Intake Form for Gulf Breeze Clinic

Intake Form

Gulf Breeze Clinic Patients Only
Personal Information
Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date *

Month Day Year
Gender *
Employer
E-mail
Occupation
Marital Status
Spouse's Name
Spouse's Occupation
Spouse's Employer
Emergency Contact *
Emergency Contact Phone Number *
Primary Care Provider
Primary Care Provider Phone Number
How were you referred to our office?

History of the Present Problem
Purpose of this appointment: *
Have you ever had the same or a similar problem?

Yes No
If yes, please describe:

Social History
Do you do any of the following? (Please check all that apply)

Exercise Use tobacco products Consume caffeine Sleep well at night Drink alcohol Take vitamin supplements
If you checked any of the options above, please detail below:
What are your hobbies?

The Therapy Process
Working with you to identify presenting issues and develop a plan of care is the goal. However, it is your commitment to identifying personal goals towards which you desire to move and obstacles which may prevent that movement which will, in large part, determine the success of the therapy. If you have a crisis situation develop after hours, call the suicide prevention hotline at (800) 784-2433 or go to your local emergency room.

The privacy regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require ethical and legal commitment to the confidentiality of your Personal Health Information.
Legal Responsibility
Under the laws of the United States and the state of Kansas your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect.

Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.
Use and Disclosure of your Personal Health Information (PHI)
Your PHI will not be used or disclosed for any purpose not listed below, without your specific written authorization. You must give written authorization to disclose your health information to anyone for any reason you want. Any specific written authorization you provide may be revoked at any time by your written request.

 Health Care Provider - PHI may be used and disclosed to your physician or other healthcare provider who is also treating you.

 Payment - Your PHI may be used and disclosed to your health plan or other third party for payment of services provided for you. If your contract with your insurance company requires that information relevant to the services provided be given before payment, providing them with a clinical diagnosis, as well as clinical information such as treatment plans or summaries and/or copies of any records maintained about your therapy sessions may be required.

 Health Care Operations - Your PHI may be used and disclosed to staff members for the purpose of obtaining insurance eligibility, billing health insurance and inquiring about claim status.

 As Law Requires - Your PHI may be used and disclosed to any person required by federal, state, or local laws to have lawful access to your treatment program.

 Court Orders, Judicial and Administrative Proceedings, and Law Enforcement - Your PHI may be disclosed as part of a court proceeding, in response to a subpoena, or in other situations as required by law.

 Appointment Reminders - You may be contacted by phone or email for an appointment reminder. If contact is by phone, a recorded message may be left on your answering machine.

 Therapist Cancellation – If for some reason an appointment must be cancelled, you will be contacted by phone or email. If contact is by phone, a recorded message may be left on your answering machine/voicemail.

 Victims of Abuse, Neglect, or Domestic Violence - Your PHI may be used or disclosed to authorized persons from state agencies in cases of disclosures required by applicable state laws governing abuse, neglect, criminal activities, threats to the health/safety of the client and others, domestic violence, etc. In the case of minor children, the law requires such information to be disclosed.

 Event of an Emergency - Your PHI may be disclosed to a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, you will be given an opportunity to object. If you object or are not present or are incapable of responding, your PHI will be used or disclosed in your best interest at that time. In so doing, only the aspects of your PHI that are necessary for response to the emergency will be used or disclosed.
Communication
We are committed to ensuring that your privacy is protected. Should we ask you to provide certain information by which you can be identified when using this website; you can be assured that it will only be used in accordance with this privacy statement.

We will not intentionally share the contents of any email or information submitted via the internet with any third party. However, due to the nature of electronic communications, we cannot and do not provide any assurances that the contents of your email will not become known or accessible to third parties. We urge you not to provide any confidential information to us via electronic communication. Should you choose to communicate via email, the provider contacted will respond to any emails sent until you request that form of communication to cease. Please take all precautions necessary to secure your email should you choose to use it to contact the provider.
For Questions, Concerns or Complaints
As a mental health professional licensed by the State of Kansas through the Behavioral Sciences Regulatory Board (BSRB), I am committed to practice according to the ethics of my profession. You may contact the BSRB and/or the secretary of the United States Department of Health and Human Services with questions or to register complaints about any licensed mental health professional.

Signature and Submission
Please type your name below to indicate consent to treatment.
Patient's Signature *
Date *

Month Day Year
If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.
Parent/Guardian Signature
Date

Month Day Year
Enter the message as it's shown *
Should be Empty:

Intake Form

Personal Information

Personal History

History of the Present Problem

Social History

The Therapy Process

Legal Responsibility

Use and Disclosure of your Personal Health Information (PHI)

Communication

For Questions, Concerns or Complaints

Signature and Submission