Telehealth Inclusive Intake Form

Intake Form

Please use one form per person.
Personal Information
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Social Security Number *
Please upload a copy of your identification:

Browse Files
If this form is being submitted for a minor, please send the responsible party's identification Cancel of
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
Gender *
Employer
E-mail
Occupation
Marital Status
Spouse's Name
Spouse's Occupation
Spouse's Employer
Number of Children
Children's Names, Ages
Emergency Contact *
Emergency Contact Phone Number *
Primary Care Physician
Primary Care Physician's Phone Number
How were you referred to our office?

Financial Information
How I plan to pay for therapy: *

I plan to use my insurance. I want to pay for my therapy. I have an EAP authorization from my employer.
Primary Insured's Name *
Primary Insured's Date of Birth *
Primary Insured's Social Security Number *
Insurance Company *
Insurance Contact Number *
Member ID *
Please upload the front and back of your insurance card here:

Upload a File

Cancel of
EAP Company *
EAP authorization number *
Number of EAP authorized sessions *
Cancellation & Rescheduling Policy *

Twenty-four hour notice is required for the cancellation or rescheduling of an appointment. Appointments changed with less than 24 hours notice will incur a $25 charge. For clients who are utilizing insurance or EAP benefits, this charge is NOT billable and will be your responsibility. Payment of this charge is required prior to the next appointment.

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:
Have you been treated for a mental health problem in the last year

Yes No

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?

Consent to utilize teletherapy services with Dr. Hayes: *

Yes No
I hereby consent to engage in teletherapy with Dr. Everett C. Hayes. I understand that “teletherapy” includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. I understand that teletherapy also involves the communication of my medical/mental health information, both orally and visually.

I understand that I have the following rights with respect to teletherapy:
- I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment.
- The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, which are discussed in detail in the general Informed Consent I received prior to this consent form.
- I understand that there are risks and consequences from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on the part of Dr. Hayes that: the transmission of my information could be disrupted or distorted by technical failures; that the transmission of my information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
- In addition, I understand that teletherapy based services and care may not be as complete as face-to-face services.
- I also understand that if Dr. Hayes believes I would be better served by another form of therapeutic services (e.g. face-to-face services) I will be referred to a professional who can provide such services in my area.
- Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy and that despite my efforts and the efforts of my psychologist, my condition may not be improved, and in some cases may even get worse.
- I understand that I may benefit from teletherapy, but that results cannot be guaranteed or assured.
  I accept that teletherapy does not provide emergency services. During our first session, Dr. Hayes and I will discuss an emergency response plan. If I am experiencing an emergency situation, I understand that I am to call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts of making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK(8355 for free, 24-hour hotline support.
- I understand that I am responsible for (a) providing the necessary computer, telecommunication equipment and internet access for my teletherapy sessions, (b) the information security on my computer, and (c) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my teletherapy session.
- I understand that while email may be used to communicate with Dr. Hayes, the confidentiality of emails cannot be guaranteed.
- I understand that I have a right to access my medical information and copies of medical records in accordance with HIPAA privacy rules and applicable state law.
*

I have read, understand and agree to the information provided above.

Informed Consent & Confidentiality Policy - Page 1/5
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.

Informed Consent & Confidentiality Policy - Page 2/5
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.

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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 insurance 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 through the communication option which you authorize for a reminder.

· Therapist Cancellation – If for some reason an appointment must be cancelled, you will be contacted through the comunication option with you authorize.

· 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.

Informed Consent & Confidentiality Policy - Page 4/5
Patient Rights

· With limited exceptions, you can make a written request to inspect your PHI that is maintained by us for our use. Your PHI includes basic information about your diagnosis, treatment dates, treatment plans, intake and termination summaries. Psychotherapy notes may be exempt from this ruling.

· Requested copies of any PHI information will be provided at the cost of $.25 per page.

· You must make a written request to have your PHI communicated with you by alternative means at an alternative location. (An example would be if your primary language is not spoken and a child for whom you have lawful custody is being treated.) Your written request must specify the alternative means and location.

· You can make a written request that restrictions be placed on other ways we use or disclose your health information. Any or all of your requested restrictions may be denied. If these restrictions are agreed to, they will be abided by in all situations except those in which professional judgment constitutes an emergency.

· You can make a written request that your PHI be amended. If approved, your records will be changed accordingly. Notification will also be made to anyone else who may have received this information and anyone else of your choosing. If denied, you can place a written statement in your records disagreeing with the denial of your request.

Informed Consent & Confidentiality Policy - Page 5/5
For Questions, Concerns, and 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.

Contact Information
I understand that my therapist may need to contact me between sessions and have indicated my best contact information for this below.
Select one:
Phone Number *

Area Code Phone Number
E-mail *
Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. Please do not include personal identifying information such as your birth date, or personal medical information in any emails you send to us. No one can diagnose your condition from email or other written communications, and communication via our website cannot replace the relationship you have with a physician or another healthcare practitioner.
Select one:
Phone Number

Area Code Phone Number
E-mail

Kansas Directive
For patients in Kansas only.
In Kansas, licensed mental health professionals are required to consult with a client’s primary care physician or psychiatrist whenever symptoms of a mental health diagnosis are present. The purpose of such consultation is to determine if there may be a medical condition or medication that may be causing or contributing to the client’s symptoms. The client/parent/legal guardian may also choose to waive such consultation. The clinician may provide treatment or evaluation until such time that the medical consultation is obtained or waived.
*

I choose to waive the consultation, understanding that I may at any time complete a release of information to the physician or psychiatrist of my choice. I accept the consultation and will complete a release of information to the physician or psychiatrist of my choice.

Signature and Submission
Please type your name below to indicate consent to treatment and acknowledgement of Informed Consent & Privacy Policy.
Patient's Signature *
If patient is a minor, the parent or guardian must sign to consent to the minor receiving treatment.
Should be Empty:

Intake Form

Personal Information

Financial Information

Personal History

History of the Present Problem

Social History

Family History

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Contact Information

Kansas Directive

Signature and Submission