Polizzi Psychological Services, LLC



Intake EvaluationPolizzi Psychological Services, LLCClient Information (Who will the therapist be seeing?)Last Name: First: Mi:Address: Email Address: Date of Birth : / / Emergency Contact: Phone:(Relationship to Emergency Contact): Primary Physician: Referred by: Contact Please place a check next to which number(s) you preferred to be contacted at)Home Phone: Cell Phone: Work Phone: Reason for Seeking Services: I authorize Polizzi Psychological Services, LLC to release any and all medical information deemed necessary for the purpose of processing out of network insurance claims on my behalf. I understand that I am responsible for all charges not covered by insurance. A photocopy of this authorization shall be considered as valid and effective as the original.Signature Date / / PERSONAL AND MEDICAL HISTORyPersonal HistoryMilitary History: ? No ? Yes – Dates of Service Branch ________________________Highest level of Education __________________Did you Experience difficulties in School?_______________________________ ______________________________________________________________________________Work/Occupational History: ? Retired ? Disabled ? Student ?Unemployed profession: ____________________________________________________________________________________issues with work? __________________________________________________________Legal History: ? None ? Yes _______________________________________________ ______________________________________________________________________________Medical HistoryHow would you rate your overall health? ? Excellent ? Good ?Average ? PoorDo you have any ongoing health issues? ? No ? Yes (please describe) __________________________________________History of major surgeries, head traumas or illnesses: ____________All Current MedicationsDoseFor what conditionPrior Psychiatric / Behavioral MedicationsDoseFor what conditionAllergies: ? None ? Food ? Drugs ? Environmental ? Other (please specify for all items checked) ____________________________________________Change in__________________________________________________________________ Appetite?___________________________________________________________________Have you experienced any unexplained weight gain or loss in the past 6 months? ? No ? Yes (please describe):_____________________________ _____________________________________________________________________________How many hours a night on average do you sleep? _____________________Do you require Sleep medication to fall Asleep? ________________________ or Stay Asleep? ____________ Do you have poor sleep or restless sleep?______________________________________________________________________________ Pain AssessmentDo you experience ongoing pain? ? No ? Yes If yes, is it constant pain? ? No ? Yes Please describe your pain and its location: Drug / Alcohol /Addictions InformationDo you or someone close to you have a problem with drugs, alcohol, gambling or other addictions? ? No ? Yes – if Yes, please describe Did you have a problem with drugs or alcohol in the past? If yes, please describe:__________________________________________________________________________________________________________________________________________How much of the following do you consume in an average week? ? Beer ______? Wine ? Mixed drinks ______? Drugs (Presecription or street drugs) ______Do you have a problem or concerns with the following? ? Tobacco ? Food ? Pornography ? Internet ? Sex ? NoneDo you consider yourself in recovery? ? No ? Yes – Length of time in recovery _____Trauma HistoryHAVE YOU EVER EXPEREINCED OR BEEN THE VICTIM OF A TRAUMATIC EVENT? eVENTS INCLUDE: RAPE, DOMESTIC VIOLENCE, PHSYCIAL, SEXUAL, EMOTIONAL ABUSE AS A CHILD, OR EVENTS LIKE HOUSE FIRES, CAR ACCIDENTS, ROBBERIES, ASSAULTS:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________FAITH/spiritualitywere you raised in any particular Religious faith, or is faith important to you today? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Mental HealthPrior mental health outpatient services used or hospitalizations:WhereWhenPurposeOutcomeFamily Mental Health Historyhas anyone in your family of origin experienced mental health issues or addiction issues? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Symptom checklist: “I have problems with the following….” over the last two weeks. Please check all that apply:____Agitation ____Angry outbursts____Crying spells____can’t sleep____easily startled____eating too much____drinking too much____feeling depressed or down____feeling paranoid ____feelings of being better off dead____feelings hopeless/helpless____feelings of worthlessness____focus on numbers and or counting____worrying about germs or cleanliness____hearing things others do not hear____fears or phobias____impending sense of doom____impulsiveness____isolating____learning difficulties____legal/financial problems____losing periods of time____loss ofinterest in activities i used to enjoy____memory problems____mood swings____no appetite____nervousness____problems with gambling or pornography____nightmares____not getting along with others____panic attacks____problems concentrating____rapid thoughts____repetitve behaviors____seeing things others do not see____sexual ability issues____spending too much money____suicidal thoughts____thoughts I cannot stop____Trauma History____using drugs too much____wanting to cut or harm myself____Work issues____Relationship issues ____conflict with children or family membersDo you have any other issues or concerns? Please describe: ____________________________________________________________Policies and Procedures: By initialing each line below you are agreeing to the terms and conditions set forth in each of the following sections.FEE AGREEMENTI acknowledge that the full fee for Polizzi Psychological Services, LLC sessions are as follows.Initial Assessment$150.00Individual/Couples Session: $140.00In-Home Grief Counseling $65.00/hr.Fees are per session and payment is expected in full at each session unless another plan has been agreed upon and otherwise noted. Acceptable forms of payment include: cash, FSA or HSA accounts, credit, and or debit cards. Payment arrangements for credit or debit or FSA/HSA accounts can be made through Ivy Pay. A Receipt for Services can be provided to client for determination of out of network reimbursement. It is the client’s responsibility to contact their insurance company to determine if they qualify for out of network mental health reimbursement. I authorize the release of any information necessary to process claims for services rendered to me by Polizzi Psychological Services, LLC for the processing of out of network claims. CLIENT RIGHTS AND RESPONSIBILITIESAs a Client of Polizzi Psychological Services, LLC you have the right to:Receive counseling services without regard to race, religion, sex, national origin, sexual orientation, age or disability.Be treated with dignity and respect at all times.Be accepted for counseling only if Dr. Polizzi has the training or ability to meet your needs.Be referred appropriately when Dr. Polizzi is not able to meet your needs in a reasonable and timely manner.Participate in the development of an individualized treatment plan including goal setting, treatment methods and expected/estimated duration of counseling.Be informed of the cost of the services and receive appropriate care regardless of the source(s) of payment.Confidentiality of information as prescribed by law. Voice a grievance or complaint about treatment and/or staff without fear of reprisal or discrimination, and have the grievance investigated. The grievance procedure is:Request a meeting with Elizabeth Polizzi, Ph.D., HSPP, owner. The complaint should be presented in writing at this time.Designate a person for making decisions if you are incapable of understanding a suggested treatment or procedure or are unable to communicate your wishes. Be informed of rules and regulations regarding your own conduct. Request Access to your Protected Health Information (PHI) LIMITATIONS TO CONFIDENTIALITYIf Dr. Polizzi has cause to believe that you are likely to harm yourself, she may take action necessary to protect your safety by contacting your emergency contact, law enforcement officers, an ambulance transport and/or a physician.If Dr. Polizzi has cause to believe you are likely to harm another person, she may take action necessary to protect their safety by contacting the individual that has been threatened, law enforcement or a physician.If Dr. Polizzi has cause to believe a child has been or may be abused or neglected, she is required to make a report to the appropriate state agency.If Dr. Polizzi has cause to believe an elderly or disabled person has been or may be abused, neglected, or subject to financial exploitation, the clinician is required to make a report to the appropriate state rmation disclosed about a person from whom you sought past counseling behaving toward you in a sexually inappropriate manner must be reported (your identity may remain anonymous at your request).If your records are requested by a valid subpoena or court order, we must respond.Confidentiality belongs to you, the client. If you would like your PHI released to a third party, you will be asked to complete a Release of Information Form to specify exactly which information from your case is to be released. CLIENT RESPONSIBILITIESParticipate actively in the counseling process, including development and completion of treatment suggestions.Give 24-hour notice if an appointment cannot be kept. Failure to do so will result in Client being billed 60$ for a late cancellation/no show missed appointment fee. Notify the office in the event of change of address, phone number or emergency contact RMED CONSENT FOR COUNSELING/PSYCHOTHERAPYAs a client, you need to be informed of certain key aspects involving all counseling situations. Counseling attempts to teach you alternative ways of coping with problems in living. As such, no guarantee exits that you will automatically feel better from coming to counseling. I provide the following information and ask that you read it carefully, discuss it with me and ask any questions that you may have. Please sign, acknowledging that you understand this information and give voluntary consent to participate in therapy.CANCELLATION, SCHEDULING AND NO-SHOW POLICYAn agreement will be made between Dr. Polizzi and client regarding the frequency of therapy. The frequency of therapy will be developed with the intent of maximizing the therapeutic effect of treatment. Cancellations will compromise progress. Cancelled appointment times could also be given to other patients. Failure to provide notice will result in Client being billed 60$ for a late cancellation/no show missed appointment fee. Fee will be waived ONLY in case of unexpected illness or emergencies.When the need arises to cancel an appointment, we request notification as soon as possible, but preferably within 24 hours before the scheduled appointment time. Therapist cancellations will not count against client. If your account has been sent to collections, you cannot be rescheduled. Reconciled accounts will be considered on a case by case basis. ______________EMERGENCY POLICYI acknowledge that Polizzi Psychological Services LLC, does not provide emergency or after-hours sessions or services. In the event of an emergency, policy is to call 911 or to go immediately to a local hospital ER for evaluation. I recognize that Emergency or In-Patient personnel may contact Dr. Polizzi for coordination of my care. Client SignatureDate______Client Printed NameNOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENTI understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.Obtain payment from third-party payers.Conduct normal healthcare operations such as quality assessments and physician certification.I have read, received and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.I understand that I may request, in writing, that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do not agree then you are bound to abide by such restriction.Client Name:_________Signature:DATE:________________ ................
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