Dr Thorsheim Pre Appointment Information

Pre Appointment Information
Date

MonthDayYear
Thomas E. Thorsheim, Ph.D.

- Incorporated -
Licensed Psychologist (SC Lic. # 996)
1326 Haywood Road, Suite 102
Greenville, SC 29615

Tel: 864-421-0098 / Fax: 864-421-0099

*NOTE: For couple's therapy, please complete two separate intake forms. For children, please complete only applicable information.
Patient Name*
Referred by
Address*
Home Phone*
Gender
Date of Birth*

MonthDayYear
Date
Age:
Marital Status: Single / Married / Partnered / Divorced / Widowed

SingleMarriedPartneredDivorcedWidowed
School, District, and Grade/Year in School (if applicable)
Profession/Employer (if applicable)
Please indicate the primary phone number or preferred mode of contact
May I text you information to the above number related to scheduling or content related to our work together?*

YesNo
Are there any special instructions for contacting you?
Email Address(es)
example@example.com
If you wish, please provide the name/number of an emergency contact:
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.

Other Household Members

	Full Name	Birthdate	Relationship
Household Member 1
Household Member 2
Household Member 3
Household Member 4
Household Member 5

CONSENT TO MENTAL HEALTH EVALUATION & TREATMENT
I hereby authorize Dr. Thorsheim to provide mental health services to me (or to my minor child – if the child is the patient being treated).

Please Note: You will not be an offical patient until after your first appointment.
Name of Patient*
Signature of Patient (or guardian, in the case of a minor)*

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DATE

MonthDayYear
Date
Signature of Child (assent to treatment - if child is primary patient)

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DATE

MonthDayYear
Date
Provider:

Thomas E. Thorsheim, Ph.D.
Signature of Provider

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DATE

MonthDayYear
Date

Thomas E. Thorsheim, Ph.D.

- Incorporated -
Licensed Psychologist
1326 Haywood Road, Suite 102
Greenville, South Carolina
Tel. 864-421-0098

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY.

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent.

I may use/disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

I may use or disclose PHI without your consent or authorization in the following circumstances:
- Child Abuse: If I have cause to believe that a child has been, or may be, abused, neglected, or sexually abused, I must make a report of such within 48 hours to the South Carolina Department of Protective and Regulatory Services (Child Protective Services) or to any local or state law enforcement agency.
- Adult and Domestic Abuse: If I have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, I must immediately report such to the Department of Protective and Regulatory Services (Adult Protective Services).
- Health Oversight: If a complaint is filed against me with the State Board of Examiners of Psychologists, the Board has the authority to subpoena confidential mental health information from me relevant to that complaint.
- Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information, without written authorization from you or your personal or legally appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if the evaluation is court-ordered or is being conducted for a third party.
- Serious Threat to Health or Safety: If it is determined that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, I may disclose relevant confidential mental health information to medical or law enforcement personnel.
- Worker’s Compensation: If you file a worker's compensation claim, I may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier.
Psychologist’s Duties:
- I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
- I reserve the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, I am required to abide by the terms currently in effect.
- If I revise my policies and procedures, I will post notice of such revision in a visible location. I may also elect to notify you by mail at the billing address which you have provided to me.
Complaints:

If you are concerned that your privacy rights have been violated, or you disagree with a decision made about access to your records, you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services.
Signature*

Clear
Date

MonthDayYear
Date
Provider:

Thomas E. Thorsheim, Ph.D.
Signature

Clear
Date

MonthDayYear
Date

Thomas E. Thorsheim, Ph.D.

- Incorporated -
Licensed Psychologist
1326 Haywood Road, Suite 102
Greenville, South Carolina
Tel. 864-421-0098

PAYMENT POLICY & FEE RATES

All services rendered are your financial responsibility. You are responsible for full payment at time of service regardless of insurance coverage. Dr. Thorsheim will bill you directly and will not bill your insurance provider. However, you may Independently choose to seek reimbursement from your insurance carrier. Dr. Thorsheim will provide you receipts and specific billing codes for you to expedite any reimbursement from your insurance carrier.

If you are issued reimbursement from your insurance, please ask that your insurer send payment directly to you, as my office does not cash third-party checks from insurance.

FEE SCHEDULE

* PLEASE NOTE: 48 hours advanced notice is requested to change or cancel an appointment. A minimum of a full 24 hour notice of cancellation is required. Appointments canceled less than 24 hours prior will be billed at the full fee rate.

Initial Diagnostic Interview (60 min):	$280
Individual Psychotherapy (45 min):	$240
Individual Psychotherapy (60 min):	$280
Family/Couples Psychotherapy (60min):	$280
Group Psychotherapy:	$85
Psychological Testing: Fees vary based on testing required.	Contact to Discuss
Executive/Physician Coaching (60 min):	Contact to Discuss Various Offerings

By signing below, I acknowledge understanding of the above fee schedule. I am aware that Dr. Thorsheim has chosen not to participate in insurance panels and that he does not receive third-party reimbursement from insurers. In addition, I understand that he opts out of Medicare and never seeks or obtains reimbursement from Medicare.

**I also understand that in the event of a missed appointment or late cancellation (i.e. less than minimum of a full 24 hour notice), I would be charged in full.

Signature*

Clear
Date

MonthDayYear
Date

Thomas E. Thorsheim, Ph.D.

- Incorporated -
Licensed Psychologist
1326 Haywood Road, Suite 102
Greenville, South Carolina
Tel. 864-421-0098

Good Faith Billing Esimate

In accordance with the No Surprises Act of 2022, as a mental health care provider, I am required to provide you a good-faith estimate of what fees you can reasonably anticipate as a patient. The below estimates assume you are fully self-pay and not receiving out-of-network insurance reimbursement.

I provide a range of clinical services, including the following:

CPT Code	Description
90791	Diagnostic Intake Evaluation, 60 minutes ($280)
90834	Psychotherapy, 45 minutes ($240)
90837	Psychotherapy, 60 minutes ($280)
90846	Family or couples’ psychotherapy, without patient present, 60 minutes ($280)
90847	Family or couples’ psychotherapy, with patient present, 60 minutes ($280)
90853	Group psychotherapy, 90 minutes ($85)

If services are being offered remotely, the “-95” designation is added after a given procedure (CPT) code.

When needed, I also provide psychological testing. If testing is indicated, I fully explain the purpose of the assessment and provide a firm fee quote before any work. Test fees vary depending on the amount of assessment required.

The frequency of therapeutic services provided typically ranges from 12-50 sessions/year.

For 45-minute individual psychotherapy, this is equivalent to a total of $2,880 to $12,000 per year.
For family or couples’ psychotherapy, this is equivalent to a total of $3,360 to $14,000
Group psychotherapy is a weekly commitment, and this is equivalent to a total of $4,250 per year.

Please note the following:

I may recommend additional items or services as part of treatment that are not reflected in the estimate. These services would need to be scheduled separately. You always have a right to understand why services are recommended and always deserve a clear and complete explanation for any variance above and beyond the above estimates.

The total length of treatment varies tremendously from one patient to another. Some patients have discrete, concrete treatment goals involving symptom reduction and well-defined objectives. Psychotherapy is a long journey of ongoing self-discovery, learning, and growth for other patients. You always have a right to change or revise your own treatment objectives. It is essential that you get what you most want out of the therapy process and that you understand where treatment is going.

Name of Patient*
Date of Birth*

MonthDayYear
Date
Signature of Patient or Guardian*

Clear
Date

MonthDayYear
Date

Items to consider - and if you'd like, to write about - prior to your first appointment.
Please share a few brief thoughts about what you would like assistance with in our work together (we will discuss at length during your first session).
What has prompted you to get help for these concerns right now?
If you've been to therapy before (or had psychological testing) how was that experience for you? Is there anything in particular that you found especially helpful and/or unhelpful?
Should be Empty:

	Yes	No	Unknown
Hearing problems
Vision problems
Headaches
Head injury
Blackouts / fainting
Seizures / convulsions
EEG / Brain wave test
Diabetes (or anyone in the family?)
Asthma / breathing problems
Serious accident / injury
Surgery
Hallucinations
Congenital defects
Suicide gesture / attempt
Female/Gyn. problems / pregnancy
Venereal disease
Measles (what type)
Mumps
Chicken Pox
Rheumatic Fever
Tuberculosis
Diphtheria
Enuresis / Encopresis
GI Problems
Repeated infections
Urinary
Cardiovascular
Respiratory

Pre Appointment Information

Thomas E. Thorsheim, Ph.D.

A. MEDICAL HISTORY

B. ALLERGIES / TYPE OF REACTION:

C. MEDICATION HISTORY:

D. DRUGS AND ALCOHOL

E. PREVIOUS THERAPY, PSYCHOLOGICAL OR PSYCHIATRIC TREATMENT

CONSENT TO MENTAL HEALTH EVALUATION & TREATMENT

I hereby authorize Dr. Thorsheim to provide mental health services to me (or to my minor child – if the child is the patient being treated).

Provider:

Thomas E. Thorsheim, Ph.D.

NOTICE OF PRIVACY PRACTICES

Provider:

Thomas E. Thorsheim, Ph.D.

PAYMENT POLICY & FEE RATES

FEE SCHEDULE

Thomas E. Thorsheim, Ph.D.

Good Faith Billing Esimate

Items to consider - and if you'd like, to write about - prior to your first appointment.