New Client Registration Form

 New Client Registration Form
Client Information
Full Name: __________________________________________ Date of Birth: _____________________
Street Address: _______________________________________ City/State: ________________________
Zip Code: ____________________________
Phone Number: ________________________________
Spouse/Significant Other Information
Name: __________________________________________
Date of Birth: _____________________
Street Address: _______________________________________ City/State: ________________________
Zip Code: ____________________________
Phone Number: ________________________________
Secondary Party Payer Information
Name: __________________________________________
Date of Birth: _____________________
Street Address: _______________________________________ City/State: ________________________
Zip Code: ____________________________
Relationship to Client:
Phone Number: ________________________________
_________________________________________________________________
Insurance Information
Insurance Company Name & Plan Name: ____________________________________________________
Street Address: _________________________________ Phone Number: __________________________
Zip Code: ___________________ City/State: ________________________________________________
Identification Number: ________________________________ Group Number: ___________________
Policy Holder’s Name: _________________________________ Date of Birth: _____________________
Relationship to Client:
_________________________________________________________________
By signing the statement below, I am confirming that all of the above information that I have provided is accurate and up to
date.
______________________________________________________
Signature
___________
Date
______________________________________________________
Guardian (for individuals under the age of 18)
___________
Date
Informed Consent to Treatment Form I consent to take part in treatment at LivingRite, The Center for Behavioral Health. I have received and read the Intake Information packet explaining psychotherapy practices and office policies, privacy policies, fees for services and other policies, and agree to its terms. I have received and read the Privacy Policies form as required by the Health Insurance Portability and Accountability Act. I will ask for an explanation and clarification of any part of the Intake Information packet or Privacy Notice I do not understand. I understand that I am responsible for my bill, and that co‐pays, coinsurances and out‐of‐pocket responsibilities will automatically be charged to my credit card after the service has been provided. While LivingRite, The Center for Behavioral Health will assist me in pursuing insurance reimbursement, I understand that unpaid bills will become my responsibility and that failure to make payment within 90 days may result in turning my account over to a collection agency along with accruing additional fees. I understand that insurance covers psychological testing services very inconsistently, and that LivingRite, The Center for Behavioral Health will do their best to verify in advance if the cost of psychological testing will be covered, but in general I understand that I should expect to pay out‐of‐pocket for psychological testing not covered by my insurance company. Additionally, I understand that LivingRite, The Center for Behavioral Health may elect to end treatment if timely payment for services is not made. I understand that my credit card will automatically be charged $50 for failing to show or failing to give at least 24 hours’ notice when canceling an appointment. I understand that insurance companies cannot be billed for this fee and therefore this fee will be my responsibility, and that any recurring appointments scheduled in the future will be automatically cancelled unless I give verbal confirmation to LivingRite staff that I would like to keep my appointment. If I am electing to use my insurance benefits, I authorize the release of necessary information to my insurance company so that LivingRite, The Center for Behavioral Health, acting as my agent, may pursue payment for the services provided to me. I authorize insurance payments to be sent directly to LivingRite, The Center for Behavioral Health. _____________________________________________________________________________________________ Client Signature (Parent signs for clients under the age of 12 years old) Date _____________________________________________________________________________________________ If the client is between 12 and 18 years old, client and parent/guardian signature is required Date _____________________________________________________________________________________________ Other Family Member Date LivingRite, The Center for Behavioral Health has my permission to keep the Credit/Debit Card below on file: Credit Card Type: Visa MasterCard Discover American Express Card Number: __________________________________________________ Expiration Date: _______________ Cardholder Signature: ___________________________________________________________________________ LIVINGRITE EMAIL CONFIDENTIALITY
RELEASE AGREEMENT (Required)
I ___________________________________, understand that CONFIDENTIALITY OF EMAIL
COMMUNICATIONS WITH MY THERAPIST CANNOT BE GUARANTEED.

Emails go through several intermediate stations before reaching their destination. Someone at any point
along the line could potentially access electronic communications and even store the messages contained
within.

Emails may remain stored in various places of a computer system and could surface at a later time.

Computers, particularly those on DSL lines, are vulnerable to electronic eavesdropping.
Knowing the above information and considering other possibilities not yet known that could further jeopardize
confidentiality;

I give my permission to my therapist to respond to my emails according to his/her professional
judgment.

I give my permission to LivingRite staff to send emails directly related to billing, such as invoices and
payment confirmations.
I further agree that I will not attempt to extend therapy via emails, but only use it to conduct business of
information sharing, such as scheduling or canceling an appointment. Any therapeutic issues I will handle either
during the therapeutic face to face meeting, or as appropriate, by telephone in emergencies. Email is not
appropriate for urgent or emergency situations. Provider cannot guarantee that any particular email will be read
and responded to within any particular period of time.
____________________________________
Client’s Name (Please Print)
____________________________________
Client’s Email (Please Print)
____________________________________________________
Client Signature
Date
(Or Parent’s Signature if Client is a minor)
____________________________________________________
Witness
Date - Individual Patient Rights –
1. All patients have the right to inspect and copy their own protected health information (the medical
record) on request, except for mental health records, which must be reviewed with a psychologist first.
In cases where exposure to the record might be harmful to the patient, the psychologist may deny the
request. If you request a copy of your psychiatric record, your provider will generally review the record
with you. The provider may rarely have information in the chart that a patient should or could not
read, but much may require explanation. The provider also reserves the right to withhold records due
to unpaid balances.
2. Patients also have the right to amend or append their medical (or psychiatric) record. Physicians, and
your provider, reserve the right to deny such a request if he or she believes that the information in the
medical record is accurate, but in that case the patient request must still be attached to the medical
record.
3. Patients have the right to an accounting of all disclosures to other parties. This means that if you ask
your provider for a list of whom he or she has released psychiatric information to, they will supply it to
you.
4. Patients have the right to have reasonable requests for confidential communications accommodated.
5. You can give your provider written authorization for him or her to disclose your psychiatric
information to anyone you choose, and you may revoke authorization in writing at any time. You can
send a written complaint to the Secretary of US Department of Health and Human Services. Our
staff can be contacted at 815.758.8400 and can provide you with the appropriate address upon
request.
6. Patients can file a complaint with LivingRite or with the Office of Civil Rights in the Department of
Health and Human Services about any violation of the rights listed above. There will be no prejudice
for filing such a complaint.
7. Patients have the right to receive a written notice of privacy practices from providers and health plans.
~New Privacy Provisions and Changes ~
New HIPAA (Health Insurance Portability and Accountability Act) Privacy Standards were created to protect
patients’ health information when it is disclosed but also to facilitate the flow of medical information between providers. With
other medical providers, billing, and for safety or security reasons, there is less protection of confidentiality than there used to be.
However, in other areas, such as releasing psychotherapy records, there is more privacy protection. Please read the following so
that you understand your rights as a patient as well as the new rules about patient confidentiality. Feel free to ask your
behavioral health provider about privacy, confidentiality, or your psychiatric record.
1. Permission from the patient is no longer required for transfer of psychiatric and medical information between providers
as long as only the necessary information is supplied. This means that if your primary care doctor, pharmacist, or
emergency room physician calls to find out if you are in treatment, what the diagnosis is, or what medications you are
on, your provider can convey this information if it is medically relevant to your treatment with them. In practice, your
provider will almost always discuss this with you personally before or after the fact, depending on the urgency and
depth of the request. If you think this might present a problem for you, please let your provider know ahead of time.
2. Permission from the patient is no longer required for transfer of psychiatric information needed for business pertaining
to insurance or payment as long as only the necessary information is supplied (usually the diagnosis and type of
treatment, but perhaps more). In practice, many insurance companies still require you to sign the first insurance sheet
for authorization. In general, providers at LivingRite will discuss any unusual requests for information from an
insurance company with the patient first.
3. Remember that if all the psychiatric records are requested, a treatment summary is usually given instead, except if the
treatment consists solely of psychopharmacological treatment or brief medication visits. While brief medication visits
fall under HIPAA guidelines, psychotherapy visits are specifically excluded, meaning authorization from the patient is
still required for release of information in those notes and a summary is given in place of the record.
4. The substance abuse records from alcohol and drug programs are exempt from any disclosure without patient permission.
If you are admitted to a treatment program for substance abuse, be sure to sign a release for your behavioral health
provider so he or she can talk to the other providers and obtain a discharge summary and lab data upon your discharge.
Without this, your provider cannot obtain any information.
5. Your provider may have to disclose some of your psychiatric information when required to do so by law. This includes
mandated reporting of child abuse or elder abuse (this is not new).
6. National security and public health issues: Your provider may be required to disclose certain information to military
authorities or federal health officials if it is required for lawful intelligence, public health safety, or public security.
~Psychotherapy Services & Office Policies~
Welcome to LivingRite, The Center for Behavioral Health. We thank you for choosing us as your therapy provider. The
following information is provided to make you more familiar with our office policies and conduct of psychotherapy. If you have
any questions, please feel free to ask any of our providers and we would be happy to answer them for you.
1. Office Visits: Once you have been assigned to a provider, you can expect the following:
The Initial Evaluation will last approximately 55-60 minutes. During this time you will be asked to fill out a series of forms
unless you filled out the appropriate forms located on our website, and you will also have our office policies and procedures
explained to you. You will also be able to learn about your rights to confidentiality and have any questions answered during
this time. Please arrive approximately 15 minutes early to your first appointment to process the necessary paperwork. Please
bring your insurance card so that we can make a copy for our files. After the initial evaluation, appointments are 50-60 minutes
in length. We respect the time of all of our clients. Therefore, our providers do our best to start and end all appointments on
time. We require a 24-hour notice for cancellations or changes to your appointments. Messages can be left with your provider
or our administrative staff at any time. You may also email cancellations to [email protected] We will waive a late
cancellation or one no-show per year if there is an emergency. After the second missed appointment or late cancelation, you will
be charged $50.00 for each missed session or late cancellation. Also, if you have a recurring appointment scheduled with your
therapist, any no-show or cancellation will cancel all subsequent appointments unless you confirm with our staff that you
would like to keep your future appointments.
2. Office Location: We are located at 2401 West US Highway 20, Suite 206, Pingree Grove, IL, 60140. When arriving to your
appointments, check in at the computer screen mounted on the wall as you walk in our office. Please know that all providers
try to start and end appointments on time. We feel that your time is valuable and you deserve to be seen promptly. Please
know that if you are arriving to an appointment late, we will still end your session on time and you be charged a full fee for
that session.
3. Professional Fees: (Doctorate/Masters Level Therapists)
$230/$190 Intake Session (60 Minutes)
$185/$150 Individual Therapy Session (50-60 minutes)
$100/$80 ½ Therapy Session (25-30 minutes) *Certain Circumstances Only
$185/$150 Couples/Family Session (50-60 minutes)
(Cost based on Individual Consideration) Extended Therapy Session (75-90 minutes) * Certain Circumstances Only
$50/$40 Group Therapy Session
$50/$50 Late Cancellation/No-Show Fee
Co-payments are due at the time of the service unless other arrangements have been made in advance with your provider.
Remittance in the form of cash, credit/debit and check can be made payable to LivingRite. We now accept Visa, MasterCard,
Discover and American Express. Payments are also accepted online at www.LivingRite.org. All returned checks will result in
a charge of $25.00.
4. Using Insurance: If you will be using your insurance, it is important for you to know your benefits before you come in for an
initial office visit and if your therapy requires authorization by a managed care company. Both you and LivingRite will both
receive a confirmation letter stating what has been authorized. If your provider is contracted with your insurance company,
LivingRite will file the claim on your behalf as a courtesy to you. You will be responsible for your co-pay and services that are
not covered by your insurance company. Please note that benefit quotes are not a guarantee of payment. We will not know your
actual coverage until we receive an Explanation of Benefits (EOB) from your insurance provider. However, in most cases,
quotes made by the insurance companies reflect a fairly accurate description of coverage. You can find out these details by
contacting your insurance company using the customer service number on the back of the card. If your provider is not in
network with your insurance company, you may be expected to pay for services up front and wait for reimbursement from your
insurance company. Payment is expected in full to the provider at the time of each service. Your insurance company will then
reimburse you for the covered amount. Often, there is a yearly maximum on either the number of visits or the amount paid for
psychiatric services, unless your plan has a parity clause. A parity clause means that psychiatric illnesses with a biological cause
(most depressions, many anxiety disorders, bipolar disorder, and some other illnesses) are covered as long as medically necessary
without a yearly maximum, just like any other medical illnesses.
5. Confidentiality: Your confidentiality is protected by federal HIPPA and the Illinois Mental Health Law. Your records and
information about your therapy can only be released with your written permission. Exceptions to this rule include current abuse
of a child or elderly person, imminent threats of harming yourself or another person, and in rare circumstances, a court order. If
you are involved in litigation, it is our office’s policy to not be involved. If you believe there will be or might be any legal
ramifications to your case, please let your provider know so he or she can discuss this with you before starting treatment. If
this is something you are seeking, please notify the office and we will make appropriate referrals. LivingRite submits insurance
claims electronically and we understand that this system is secure and HIPAA compliant. We do all of our own billing and
your provider is responsible for scheduling your appointments with you. Your provider is the only one who has access to your
records, and our billing staff is only given information required for billing purposes as allowed by HIPAA. Providers at
LivingRite sometimes obtain consultation for their cases. Specific information is exchanged in meetings, but will not go beyond
the consultants. If you do not want any of your records or information released, you have the option of paying for your
treatment privately and not having anything sent to your insurance company.
6. Coverage: If your provider is out of town, the name and number of the covering behavioral health provider will be provided
to you. Usually the covering provider is indicated during your first visit. They too will act according to the policies outlined
above.
7. Phone Calls: If you leave a message your call will be returned as soon as possible. This usually means that your provider will
contact you during office hours. If you have a situation that requires more urgent attention, please discuss with your provider
appropriate contact options. We do not provide 24-hour emergency care. Therefore, we expect that in life-threatening
emergency situations you leave a message for your provider discussing the nature of your status as well as call 911 or go to the
nearest emergency room for assistance. You may also call the 24 hour hotline, (800) SUICIDE, if you have a life-threatening
emergency and are unable to reach your provider. If your therapist is out of the office for an extended period of time, you will be
given the name and telephone number of the covering provider.
8. Notification to Primary Care Physician (PCP) is requested by many insurance companies to coordinate treatment. Please be
prepared to bring the name, address and telephone number of your PCP to the first office visit. You may authorize a release of
information to your PCP and insurance company at the time of the first visit to coordinate this care.
9. Our Philosophy of Care: At LivingRite we believe that change occurs from the guidance and support of a qualified, caring
provider and active participation from the client. We believe that most individuals will experience some type of life event
during their lifespan that requires therapeutic intervention. Therefore, we do not treat our clients as “patients,” but as active
participants in their own recovery. You will be cared for and respected by a treatment team that is educated in the latest
interventions and treatment options, therefore assisting you toward optimal wellness.
*We look forward to providing you with quality care that is based on the most empirically validated treatments in the field of
behavioral health. It is our mission to provide a safe and welcoming environment that awards itself to continued growth and
change. Again, we would like to welcome you to our practice and hope that you have found the support and guidance that you
deserve!
Please check the box next to the following documents to confirm that you have received, read, understood and
had any questions answered regarding their content, and sign your name below;
New Patient Registration Form
Informed Consent to Treatment Form
Email Release Agreement
Psychotherapy Practices & Office Policies Form
Privacy Policies Form
Individual Patient Rights Form
________________________________________
Signature
___________
Date
________________________________________
Guardian (if under 18 years of age)
___________
Date
________________________________________
Witness
___________
Date
LivingRite Psychological History Questionnaire Client Information Client Name: Gender: Religious Affiliation: Date of Birth: Race/Ethnicity: Marital Status: □ Never Married □ Married □ Domestic Partnership □ Separated □ Divorced □ Widowed I live with: □ Spouse/partner □ Parents □ Friend(s) □ Children □ Siblings □ Alone □ Other: ________ Spouse / Significant Other Information Name: Home Phone: Date of Birth: Alternate Phone: Educational / Employment History What is the highest level of schooling that you have achieved? Are you currently in school? □ Yes □ No If yes, what grade level? Please list your current or most recent school that you attended: Present job: Employer: Length of time at present job: Level of job satisfaction (1 – 10): Work History: General Health History How would you rate your current physical health? □ Poor □ Unsatisfactory □ Satisfactory □ Good □ Very Good Please list any specific health problems you are experiencing: How would you rate your current sleeping habits? □ Poor □ Unsatisfactory □ Satisfactory □ Good □ Very Good Please list any specific sleep problems you are experiencing: ______ How would you rate your appetite recently? □ Poor □ Unsatisfactory □ Satisfactory □ Good □ Very Good Please list any specific problems you are experiencing with your appetite/eating patterns: How many times per week do you generally exercise? What types of exercise do you participate in? ______ Do you experience disability or functional limitations due to your health problems? □ Yes □ No If yes, please explain: __________________________________________________________________________________________________ Please list any current medications (name of medication, dosage, prescribing physician): Please list any family history of health problems of which you are aware: _____ Mental Health / Substance Use History Have you previously received any type of mental health services (e.g., psychotherapy, psychiatry)? □ Yes □ No If yes, please list dates of services and previous practitioner(s), as well as problem treated: Have you ever been admitted to the hospital for mental health or addiction issues? □ Yes □ No If yes, please list dates and locations of admission: Have you ever received a psychiatric diagnosis? □ Yes □ No If yes, please explain: Are you currently taking any psychiatric medication? □ Yes □ No If yes, please list (name of medication, dosage, prescribing physician): Have you EVER been prescribed psychiatric medication? □ Yes □ No If yes, please list and provide dates: Please list any family history of mental health problems of which you are aware: Please describe your use of substances over the past year (includes alcohol, illegal drugs, caffeine, tobacco, and misuse of prescription medications): Have you experienced a recent increase in your use of alcohol and/or other substances? □ Yes □ No Do you, your family, or your friends see your current usage as a problem? □ Yes □ No If yes, when did it become problematic? Current Areas of Concern Have you recently been experiencing any of the following? (Mark all that apply) Feeling sad/down Excessive fears Change in eating patterns Too much energy Feeling worthless or guilty Temper outbursts/Aggression Decreased interest in activities Feeling judged by others Agitation/being upset Being overly irritable Decreased ability to concentrate Relationship difficulties Decreased enjoyment Feeling uncomfortable around others Being overactive Feeling on top of the world Difficulty making decisions Being impulsive Significant weight change Unpleasant thoughts about an event Losing things Engaging in risky behavior Thoughts of death Losing track of time Change in sleeping patterns Obsessive or intrusive thoughts Being disorganized Feeling anxious Compulsive behaviors Feeling disconnected from oneself Feeling restless, or slowed down Suicidal thoughts/behaviors Having feelings of unreality Feeling worried a lot Homicidal thoughts/behaviors Seeing or hearing things others don’t Panic Attacks Withdrawal, isolation Feeling excessively tired Feeling overwhelmed Using alcohol, drugs, cigarettes Other: Please explain how these problems are currently interfering in your life: If you marked “Suicidal thoughts/behaviors,” or “Homicidal thoughts/behaviors,” please answer the following: Are you presently suicidal or homicidal? □ Yes □ No Have you attempted to commit suicide or homicide in the past? □ Yes □ No If yes, how? Is there a history of suicide in your nuclear and/or extended family? □ Yes □ No Are there any other risk‐taking or self‐harming behaviors that you engage in? □ Yes □ No If yes, please explain: Please describe the history of these behaviors or thoughts: _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________ Please describe any significant life changes or stressful events you have experienced recently: Please describe your current financial situation: _____________________________________________
___________________________________________________________________________________________ Relationship History Are you currently in a romantic relationship? □ Yes □ No If yes, for how long? If yes, please give name of ex‐spouse(s) and date(s) of previous marriage(s): Level of relationship satisfaction (1 – 10): Currently married? □ Yes □ No If yes, date of marriage: Previously married? □ Yes □ No History of marital problems (current or past): Who can you count on for support? Check as many as apply. □ Parents □ Spouse □ Siblings □ Extended Family □ Employer □ Church □ Pastor □ Co‐worker □ Neighbor(s) □ Close Friend □ Self‐help Group □ Community Services □ Therapist □ Medical Doctor List close friends, outside of family, if any: Please list all individuals present in the home during your childhood/adolescence: What was your birth order? I was the out of children. Who primarily raised you? Developmental History How would you describe your childhood? □ Traumatic □ Painful □ Uneventful □ Good □ Happy Did you have any unusual or traumatic experiences as a child? □ Physical Abuse □ Mental Abuse □ Verbal Abuse □ Sexual Abuse □ Neglect □ Other □ None If yes, please explain: ______ Were there any significant changes/losses in your family while growing up? If yes please explain: _______________________________________________________________________________ ________________________________________________________________________________________________ Are all you immediate family members still living? □ Yes □ No If no, please indicate the date and cause of death of each family member: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Have you ever been the perpetrator of abuse, neglect, or violence toward another person? □ Yes □ No If yes, please explain: __________________________________________________________________________________________________ Legal History Have you ever been arrested? □ Yes □ No If yes, what were the charges? Do you have any current legal charges pending? □ Yes □ No If yes, please explain: _____________ Are there any other things that would be helpful for your therapist to know about you? What would you like to accomplish out of your time in therapy? Date: Read and Reviewed by: (Clinician) Date: Miscellaneous Client Signature: