Client Demographic Information
This Form is HIPPA compliant
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Other (see below)
Or Please Share How You Identify
Date of Birth
*
Phone Number
*
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Your Status
Please share what you're currently experiencing. You May Choose More Than One.
*
Depression
Anxiety
Past Trauma
School/Work Pressure
Family Conflict
Problems With My Significant Other
Mood Swings
Grief/Loss
Not Sure
Other
If other please explain
What brings you to counseling at this time? What there a specific event? Please be as detailed as you can.
*
Have You Ever Seen a Therapist Before?
*
Yes
No
Have You Ever Seen a Psychiatrist Before?
*
Yes
No
Are You Currently Seeing a Psychiatrist?
*
Yes
No
If yes, what medications are you taking?
Back
Next
Your Status
Continued
If you are seeing a Psychiatrist please provide his/her/they/them name and number. Your Psychiatrist will only be contacted with your written permission, or in case of an emergency.
Do you use alcohol?
*
Rarely
Occasionally
Often
No
Do you use recreational drugs?
*
Rarely
Occasionally
Often
No
Do you currently have thoughts and/or urges to harm yourself or others?
*
Yes
No
If you are currently experiences urges and/or thoughts to harm yourself or others, please call 911 immediately or go to your nearest emergency room.
Have you ever been psychiatrically hospitalized?
*
No
Yes
Back
Next
Health Insurance Information
Insurances Accepted: Aetna, Oxford, Health First, Oscar, Cigna
If You Do Not Have One of The Above Insurances, Please Skip This Section
Name of Health Insurance Company (Not Your Personal Name.)
Please do not enter your personal name here. Insurance Policy Name Only.
Are You The Primary Policy Holder?
Yes
No
Relationship to Policy Holder
Self
Child
Spouse
Back
Next
Policy Holder Details
THE PRIMARY POLICY HOLDER'S DETAILS
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth of Primary Policy Holder
Date of Birth of Insured
Back
Next
Insurance Policy
THIS INFORMATION CAN BE FOUND ON YOUR INSURANCE CARD
Policy ID Number
Group Number
Effective / Start Date
Insurance Phone Number: Found On Insurance Card
Please enter a valid phone number.
Back
Next
If You Are Paying Out of Pocket Only Please Answer This Section.
If you are paying out of pocket
Please Choose Your Income Category
Please Select
$0-$80k income......$85 per session
$80k-$100k income...$100 per session
$100k-$120k income..$120 per session
$120k-$140k income..$140 per session
$140k-$160k income..$160 per session
$160k-$170k income..$170 per session
$180k-$200k income..$200 per session
$200k-$plus income..$250 per session
If Adam Lukeman offered you a specific rate, please write it down here:
blanks
Back
Next
Payment and Cancellation Policy
Payment Policies. * Adam Lukeman is happy to offer a sliding scale and to accept Aetna insurance. To make this financially feasible, Adam Lukeman ask for your help and understanding of the following policies: • You are responsible for your own insurance.• If your insurance is denied for any reason, you are responsible for the balance • Patients are responsible for all session fees, deductibles, and co-pays on the date of service • To avoid insurance denials, patients are responsible for notifying us of the information below: * All Insurances under your name that may be active (primary and secondary. Please note that if you have more than one insurance plan, and we don’t know, your benefits will be denied) * Changes in your insurance. * Please note that if your insurance isn’t active, your benefits will be denied, and you will be responsible for paying your balance in full. To notify us about any of the above, please contact Adam Lukeman, LCSW at contact@adamlukeman.com. * Cancellations and rescheduled appointments require 24-hour notice – without which there will be an $80 fee. We ask that all clients keep a valid credit/debit card on file, which will be charged if they cancel or reschedule without 24 hour notice. If you do not have a card on file or your card is declined, in order to continue treatment, you must pay your invoice in full on or before your next session. This being said, we understand that in extreme circumstances, there may be emergencies that keep you from giving proper notice. If you feel there were extenuating circumstances, please contact Adam Lukeman, LCSW. Credit Cards - As much of our administrative and billing process is done remotely, we ask that all patients leave a valid credit/debit card on file. Any session fees you might have will be charged to your card within 24-48 hours of your session. Adam Lukeman truly appreciate your understanding in these matters.
*
I have read, understand and agree to the payment and cancellation policy.
My signature indicates that I have read, understand and agree to the Payment and Cancellation policy.
*
I have read and understand the Payment Policy.
Back
Next
Credit Card Policy
Please Read Carefully and Sign Below
At some point you may be asked for your credit card information. By signing below you are granting Adam Lukeman, LCSW the right to charge your credit card for co-payments, deductibles, session fees and late cancellation fees which may exist. Please speak to Adam Lukeman, LCSW about any special needs regarding billing and your credit card.
*
I agree to allow Adam Lukeman, LCSW charge my credit card as stated in the Credit Card Policy.
My signature indicates that I have read, understand and agree to the Credit Card Policy.
*
I understand and agree to the above credit card policy.
Back
Next
Notice of Privacy Practices
Please Read
This notice describes how medical information about you may be used and disclosed and how you can get access to it. Please review carefully. 1. Your medical records are used to provide treatment, bill and receive payments, and conduct healthcare operations. Examples of these activities include but not limited to review of treatment records to ensure appropriate care, electronic or mail delivery of billing for treatment to you or other authorized payers, appointment reminder telephone calls, and records review to ensure completeness and quality of care. Use and disclosure of medical records is limited to the internal used outlined above except required by law or authorized by the patient or legal guardian. 2. Federal and State laws require abuse, neglect, domestic violence, threats to others and statement regarding self harm to be reported to social services or other protective agencies. If such reports are made they will be disclosed to you or your legal representative unless disclosure increases risk of further. 3. Disclosed information will be limited to the minimum necessary. You may request an account for any uses or disclosures other than those described in Sections 1 and Sections 2. 4. You, or your legal representative, may request your records to be disclosed to yourself or any other entity. Your request must be made in writing, clearly identify the person authorized to request the release, specify the information you want disclosed, the name and address of the entity you want the information released to, purpose and the expiration date of the authorization. Any authorization provided may be revoked in writing at anytime. Psychotherapy notes are part of your medical records. We have 30 days to respond to a disclosure request and 60 days if the records is stored off site. 5. You may request corrections to your records. 6. A request for disclosure may be denied under the following circumstances: disclosure would likely endanger the life or physical safety of you or another person, requested information references other persons, except another healthcare provider, or if released to a legal representative If a request for disclosure is denied for reasons outlined in Section 6, you or your legal representative may request review of the denial. A review will be conducted by another 7. licensed healthcare provider appointed by the original reviewer, who was not involved in the original decision to deny access. A review will be concluded within 30 days. 8. You may request that we restrict uses and disclosures outlined in Section 1. However, we are not required to agree to the restrictions. If an agreement is made to restrict use or disclosure, we will be bound by such restriction until revoked by you or your legal representative orally or in writing except when disclosure is required by law or in an emergency. We may also revoke such restrictions but information gathered while required by law or in an emergency. We may also revoke such restrictions but information gathered while the restriction was in place will remain restricted by such an agreement. 9. If you wish to complain about privacy related issues you may contact the Secretary of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington DC, 20201. In any case there will not be any retaliation against you or your legal representative for filing a complaint. 10. This agreement may be modified or amended as required by law or in the course of health care operations.
*
I have read, understand and agree to the Notice of Privacy Practices.
My signature indicates that I have read and understand the Notice of Privacy Practices.
*
I understand and agree to above privacy policy.
How I Found Adam
*
Psychology Today
Referral From Friend
Referral From a Psychiatrist
Columbia University
Web Search
MyWellBeing.com
Other
Go To Final Step
Should be Empty: