dosages: * Have you ever used drugs for other than prescribed medical purposes? * yes No Have you ever had a severe emotional event? If so, please explain: * Have you ever terminated a pregnancy? If yes, when? * Have you ever had a miscarriage? If yes, when? * Religious/Faith Background Current faith involvement: * Please explain any recent changes in your spiritual life * Other Information Are you willing to complete and sign a release of information so that your counselor may obtain social, psychiatric, or medical information? * Yes No Have you ever been arrested? * Yes No If yes, please explain: * Have you recently suffered loss from serious personal, social, business, or other reversals? * Yes No If yes, please explain * Have you ever been the victim of a crime? * Yes No If so, have you filed with Texas Crime Victims Compensation? * Yes No Identify any previous marriages: * Identify any history of psychiatric/emotional/drug or alcohol problems and treatments in your current family and in your family of origin: * How did you hear about Las Colinas Counseling Center? * Education (Highest level completed): * Have you ever had any counseling or therapy before? * Yes No Outcome: * Please list names/dates of counselors: * Have you ever been in a residential or outpatient program for chemical dependency or psychiatric treatment? * Yes No If yes, please list facility, dates, and indicate if you completed the program successfully: * Please select any of the following that describe your current thoughts & behaviors: * Aggressiveness Anger Anxiety Confusion Crying Depression Feeling Helpless Irritability Impulsive Lack of Concentration Mood Changes Nightmares Panic Attacks Racing Thoughts Restlessness Suicidal Thoughts Compulsiveness Grinding Teeth Hair Chewing/Pulling Lateness Loss of Appetite Nail Biting Nervous Laughter Lack of Self Care/Appearance Procrastinating Pacing Smoking Tapping Use of Alcohol or Drugs Acknowledgement of Receipt of Notice of Privacy Practices & Consent I have received the office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that i am entitled to receive a copy of this document. (See HIPAA packet included for more details.) Please READ and SIGN in the spaces provided below: I hereby consent for therapeutic services provided by Las Colinas Counseling Center, P.A. I authorize Las Colinas Counseling Center, P.A. and its agents to release information about me necessary to obtain insurance benefits and/or to receive payment and I understand that my signature requests insurance payments be made. I agree to provide the most up to date insurance information as soon as it is known, and am aware that I will be responsible for balances owed in the event this information is not provided within the insurance’s timely filing parameters. Client’s printed name * Parent/Guardian (if applicable) * Client’s Signature (Parent/Guardian if minor) Date * Date Spouse & Significant Other Communication: (optional) Due to HIPAA rules and guidelines we are required to obtain authorization from you in order to provide information Regarding Sheduling & payment to anyone other than yourself. In the event you wish to share information other than scheduling and payment, we require a more detailed release of information form. Please inform your therapist, and/or an administrative staff in the event this is the case. Please print their name, giving your consent by initialing one or both if you wish to provide your spouse or significant other access to these services. This will expire in one year from today’s date unless specified otherwise. I authorize Las Colinas Counseling Center, P.A. to provide information to: PRINTED First & Last name (of Spouse/Significant Other) Date of Birth (of Spouse/Significant Other) Regarding Scheduling (Your initial) * Regarding Payment/Payor * Consent to Email or Text Usage For Appointment Reminders and Other Healthcare Communications If at any time I provide an email or text address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email or text address from Las Colinas Counseling Center. Please READ and SIGN in the space provided below. I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number or email to receive communication as stated above I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing (please request revocation form from admin staffs). I understand that I can respond to the email or text message to confirm my appointment. I understand that I cannot respond to the electronic communication to cancel or change my appointment. I understand that if I need to cancel I must call the office one day before my scheduled appointment. I understand that failing to respond to the email or text message does not mean my appointment has been cancelled. I understand that I may leave a voice message if I unable to reach the office staff directly. I understand that this is a service offered as a convenience, and understand I am ultimately responsible for any missed appointment fees regardless of whether I receive an electronic reminder or not. Please choose the form of reminder you wish to receive: TEXT E-MAIL The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information is * The email that I authorize to receive email messages for appointment reminders and general health reminders, feedback, information is * Client’s Printed Name * Parent/Guardian (if applicable) * Client’s Signature (Parent/Guardian if minor) * Date * The practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details). I have read the office’s Notice of Privacy (HIPAA document) which explains cancellation fees and additional charges outside of my session fees. I understand that I am entitled to receive a copy of this document, and can always obtain a copy when and if needed.
