Jami Hamilton-Ansley Intake Forms

Jami Hamilton-Ansley, LCSW, RPT
PROBASCO & ASSOCIATES

1129B W. Kansas
Liberty, Missouri 64068
(816) 781-8550
email: jamih2000@yahoo.com

Personal Information
Name:
Address:
Home Phone:
Buisness Phone:
Cell Phone:
Email Address:
Gender:
Refferred By:
Primary Care Physician: (Name, Phone Number, and Address)
Responsible Party (if applicable)
Parent/Guardian:
Address:
Home Phone Number:
Buisness or Cell Number:
Emergency Contact Information: (Name, Phone Number, Relationship)
Insurance Information
Name of Insured:
Birthdate of Insured:
Insured ID#
Group #
Relation to Insured:
Name of Employer:
Employer Phone Number:
Insurance Company Name:
Insurance Phone Number:
Insurance Address:
By checking below I authorize the release of medical information necessary to process an insurance claim. I authorize payment of benefits to Clinical Counseling Associates, Inc. for services rendered. I understand that I am responsible for any charges not covered by my insurance plan. I understand that a statement of account will be sent monthly to keep me apprised of my account status and what amount I am responsible for. I understand that if I have any questions regarding my account, I may call the office for assistance.
Clients should keep their appointment or call at least 24 hours in advance to cancel visits. If not, the client will be charged for the visit at 50% of the regular fee. The second time this occurs, you will be charged the full regular fee. (Insurance can not be billed for a no show charge) The usual fee for professional services is $90 for the initial visit and $80 per 50-minute session thereafter. Payment will be due at the time service is rendered. We accept cash, check, credit card or debit card.
If you wish, as a courtesy we will file insurance within five business days of your visit, however, insurance coverage is not a guarantee for payment. It is the client’s responsibility to check with the insurance company regarding coverage and copayment.
If a balance is on your account, a statement will be provided monthly. If a balance remains for more than 60 days, your account will be assessed a $10 service charge. This charge will continue each month until your account is paid in full.
There will be a $30 charge for any check returned for insufficient funds, closed account, or for any other reason.
A treatment plan will be provided for $25. This will not be submitted to insurance.
School visits and observations are available for $75 per visit, plus mileage. We may not be able to submit this to insurance.
Phone consultations with schools (teachers, administrators, counselors, etc.), doctor’s office or daycare providers can be provided for a fee of $25 for every 15 minutes. This will not be submitted to insurance.
Letters to schools, doctors, counselors, etc. can be provided for a fee of $25. This will not be submitted to insurance.
STATEMENT OF UNDERSTANDING: I have read the above payment policy and agree to abide by these policies. I understand that I am responsible for 100% of charges for services provided. I understand I am responsible to pay full fees for services at the time of each session. I understand that I am responsible for contacting my insurance company to confirm coverage and/or copayments. I understand that I must provide documentation of insurance coverage before the provider will agree to accept copayments.
By checking this box, I hereby authorize the release of medical information necessary to process insurance claims. I authorize payment of benefits directly to Clinical Counseling Associates, Inc. for services rendered. If my insurance company sends me checks for payment of sessions, I agree to notify Clinical Counseling Associates, Inc. and sign over any checks to CCA as payment for any outstanding charges on my account. I understand that I am responsible for any charges on my account. I understand that a statement will be sent monthly to keep me informed of my account status. I understand that if I have any questions regarding my account, I may call the office for assistance.
Date:
COUNSELING SESSIONS AND CLIENT RIGHTS AND RESPONSIBILITIES:   All counseling sessions are by appointment only. Sessions last approximately 50 minutes once a week. Sometimes it is necessary to meet more often initially to handle crisis situations. The frequency of counseling sessions will gradually decrease as progress is made in counseling. This will also depend on your insurance policy. All clients will be treated by a licensed mental health professional with respect for their individual needs, preferences, feelings, and requirements. An individual treatment plan will be developed for each client. The client has the right to participate with the therapist in treatment planning decisions. If transfer or discharge of the patient from treatment becomes necessary, clients will be given the reasons and plan, as well as reasonable advance notice. All clients are responsible for providing the therapist with all needed information to allow them to provide appropriate care, as well as being open and honest with their therapist. Clients should ask questions so that they understand the care and instructions they are given. They should actively participate in their own treatment and carry out therapeutic homework assignments.
CONFIDENTIALITY:   Matters discussed with your therapist are protected by laws insuring your right to privacy. In most cases, your therapist is prohibited from disclosing information about your care without your written consent and then, only to the extent you authorize. Your treatment record and related financial records are kept in a file cabinet in an office, or other area not accessible to the public. Records will not be copies or otherwise made available to others, except as noted below, without a signed authorization to release information. Those cases where information may be disclosed without your consent are: 1) Information required by insurance company to process a claim or obtain further clinical visits. 2) Where child abuse is known or suspected. (Reporting is required by State Law) 3) When the abuse of an elderly or dependent person is known or suspected. (Reporting is required by State Law) 4) If there is a situation that is potentially life threatening. 5) When ordered by the Court. 6) In some cases, details of your treatment may be discussed with a clinical supervisor or another clinician for the purpose of consultation. When this is done, no identifying information will be included (i.e., the client is anonymous)
Developmental Issues
Child's Name:
Filled out by:
Relationship to child:
It is very helpful for us to have information in the following areas. Please fill out this form as completely as you can.
Family Members: (Please list - Name, Relationship, and Age of family members)
Has the child received counseling and/or play therapy before? Yes No If so, please list where and dates of services:
Pregnancy and Birth:
1. Is your child adopted? Yes No Has the child been told he/she was adopted?
2. Was the pregnancy planned?
3. How was the mother's health during pregnancy?
4. Was there anything unusual about the birth? (premature, length of labor, complications etc.)
Early Childhood:   During the first six months, did the baby or mother have any problems in the following areas? (please describe)
1. Depression:
2. Breast Feeding:
3. Formula:
4. Allergies:
5. Colic:
6. Sleeping:
After the first six months, were there any problems in the following areas? (please describe)
1. Eating difficulties:
2. Sleeping difficulties:
3. Does the child have their own bed?
If not, who does he/she sleep with?
4. Does the child wet the bed?
5. How many hours a night does the child sleep?
Temperament: (please rate the following behaviors)
1. Activity Level:
2. Adaptability:
3. Intensity:
4. Mood:
Physical:
1. Does the child have speech difficulties (stuttering, delays, etc.)
2. When did the child begin sitting?
3. When did the child begin standing?
4. When did the child begin Walking
5. Was the toilet training easy to complete?
6. Does the child still have soiling or wetting problems?
7. Any vision or hearing problems with the child?
Health:
1. Any unusual medical problems?
If yes, please explain:
2. Has the child been hospitalized frequently?
If yes, please explain
3. Is the child on any medications now?
If yes, please explain:
4. Are immunizations up to date?
5. Please list any doctors and/or professionals contacted:
Child Care
1. Does someone other than mother/father/guardian have more than occasional responsibility for the child?
2. Is the child in day care?
3. Who disciplines the child? What methods are used?
4. Do parent(s) agree on discipline method and share responsibilities?
6. How effective has this been?
Social/ School
1. Does your child have many friends?
2. What age group does the child get along with best?
3. Has the family moved frequently?
4. Has the child had any problems in school? (please describe)
Academic (learning problems, special classes):
Behavioral
2. Has the child ever had any problems with alcohol or drugs?
Other Concerns: