Psychological Eval (CHI)

PSYCHOLOGICAL ASSESSMENT FORM

(CHI/Franciscan forms for bariatric procedure)
PLEASE NOTE THIS FORM MAY NOT LET YOU SIGN IN MOBILE VERSION ON A CELL PHONE- YOU MAY NEED TO VIEW IN DESKTOP VERSION ON YOUR PHONE OR USE LAPTOP TABLET OR PC

In office appointments:

Thank you for scheduling an in-office appointment for a psychological evaluation for your bariatric surgery.

This electronic paperwork must be completed at least 3 dyas before your appointmnet or your appointment will be canceled.

You must bring with your picture ID, your insurance card and your copay, if you have one.

If you would like to be put on a cancel list, please indicate in your email and this can only happen if we receive your paperwork asap.

Patients are responsible to call their own insurance to check if they have behavioral health for this visit.

If you are unable to keep your appointment, you must call us within 24 hours of appointment to cancel. You can call 253-268-3345.

If you do not make your appointment, you will be charged a $75 No-show fee automatically on the credit card added on file when the appointment was booked.

Sincerely,

The HorizonView Health Reception Staff

Address: 1408 3rd St SE Suite 200, Puyallup, WA 98372

Phone: 253-881-1490
PATIENT INTAKE FORM

Note: This form is HIPAA compliant and secure
Patient Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
SSN*
Preferred Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.
Alternative Phone
Please enter a valid phone number.
Email
example@example.com
Social Security #
Marital Status*

MarriedDivorcedSignificant OtherSingleWidowed
Legal Gender*

MaleFemale
Preferred Pronoun

HeSheThey
Referring Physician
Primary Physician (If not establishing care with HorizonView Health)
Patient Employed

EmployedRetiredOther
Employer
Occupation/Title
Responsible Party
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number.
Alternative Phone
Please enter a valid phone number.
Employer
Social Security Number
Date of Birth*

MonthDayYear
Date
Primary Insurance
Insurance Name/Type*
Subscriber Name*

First NameLast Name
Subscriber Phone*
Please enter a valid phone number.
Subscriber Date of Birth*

MonthDayYear
Date
Subscriber Employer
Relationship to Patient*
ID Number
Group Number
Secondary Insurance
Insurance Name/Type
Subscriber Name

First NameLast Name
Subscriber Phone
Please enter a valid phone number.
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Employer
Relationship to Patient
ID Number
Group Number
Emergency Contacts
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Notify on Hospital Submission*

YesNo
Secondary Emergency Contact (if applicable)
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Notify on Hospital Submission

YesNo
Patient Race
Hispanic

YesNo
My Personal Weight Journey
Take a moment to answer the following questions about your weight, motivations and challenges to help guide conversations with your health care professional about a weight-management plan that fits your lifestyle.
Personal Information
Name*

First NameLast Name
Weight: (lbs)*
Height: (ft/inches)*
What do you feel your weight may be holding you back from doing?
Approximately how much weight would you like to lose to help you reach your goals? (lbs)*
Weight-related conditions

Select which of the following conditions or diseases you have. Write in any prescription or over-the-counter products you are currently taking.

	Yes	Description
Sleep Disorders (eg. sleep apnea, insomnia)
Chronic Pain conditions (eg. arthritis)
Cardiovascular Disease
Respiratory Disease
Gastrointestinal Disorders (eg. liver problems)
Endocrine Disorders (eg. hormone)
Diabetes or prediabetes
Depression
Other:

*This is not a complete list of all possible weight-related conditions.
LIFE MILESTONES/EVENTS & WEIGHT

In the space provided, share any life events that relate to your weight loss or weight gain. Add any specifics you would like. (Possible life events may include: Special Occasions/events (eg. wedding, baby, class reunion, vacation) Home or work changes (eg. job change, divorce, personal loss, move) Health or medical changes (eg. nutritionist, injury, surgery, medication)

	When did this occur? (Age)	Event	How much weight did you lose/gain? (lbs)	What did you do to lose weight?	Would you do it again? (Y or N)
1.
2.
3.
4.

WEIGHT-LOSS/MANAGEMENT EFFORTS

How would you describe your efforts to lose or maintain weight? Please select all that apply.

	Tried in the Past	Doing it Now
Physical Activity
Healthy Eating
Over-the-counter products
Prescription Medication
Commercial weight-loss programs (eg. weight watchers)
Bariatric Surgery

How long have you been trying to lose weight?*

Less than 2 years2 - 4 Years5 - 9 YearsAs long as i can remember
CURRENT EATING & ACTIVITY ROUTINES
How would you describe your eating habbits? Please select all that apply.*

Eat 3 meals a dayEat more than 3 meals a dayFrequent snackerHealthy eaterBinge eaterEmotional EaterConstant DieterOther:

What approaches to healthy eating have you tried in the past? Select what worked or did not work for you.*

	Worked	Did not work	Have not tried
Limiting my portion size (eg. using a smaller plate)
Cooking meals at home
Using meal replacements
Avoiding sugary foods and drinks
Tracking activity and calories
Reading food labels
Other

Other (if filled in above)
Approximately how many minutes total per week do you spend doing physical activites such as going for a walk, cleaning the house, climbing stairs, light yard work, or biking*

60 min or less (1 hour)60 - 120 min (1 - 2 hours)120 - 180 min (2 - 3 hours)more than 180 min (3 hours)
Any other weight-related information your health care professional should know?
Patient Health Questionnaire
Name*

First NameLast Name

How often have you been bothered by any of the following:*

	Not at all	Several Days	Over half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling/staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself or that you are a failure, or let yourself or your family down
7.concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking slowly that others have noticed. Or the opposite, restless/fidgety more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way

If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery DifficultExtremely Difficult
Do you have thoughts of death or suicide?*

YesNo

How often have you been bothered by any of the following?*

	Not at all	Several days	Over half the days	Nearly every day
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worry
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult
Adverse Childhood Experience (ACE) Questionnaire

While you were growing up, during your first 18 years of life:*

	Yes	No
1. Did a parent or other adult in your house often swear at you, insult you, put you down, or humiliate you? OR Act in a way that made you afraid that you might be physically hurt?
2. Did a parent or other adult in your house often push, grab, slap or throw something at you? OR Ever hit you so hard that you had marks, bruises, or were injured?
3. Did any adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? OR Did anyone attempt to have oral, anal or vaginal intercourse with you?
4. Did you often feel like no one in your family loved you or thought you were important or special? OR Did you feel like your family members didn't look out for each other, didn't feel close to each other, and didn't support each other?
5. Did you often feel like you didn't have enough to eat, had to wear dirty clothes, or had no one to protect you? OR Were your parents ever too drunk or high to take care of you or take you to the doctor if you needed to go?
6. Were your parents ever separated or divorced?
7. Was your mother or step-mother often pushed, grabbed, slapped, or had something thrown at her? OR Sometiems, often or very often kicked, bitten hit with a fist, or hit with something hard? OR Ever repeatedly hit at least a few minutes or threatened with a gun or knife?
8. Did you live with anyone who was a problem drinker or alcoholic or used drugs on a regular basis?
9. Was anyone in your household depressed, mentally ill, or ever talked about or tried to commit suicide?
10. Did anyone in your household ever go to prison?

Consent of Treatment
CONSENT: I consent to medical services discussed and ordered by a physician and given by HorizonView Health. HorizonView Health may share health information about me, my guardian(s) or parent(s) to physicians and providers who treat me.

FINANCIAL AGREEMENT: I, the patient or guarantor, certify that the information provided is true to the best of my knowledge. I accept responsibility for the medical charges incurred by the patient and agree to pay all bills at the time of service unless arrangements are made. I authorize HorizonView Health, to release any information to process insurance claims. I also authorize my insurance claim to be paid directly to HorizonView Health.

RELEASE OF INFORMATION: I permit HorizonView Health to release information needed for eligibility and benefits, and to process claims for payments. I agree that all insurance payments be paid directly to HorizonView Health for services rendered.

By my signature below, I agree to the Consent of Treatment & have received the Notice of Privacy Practices of HorizonView Health.
Signature*

Clear
Date*

MonthDayYear
Date
Notice of Privacy Practices Acknowledgement
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and Privacy Practices with respect to PHI. We are required to abide by the terms of the Notice of Privacy Practices. We reserve the right to change the terms of the Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices upon request.
Signature*

Clear
Date*

MonthDayYear
Date
THERAPY LATE CANCELLATION AND NO-SHOW POLICY
This policy has been established to provide the highest level of counseling service to all our clients. It has been proven that consistent attendance provides for the greatest opportunity for success.

By providing us with enough notice of cancellation, we may be able to accommodate other clients with your appointment time. Please provide our office with a 24-hour notice to change or cancel an appointment.

Clients who do not provide a 24-hour notice to cancel or change a scheduled appointment will be responsible for a $75.00 late cancellation fee. This charge cannot be billed to insurance.

Clients that do not contact us and do not attend their scheduled appointments are considered no shows. A $75.00 no show fee will be charged. This charge cannot be billed to insurance. If you do no-show, the $75.00 will automatically be charged to the credit card on file.

When late cancellations and/or no shows become excessive, the therapist then has the right to terminate the relationship. Two no shows and/or late cancellations over the year would be considered excessive. This policy is effective January 1st, 2021. We do understand that emergencies arise and that it may not be possible to give such a notice. Exceptions to the late cancellation and no-show policy with be determined by our office.

I have read and understand this policy.
Signature

Clear
Date

MonthDayYear
Date
Telehealth Consent Form
A Telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment (Zoom). This consent is valid for all follow-up Telehealth services with HorizonView Health.

I understand that:

I can decline the Telehealth service at any time without affecting my right to future care or treatment.
If I decline the Telehealth services, the alternative option would be in-person services.
The same confidentiality protections that apply to my other medical care also apply to the Telehealth services.
I will have access to all medical information resulting from the Telehealth service as provided by law.
The information from the Telehealth service (images that can be identified as mine or other medical information from the Telehealth service) cannot be released to researchers or anyone else without my additional written consent.
I understand that my insurance will be billed for the telehealth services, and that I will be billed for what my insurance does not cover. By signing this consent, I am giving permission to release information to my insurance company or third-party payor for billing purposes.
I have read this document carefully, and my questions have been answered to my satisfaction. I understand this consent is valiid for all telehealth follow-ups at HorizonView Health.
Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian who signed (If not patient)

First NameLast Name
Should be Empty:

PSYCHOLOGICAL ASSESSMENT FORM

PATIENT INTAKE FORM

Responsible Party

Primary Insurance

Secondary Insurance

Emergency Contacts

Secondary Emergency Contact (if applicable)

My Personal Weight Journey

Personal Information

Weight-related conditions

LIFE MILESTONES/EVENTS & WEIGHT

WEIGHT-LOSS/MANAGEMENT EFFORTS

CURRENT EATING & ACTIVITY ROUTINES

Patient Health Questionnaire

Adverse Childhood Experience (ACE) Questionnaire

Consent of Treatment

Notice of Privacy Practices Acknowledgement

THERAPY LATE CANCELLATION AND NO-SHOW POLICY

Telehealth Consent Form