letter for new clientele - best life counseling … for new clientele dear client, welcome to the...
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LETTER FOR NEW CLIENTELE
Dear Client
Welcome to the practice of Best Life Counseling This letter is intended to inform you of current billing procedures Please feel free to discuss the information in this letter with your provider
Forms 0Payment This provider accepts the foUowing forms ofpayment Visa MasterCard Discover and Electronic Checks Please indicate your preferred form of payment on the Electronic Payment Authorization form The Electronic Payment Form will be securely stored in your clinical file and may be updated upon request at any time Your provider will deduct your session fees from the account designated on this form Please be aware that all transactions will read Therapy Partner Corporation on your bank or credit card statement Therapy Partner is the merchant who processes our credit card and e-check transactions
Monthly Statements Clients will receive monthly statements via email for all sessions attended within a calendar month Clients can also log into our billing system to generate and print statements for any time period by accessing the following web address httpwwwTherapyPartnercom If you would like access to your account history please notity your provider and a usemame and password will be emailed to you
Please feel free to discuss any billing matters with your provider
Sincerely
Heather Pugh CAP LMHC SAP Owner Best Life Counseling
Iherapy Partner
ELECTRONIC PAYMENT AUTHORIZATION
Please indicate the form of payment you wish to use for any services rendered through this practice The following forms of payment are accepted Visa MasterCard Discover American Express and Electronic Checks This information will be securely stored in your clinical file and may be updated upon request at any time Please be aware that transactions will appear as Therapy Partner on your bank or credit card statement
Contact Information
Client Name ___________________ Date of Birth ________
Address ____________ City_________ State _____ Zip ___
Home Number _____________ Mobile Number _____________
Email ______
Payment Type (check one)
CreditDebit Card ____ E-Check ___
CreditDebit Card Information
Card Type (circle one) Visa Mastercard Discover American Express
Card Number ____________________________
Expiration Date ______
-or-
Electronic Check Information
BankName __________________________
Routing Number ____________ Account Number ____________
Account Holder Information Please indicate the name and address associated with the credit card or bank account you wish to use
Name ______________________________
Address ______________ City_________ State ___ Zip _____
Signature of Client or Legal Guardian Date
Please return this form to your therapist
Best Life Counseling Financial Policy
The therapist at the Best Life Counselina wouJd like to welcome you to our PractKe We strive to provide you with excellent care and our goal is to IDIke your visits bull productive bull possible
By sipl below yOll COlI dult yoa bYe read tltis poIIcJ a Itt
bull It is your responsibility to inform our office ofany address or telepbone nmnber changes bull Your account is to be kept current - accordingly all self-pay or insunnce co-paymenII and deductibles
win be collected It the TIME OF SERVICE Payable by casb cbeck Viii MasteICanI Discover or American Expras-
bull Ifyou do not have your payment (5) your appointmcat may be resdIeduIecI NO SHOW FEES are $4000
bull A mumcd check will result in a S2S service cbarp and AU future peymeuIS beina required in the fonn ofcash or credit card and the payment ofthe monies owed You may recciw reftmds ifyou have a credit balance
bull You will only be sent a staIanCnt Ifyou are owed 1JIOIJeY reftmds will be issuod within 4-6 weeks fiom the date requested ifthere are DO pendina insurance claims
bull There is a In cbarae for Ibe completion ofpaperwork(ex disability FMLA etc) This needs to be paid prior to paperwork beina done
bull Any unpaid baIances older than 30 days may be subject to 1S percent interest per moodt bull Ifyour ICCOUIIt is turned over to a collection agency you will be responsible for any cosII incurred in
collection ofsaid balance which may include collection agency fees up to 60 penent ofyour outstandina balance court costs and aUomey fees
bull Ifl need to go to court the fee is SISO per hoW and may be billed It that nde as well We require a retainer fee ofSI 00 up fiont
bull [fphone calls beyond 1S minutes you will be billed for a tbenpy sessioa
Iya Yruce ccwerqe
We wiD submit your claims however we ell tItat latl pnwlden oar Ip II witll yoa I5Il YOllr iasaruee eompaay Althouah we attempt to veritY yourbeuefits with your insurance policy please be advised this is only an estinude ofyour coverage tscd OIl the information given to 111 at tile time of the inquiJy By sip below ya COlI tllat yCHI ulldentalld bull It is your responsibility to inform 111 ofany cbanps to your insunnce policy so that your coverage caD be reshy
verified prior to your appointment bull Ifyour insunInce poJicy requires a referral ampom your prinwy care physic_ it is your responsibiJity to have
that referral faxed to our office prior to your appointment bull Not ail services are covered beDefi1l with a1J insurance p bull It is your responsibility to be aware ofwhat service (s) is beinsprovided to you and if it is a covered benefit
We realize dull temporary financial problans may affect timely payment ofyow account Ifsuch problems do arise we urge you to CODtICt us promptly for assistance in tile IIIIIIIpIDCIIt o(your accoUnt Ifyou have any questions about the above information PLEASE do DOt hesnre to ask We are here co heiR you
I have read and understand the above FillMCiai Policy and agree to meet all financial obliptions
Patient Name (PRINn Patient SipllUre
Responsible Party (PRJNn Responsible Party Signature
Therapist Name (PRlNn Therapist Signature Date
Client Intt)mlalion and Consent
rherapist
Ih~ undersigrnd is a licenSld Mental Jlealtb professional or chemical dejlndency counselor in priate practice proiding mental health care srvices to clients directly and as iUI indcpt-ndent contmclorpro iJer ti)r aril1us managed care -I1tiries In addition the undersigned thempist provides all mental health serv ices through Rest life (middotounseling
While il may not be easy to scek help from a mental health professional it is hoJkd that you will he bener ahle to UikJerstand your situation and feelings and move fi)foard resolving lour difficulties (he therapist using her knowledge of human developmtI1t and behavior wilJ make obsenations about situations as well as suggestions for new ways 10 approach them It will be important for you to explore your own feelings and thOUghts and to try new approaches in order for change to occur You may bring OIber tamily members to a therapy session if yuu teel it would be helpful or ifthis is recommended by your thempist
AppoiRttReDts
Appoinbnents are made by calling (727) 5~ Monday through friday between the hours uf900 am and 500pm Please call to cancel or reschedule at 1east4 hours in advance or yuu will be charged tor the missed appointment Third-party payments will not usually cover or reimburse for missed appointments rhe NO SHOW fee is $4000 We require a cmJit card rhat will be billed ifyou do not show for your
appointment
Number or Visits
The number ofsesions nceded depends on many factors and will be discussed by the therapist
Length or Visits
l1Jerapy sessions are 45 minutes in lengthThe initial therapy session is I liz - 2 hours
Relatioasbip
Your relationship with the therapist is a professional and therapeutic relationship In order to preserve this relationship it is imperative rhat the therapist not have any other type of relationship with )011 Personal mdor business relationships undermine the effectiveness ufthe therapeutic relationship The therapist cares about helping you bul is not in a positioo to be your ftiend or tu have a social or personal relationship ~ith you
Gills bart~ring and trclding srvices are nut appropriate iUId should not ~ shared bctw-gten you and lhe thempist
Cancellations
(an~dlations must be nlcid af least ~4 hours bertFe our sheduled appuintment othcise yOU WIU BE tUARGIO the cUSlonlaJ) fe ofstoOO lOr (hal missed appointment You are r-(loosible It calling tn cancel or reschedule your appointment We will give OU 24 hours after the NO SHOW to call and give the rcaooning tOr (he NO SII()W bciraquore charging )(JU
Pa~ment ror ~nkes
If )OU -cllpa) the charge fUr our inilial sion is SI2500 and Ilk charge liw an qucnt 4-ions is
bull
$10000 The undersigned therapist does accept assignment of insurance ~nctits The undersigned therapist ill look to )0 ou for full paYffiCnt ofour account and you 0 ill ~ responsible for paymlnt ofall charges DifTen-nt co-pa)-ffiCnts are Rquired by arious group coverage plans Your co-pa)-ment is based 1Il the mental health policy selected by your employer or purchased by ou In addition the co-pay portion dfthe undersigned therapists charges for services at the time ofsenHCS are provided It is recommended that you detennine your co-pa ments before your tirst visit by calling yout ~fits ofttce or insurdnce company
lthough it is the goal ofthe undersigned therapist to protect the confidentiality ofour records there may ~ times when disclosure ofyour records or testimony will be compelled by law Confidentiality and exceptions to confidenliality are discussed below In the event disclosure ofyour records or testimony is required by law you will be responsible for and shall pay the (osts involved in producing the records and the thlrapists nonnal hourly rate tOr the time involved in preparing for and giving testimony Such pay ments are to be made at the time or prior to the time the services are rendered by the therapist
Conrldentiality
Discussions between a therapist and a client are confidential No information will be released without the clients written consent unless mandated by law Possible exceptions to confidentiality include but are not limited to the following situations Child abuse abuse of the elderly or disabled abuse ofcriminal prosecutions child custody cases suits in which the mental health ofa party is in issue situations where the therapist has a duty to disclose or where in the therapists judgment it is necessary to wam or disclose fee disputes between the therapist and the client a negligence suit brought by the client against the therapist or the filing ofa complaint with the licensing board Ifyou have any questions regarding confidentiality you should bring them to the attention ofthe therapist when you and the therapist discuss this matter further By signing this intOrmation and consent form you are giving your consent to the tmdersigned therapist to share confidential infonnation with all persons mandated by law and with the agency that refernd you and the managed care companyandor insurance carrier responsible for providing your mental health careservices and payment for those services and you are also releasing and holding harmless the undersigned therapist 1T0m any departure from your right to confidentiality that may result In couples or family therapy confidentiality does not apply and the thenipist will use there clinical judgment when sharing infonnation
You have the right to review your chart according toState Law
If I see in the community I wiIJ not approach you (as ifcould breach confidentiality) Ifyou want to say hello please feel free to approach me However please understand I will probably not he able to spend much time talking to you Thanks for your consideration In addition you may bump into someone you know in the waiting room This may be unavoidable Please let me know if this occurs and how you feel about it
If you cannot he reached a message will be left such as - This is Heather fiom Heather PupS otTree and I m oalling formiddotmiddot Your Name Please initial the circumstance under whichou wish to he contacted
00 not contact me under any circumstances Yes )oU may contact me a described above YS contact me but only under these circumstances
Please describe conditions
IIndcrslmd (he ilhove intOrmatilaquom - - - --- -~
Signature ofPatientParent Date
Duty to Warn
to myselfor another person I ipaifically consent for the therapist to wam the person in danger and (0
wntact6 the following persons in aJdition to m~tIical and law enf(rc~t pelStmnc
~rME TELEPHONE NUMBER
I consent t(lr the undersigned therapist to communicate with me by mail and by phone at the following addresses and phone numbers and I will IMMEOIATELY advise the lherdpist in the event ofany changtS
ADDRESS fELEPHONE NUMBER
Risks of Thenpy
Therctpy is the Greek woro tor change You may learn things about yourself that you dont like Often growth cannot occur until you experience and confront issues that induce you to feel sadness sorrow anx iety or pain The success ofour work togedter depends on the quality of the efforts on both our parts and the alization that you are ~ible for lifestyle choiceschanges that may result fiom lhcrapy Specifically one risk ofmartial dterapy is fhe possibility ofexercising the divorre option - shy
Completion ofassignmentsreadings ~een therapy sessions will help therapy be more effective In addition within a reasonable period oftime after beginning treatmentbull I will discuss with you my unders1anding of the problem treatment Ifyou have any unanswered questions about any of the procedures used in the course of therapy their possible risks please ask and you will be answered fully You also have the right to ask about other treabneflts for your condition and their risks and benelits Ifyou could benefit from any treatment thai I do not provide I have an ethical obligalion to assist you in obtaining those treatments
Atlr the lirst couple meeting I will assess if I can be of benefit to you I do not accept clients who in m) )pinion I cannot help In such a case I will give you a number of referrals that you can contactI Ifat any point during ps)chotherclpY I assess that I am not being effective in helping you reach the cherapeutic goals am obligated to discuss it with you and ifappropriate to terminate treatment In such a case I till give )OU a number ofrcfcrrals that may be of help to you (f)ou quest it and authorize it in wriling
flu-Houn Fmergendes
A mental health professional or ()ur therapist is on call when your therapists otTrce is closed and can be reached for emergencitS on a twenty-ftlUf huur seven days plr wtCk basis by calling (727) 7middotU-8u6 fmrgencitS are urgent issues requiring immediate ion Please call 91 I or go to the Emergency Room if uicidal or homicidal
If the therapist does ntCd to return our phone and the call goes beyond 15 minutes you will be billed flr a therclp) session Ifit is not an emergency you may email the OllCf Heat~-r Pugh CAP SAP IMHC at
I admm Itdgc that in the cImiddotnl Ihe unckrsigncd Ihtmpsl -lUnKS incltlpacilatCI fir dies it ill htlumc
n~cSsaJ) tor anoth~r therapist to take possession ofmy tile and recurus 8) signing this information imJ consent fonn I give my consent to allo~ing another licensed mntal heahh professional selected by the undersigned titerdpist to take possession ofmy tile and records and provide me ~ith copitos upon request or ro deliver tikm to a tikrapist of my choice
llisputn
11 disputes arising out ofor in relation to this agreement to provide ps)chothcrapy services shall first be referred to mediation before and as a precondition of the initiation ofarbitration rhe mediator shall he neutral party chosen by agreement oHleather Pugh MACAP tMUG ()tner and client (s) rhe cost of I~iation bull ifany shall be split equally unless otherwise ~ed
Consenl to TreatlR~Dt
I voluntarily agree to receive Mental Health assessment care tniltment or services and authorize the undersigned therapist to provide such care treatment or services as are considered necessary and advisable
I unJerstand and agree that I will participate in the planning ofmy care lrealment or services and that I rna) stop such care treatment or services that I receive through the undersigned therapist at any time
R) signing this Client Information and Consent Fnnn I the undersigned client acknowledge that I have been both read and understood all the terms and infonnation contained herein Ample opportunity has been otTered to me to ask questions and seek clarification ofanything unclear to me
ClientiParent Date
-~----------------------------____------------------- ----_ _--__--shySocial Security Number and Address
As witnessed by
--
Tikrapists Name
Best Life Counseling Notice ofPrivacy Practices
THIS NOTICE DESCTIBES HOW UElJlCAL INFORMATION ABOUT rouJlArBE USED AND DISCLOSED AND HOW YOU CAN GETACC~TO THIS INFORMATION PlEASEREYlEW ITCAREFUUY
USt Life Ccu~ is ftqUired by Jaw to maiDIaiD the prMcyofarIaiII balIh QR infCW1Dlldioo about our pIIlients The Law RICpIifts be notified ofthese sIaidads As a part ofoufday-fo-day activities Boest Life ~ay need to use and disclose (sI8e) )OUr protected health
QIC irtfiJrm8Ja SCVCDI purposes witbouI6ntJOUI writIalllplllOftl 11IoIe pIII)ICIIICS iodade bull Boest Life cOampuueUM9 opaaliuns F_eaapIe_ Boest Life CDw~SIIIf_disuss)OUr
conditian in onIer to pnwide proper iii bull est Life ~ ayCODIalupoa JOUI Ilaquodtd balIh cm ida FarcumpIc ~t
Life ~may cd to amage JOUI pnwide with iDfia IRaIIPlt benefits and services that ~ aYaiIabIe to you
amptst Life CDft-seli~ may provide inNuU8Iion to govcmmcnt omaJs who owrsee health care _ thtaIIs to public
safety
No other uses and disdosuns of)OUr)llUkctal haIIIII cc infiIIwiD occur without your wriUaJ autborizIItion Moroovcr ifyou sign such IIIICI audIorizaIioo you have the right to ameI it111 any time YOfU6z- I yftIllalalHallllCMIIIIJM t UodIpoundthelawyoubaYcsevcndrigbls ~t
Ltfe ~ is committed to upIaolcIioamp Those tipIs indude bull The right to RJqUCSl RSbidioos OIl some ofthe waysSest Life CDftM5dl~ usesdi9cl6suns JOUI information
Best Life ~ may DOl always IIJPC ID imp or these additional restridioas bull The rigbt to l1XlCiw confidential COO-bullbullicItions WIUIeSest Life ~ QIIIIGI promise ID communicate
ill every possible way requested 1K wiD wort willi to find lIIICIccptablc WIIJ to QIImnfidcntjaIly bull The rigbt to inspect and get copies ofheaIdt ce iuiNiiiiIliIIo held by Ee5t Life CDw~ by making a
request in writing Best Life ~ bowewr may ctrc a aurabIc_ to covcr only the cOst of providing this infiJrmIItioo
bull The right 10 request Ee5t Life ~ amend 01 conect infiItUllllliua about)OlL To make bull dBIge will be nquiml to nqucst in writinamp indIidiog die RBJll you MIll JOUI raunI dwnppI Sest Life ~ may not always agnc to suck nquesIS
The rigbl to a list ofSest ufe ~ disclosuns that wac not auIborilJId by you and the discIosuns wac unrelated to bCllbOCDl or opendions Ifyou have any questions _ alIIIpIaiDIs about the WIIJSest Life ~~ JOUI aIICdod QR
information or if belieyene your privacy right have beat vioIaIaI COI1Iad the sest Life ~ PrMcy Officer (Heather Pugb CAP LMHC SAP) III 727-S46-64000I inpcrson Voucan aIsoCODlaltheSectday oftbc US DepaatnllCOl ofHealth and HUDIIID SeIYica Please DOII ~will be 110 maJiatioa filing a complaint 01 making rcquem rcgadiog your beabh care iDfonnIIIion _ for dis8gmeinamp withSest Life ~~ shyrelated decisions
Notice ofPrivacy Practices Ackftowkdarme ofRaxipt I received copy of~t Life CDft~ s Notice of Privacy PIadices I uadaSUIMI that ifsest Life ~
uses my personal hcaIdI information in a IIIIIIIIlCr IhIIl is diftilCIIl dtaaibcrcl by the NCJIia ~ Life CDftseli~
must Iirsl get my permission in writing I am aaepIing this Notice OIl behIIIfof o Myself o Another person as his _ her personal representalive (perent guardian family member de)
PritNPa~_____________________________________________________
Prit NuIe fPet ~ (ifapplicable)_______________________________
Sipaanfll~ 111_____________________IWe~________
Ptgtt Li(t ~
Best Life Counseling Adult Personal History
Client ~--_____________ Date _____
First MI Phone ~______ Cell phone-_______
Address--____________________ City State___ Zip____
Social Searity Number_____ SpouseISignificont other Social SearitY----shyBirthplace Spouses Birthploce ____ [)ate of Birth Spouses dote of Birth--____ Email Address____________________ Why are you seeking counseling_________________________
MaritallFamily
of Full Siblings of Half Siblings __ Birth order Age _--_
Single ~ Married Separated DWorced _ Widowed Living Together Caucasian African-American HispanicILatin t-taaiianlPacific Islander
Multi-Rocial ~ Asian Other Native American- Hetro-Sexuol Homosexual ampi-Sexual Other Mother OcalpCltion________________
Age Is there CI contoct__ History of Mental Iliness__________________________ History of AlcoholDrug ______--____________________
Camments_______________________________
Father ____________ O~ion----------------
Age_____ Is there a contoct __ History of Mental Iliness__________________________ History of AlcoholDrug ___________________________
COm~--_________________________________
CurTcnt Si1uation
Who do you ive with____________________________ Where do you work ________ Whot is yCQ job_______________ Where does Spouse work_________________ What is there job____ Full or Port time____________ What other jobs have you had_________________________
A~~k~b~----------------------------
Have you lived anywhere else other than your curnnt residence If so please explainlt--_______
Family History
Do you hcIft any children or stepchildren If $0 pIeast give names and ~~____________
Lowe Socioeconomic Class Middlt Closs Upper Closs Alcoholic OIootic Distant Abusivle Controlling
Family Mental HeolthlAddictionlAlcoholiSlft History ____________________
Is there anyone in yow fCllftily you do not ~ contact with If $0 with whom___________
Who was in your fCllftily while you where growing up___________________
Wh~~~MW---------------------------------------
Educatianal I Social HistaI
Eosily forms friendships Attatcis social functions Needs social inta-oction Maintains friendships o Avoids social functions
00 Supportive Fritmds No close friends
How close friends do you ~____ Eementcry 0 Middlt School - High School Bochelor [)octorol ampED
0Some College Good Student IeGrrUng DtSobilities-____ ExtroaaTiculor Activities Avg Student Poor Student Regular Special Education0
Sports Advanced CIossa School Behavicrs (Childhoad)
Tnxny Argumentative Fighting with Peers Poor Effort Attenfive Repeated Grades Expulsions Susplmsions00
Difficulty with Peers Who do you turn to for support in your lif8______________________
~-----------------------------------------
Ctrrenf Employu______________________
GoodWorkHx PoorWorkHx On Sick leove
What is your financial situotion _____________________________
Military History
No Military Hx Spouse in Militcry Raised in Military Family Army Navy Air Force Marines Other _____________
Dotes of 5avice I I to I I Honorablt Dishonorable Medicof Service Related Disability AWOL Txt at VA Hospital
ComrRellts (list combat dates if opplicabI-)___________---___________
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
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No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
Iherapy Partner
ELECTRONIC PAYMENT AUTHORIZATION
Please indicate the form of payment you wish to use for any services rendered through this practice The following forms of payment are accepted Visa MasterCard Discover American Express and Electronic Checks This information will be securely stored in your clinical file and may be updated upon request at any time Please be aware that transactions will appear as Therapy Partner on your bank or credit card statement
Contact Information
Client Name ___________________ Date of Birth ________
Address ____________ City_________ State _____ Zip ___
Home Number _____________ Mobile Number _____________
Email ______
Payment Type (check one)
CreditDebit Card ____ E-Check ___
CreditDebit Card Information
Card Type (circle one) Visa Mastercard Discover American Express
Card Number ____________________________
Expiration Date ______
-or-
Electronic Check Information
BankName __________________________
Routing Number ____________ Account Number ____________
Account Holder Information Please indicate the name and address associated with the credit card or bank account you wish to use
Name ______________________________
Address ______________ City_________ State ___ Zip _____
Signature of Client or Legal Guardian Date
Please return this form to your therapist
Best Life Counseling Financial Policy
The therapist at the Best Life Counselina wouJd like to welcome you to our PractKe We strive to provide you with excellent care and our goal is to IDIke your visits bull productive bull possible
By sipl below yOll COlI dult yoa bYe read tltis poIIcJ a Itt
bull It is your responsibility to inform our office ofany address or telepbone nmnber changes bull Your account is to be kept current - accordingly all self-pay or insunnce co-paymenII and deductibles
win be collected It the TIME OF SERVICE Payable by casb cbeck Viii MasteICanI Discover or American Expras-
bull Ifyou do not have your payment (5) your appointmcat may be resdIeduIecI NO SHOW FEES are $4000
bull A mumcd check will result in a S2S service cbarp and AU future peymeuIS beina required in the fonn ofcash or credit card and the payment ofthe monies owed You may recciw reftmds ifyou have a credit balance
bull You will only be sent a staIanCnt Ifyou are owed 1JIOIJeY reftmds will be issuod within 4-6 weeks fiom the date requested ifthere are DO pendina insurance claims
bull There is a In cbarae for Ibe completion ofpaperwork(ex disability FMLA etc) This needs to be paid prior to paperwork beina done
bull Any unpaid baIances older than 30 days may be subject to 1S percent interest per moodt bull Ifyour ICCOUIIt is turned over to a collection agency you will be responsible for any cosII incurred in
collection ofsaid balance which may include collection agency fees up to 60 penent ofyour outstandina balance court costs and aUomey fees
bull Ifl need to go to court the fee is SISO per hoW and may be billed It that nde as well We require a retainer fee ofSI 00 up fiont
bull [fphone calls beyond 1S minutes you will be billed for a tbenpy sessioa
Iya Yruce ccwerqe
We wiD submit your claims however we ell tItat latl pnwlden oar Ip II witll yoa I5Il YOllr iasaruee eompaay Althouah we attempt to veritY yourbeuefits with your insurance policy please be advised this is only an estinude ofyour coverage tscd OIl the information given to 111 at tile time of the inquiJy By sip below ya COlI tllat yCHI ulldentalld bull It is your responsibility to inform 111 ofany cbanps to your insunnce policy so that your coverage caD be reshy
verified prior to your appointment bull Ifyour insunInce poJicy requires a referral ampom your prinwy care physic_ it is your responsibiJity to have
that referral faxed to our office prior to your appointment bull Not ail services are covered beDefi1l with a1J insurance p bull It is your responsibility to be aware ofwhat service (s) is beinsprovided to you and if it is a covered benefit
We realize dull temporary financial problans may affect timely payment ofyow account Ifsuch problems do arise we urge you to CODtICt us promptly for assistance in tile IIIIIIIpIDCIIt o(your accoUnt Ifyou have any questions about the above information PLEASE do DOt hesnre to ask We are here co heiR you
I have read and understand the above FillMCiai Policy and agree to meet all financial obliptions
Patient Name (PRINn Patient SipllUre
Responsible Party (PRJNn Responsible Party Signature
Therapist Name (PRlNn Therapist Signature Date
Client Intt)mlalion and Consent
rherapist
Ih~ undersigrnd is a licenSld Mental Jlealtb professional or chemical dejlndency counselor in priate practice proiding mental health care srvices to clients directly and as iUI indcpt-ndent contmclorpro iJer ti)r aril1us managed care -I1tiries In addition the undersigned thempist provides all mental health serv ices through Rest life (middotounseling
While il may not be easy to scek help from a mental health professional it is hoJkd that you will he bener ahle to UikJerstand your situation and feelings and move fi)foard resolving lour difficulties (he therapist using her knowledge of human developmtI1t and behavior wilJ make obsenations about situations as well as suggestions for new ways 10 approach them It will be important for you to explore your own feelings and thOUghts and to try new approaches in order for change to occur You may bring OIber tamily members to a therapy session if yuu teel it would be helpful or ifthis is recommended by your thempist
AppoiRttReDts
Appoinbnents are made by calling (727) 5~ Monday through friday between the hours uf900 am and 500pm Please call to cancel or reschedule at 1east4 hours in advance or yuu will be charged tor the missed appointment Third-party payments will not usually cover or reimburse for missed appointments rhe NO SHOW fee is $4000 We require a cmJit card rhat will be billed ifyou do not show for your
appointment
Number or Visits
The number ofsesions nceded depends on many factors and will be discussed by the therapist
Length or Visits
l1Jerapy sessions are 45 minutes in lengthThe initial therapy session is I liz - 2 hours
Relatioasbip
Your relationship with the therapist is a professional and therapeutic relationship In order to preserve this relationship it is imperative rhat the therapist not have any other type of relationship with )011 Personal mdor business relationships undermine the effectiveness ufthe therapeutic relationship The therapist cares about helping you bul is not in a positioo to be your ftiend or tu have a social or personal relationship ~ith you
Gills bart~ring and trclding srvices are nut appropriate iUId should not ~ shared bctw-gten you and lhe thempist
Cancellations
(an~dlations must be nlcid af least ~4 hours bertFe our sheduled appuintment othcise yOU WIU BE tUARGIO the cUSlonlaJ) fe ofstoOO lOr (hal missed appointment You are r-(loosible It calling tn cancel or reschedule your appointment We will give OU 24 hours after the NO SHOW to call and give the rcaooning tOr (he NO SII()W bciraquore charging )(JU
Pa~ment ror ~nkes
If )OU -cllpa) the charge fUr our inilial sion is SI2500 and Ilk charge liw an qucnt 4-ions is
bull
$10000 The undersigned therapist does accept assignment of insurance ~nctits The undersigned therapist ill look to )0 ou for full paYffiCnt ofour account and you 0 ill ~ responsible for paymlnt ofall charges DifTen-nt co-pa)-ffiCnts are Rquired by arious group coverage plans Your co-pa)-ment is based 1Il the mental health policy selected by your employer or purchased by ou In addition the co-pay portion dfthe undersigned therapists charges for services at the time ofsenHCS are provided It is recommended that you detennine your co-pa ments before your tirst visit by calling yout ~fits ofttce or insurdnce company
lthough it is the goal ofthe undersigned therapist to protect the confidentiality ofour records there may ~ times when disclosure ofyour records or testimony will be compelled by law Confidentiality and exceptions to confidenliality are discussed below In the event disclosure ofyour records or testimony is required by law you will be responsible for and shall pay the (osts involved in producing the records and the thlrapists nonnal hourly rate tOr the time involved in preparing for and giving testimony Such pay ments are to be made at the time or prior to the time the services are rendered by the therapist
Conrldentiality
Discussions between a therapist and a client are confidential No information will be released without the clients written consent unless mandated by law Possible exceptions to confidentiality include but are not limited to the following situations Child abuse abuse of the elderly or disabled abuse ofcriminal prosecutions child custody cases suits in which the mental health ofa party is in issue situations where the therapist has a duty to disclose or where in the therapists judgment it is necessary to wam or disclose fee disputes between the therapist and the client a negligence suit brought by the client against the therapist or the filing ofa complaint with the licensing board Ifyou have any questions regarding confidentiality you should bring them to the attention ofthe therapist when you and the therapist discuss this matter further By signing this intOrmation and consent form you are giving your consent to the tmdersigned therapist to share confidential infonnation with all persons mandated by law and with the agency that refernd you and the managed care companyandor insurance carrier responsible for providing your mental health careservices and payment for those services and you are also releasing and holding harmless the undersigned therapist 1T0m any departure from your right to confidentiality that may result In couples or family therapy confidentiality does not apply and the thenipist will use there clinical judgment when sharing infonnation
You have the right to review your chart according toState Law
If I see in the community I wiIJ not approach you (as ifcould breach confidentiality) Ifyou want to say hello please feel free to approach me However please understand I will probably not he able to spend much time talking to you Thanks for your consideration In addition you may bump into someone you know in the waiting room This may be unavoidable Please let me know if this occurs and how you feel about it
If you cannot he reached a message will be left such as - This is Heather fiom Heather PupS otTree and I m oalling formiddotmiddot Your Name Please initial the circumstance under whichou wish to he contacted
00 not contact me under any circumstances Yes )oU may contact me a described above YS contact me but only under these circumstances
Please describe conditions
IIndcrslmd (he ilhove intOrmatilaquom - - - --- -~
Signature ofPatientParent Date
Duty to Warn
to myselfor another person I ipaifically consent for the therapist to wam the person in danger and (0
wntact6 the following persons in aJdition to m~tIical and law enf(rc~t pelStmnc
~rME TELEPHONE NUMBER
I consent t(lr the undersigned therapist to communicate with me by mail and by phone at the following addresses and phone numbers and I will IMMEOIATELY advise the lherdpist in the event ofany changtS
ADDRESS fELEPHONE NUMBER
Risks of Thenpy
Therctpy is the Greek woro tor change You may learn things about yourself that you dont like Often growth cannot occur until you experience and confront issues that induce you to feel sadness sorrow anx iety or pain The success ofour work togedter depends on the quality of the efforts on both our parts and the alization that you are ~ible for lifestyle choiceschanges that may result fiom lhcrapy Specifically one risk ofmartial dterapy is fhe possibility ofexercising the divorre option - shy
Completion ofassignmentsreadings ~een therapy sessions will help therapy be more effective In addition within a reasonable period oftime after beginning treatmentbull I will discuss with you my unders1anding of the problem treatment Ifyou have any unanswered questions about any of the procedures used in the course of therapy their possible risks please ask and you will be answered fully You also have the right to ask about other treabneflts for your condition and their risks and benelits Ifyou could benefit from any treatment thai I do not provide I have an ethical obligalion to assist you in obtaining those treatments
Atlr the lirst couple meeting I will assess if I can be of benefit to you I do not accept clients who in m) )pinion I cannot help In such a case I will give you a number of referrals that you can contactI Ifat any point during ps)chotherclpY I assess that I am not being effective in helping you reach the cherapeutic goals am obligated to discuss it with you and ifappropriate to terminate treatment In such a case I till give )OU a number ofrcfcrrals that may be of help to you (f)ou quest it and authorize it in wriling
flu-Houn Fmergendes
A mental health professional or ()ur therapist is on call when your therapists otTrce is closed and can be reached for emergencitS on a twenty-ftlUf huur seven days plr wtCk basis by calling (727) 7middotU-8u6 fmrgencitS are urgent issues requiring immediate ion Please call 91 I or go to the Emergency Room if uicidal or homicidal
If the therapist does ntCd to return our phone and the call goes beyond 15 minutes you will be billed flr a therclp) session Ifit is not an emergency you may email the OllCf Heat~-r Pugh CAP SAP IMHC at
I admm Itdgc that in the cImiddotnl Ihe unckrsigncd Ihtmpsl -lUnKS incltlpacilatCI fir dies it ill htlumc
n~cSsaJ) tor anoth~r therapist to take possession ofmy tile and recurus 8) signing this information imJ consent fonn I give my consent to allo~ing another licensed mntal heahh professional selected by the undersigned titerdpist to take possession ofmy tile and records and provide me ~ith copitos upon request or ro deliver tikm to a tikrapist of my choice
llisputn
11 disputes arising out ofor in relation to this agreement to provide ps)chothcrapy services shall first be referred to mediation before and as a precondition of the initiation ofarbitration rhe mediator shall he neutral party chosen by agreement oHleather Pugh MACAP tMUG ()tner and client (s) rhe cost of I~iation bull ifany shall be split equally unless otherwise ~ed
Consenl to TreatlR~Dt
I voluntarily agree to receive Mental Health assessment care tniltment or services and authorize the undersigned therapist to provide such care treatment or services as are considered necessary and advisable
I unJerstand and agree that I will participate in the planning ofmy care lrealment or services and that I rna) stop such care treatment or services that I receive through the undersigned therapist at any time
R) signing this Client Information and Consent Fnnn I the undersigned client acknowledge that I have been both read and understood all the terms and infonnation contained herein Ample opportunity has been otTered to me to ask questions and seek clarification ofanything unclear to me
ClientiParent Date
-~----------------------------____------------------- ----_ _--__--shySocial Security Number and Address
As witnessed by
--
Tikrapists Name
Best Life Counseling Notice ofPrivacy Practices
THIS NOTICE DESCTIBES HOW UElJlCAL INFORMATION ABOUT rouJlArBE USED AND DISCLOSED AND HOW YOU CAN GETACC~TO THIS INFORMATION PlEASEREYlEW ITCAREFUUY
USt Life Ccu~ is ftqUired by Jaw to maiDIaiD the prMcyofarIaiII balIh QR infCW1Dlldioo about our pIIlients The Law RICpIifts be notified ofthese sIaidads As a part ofoufday-fo-day activities Boest Life ~ay need to use and disclose (sI8e) )OUr protected health
QIC irtfiJrm8Ja SCVCDI purposes witbouI6ntJOUI writIalllplllOftl 11IoIe pIII)ICIIICS iodade bull Boest Life cOampuueUM9 opaaliuns F_eaapIe_ Boest Life CDw~SIIIf_disuss)OUr
conditian in onIer to pnwide proper iii bull est Life ~ ayCODIalupoa JOUI Ilaquodtd balIh cm ida FarcumpIc ~t
Life ~may cd to amage JOUI pnwide with iDfia IRaIIPlt benefits and services that ~ aYaiIabIe to you
amptst Life CDft-seli~ may provide inNuU8Iion to govcmmcnt omaJs who owrsee health care _ thtaIIs to public
safety
No other uses and disdosuns of)OUr)llUkctal haIIIII cc infiIIwiD occur without your wriUaJ autborizIItion Moroovcr ifyou sign such IIIICI audIorizaIioo you have the right to ameI it111 any time YOfU6z- I yftIllalalHallllCMIIIIJM t UodIpoundthelawyoubaYcsevcndrigbls ~t
Ltfe ~ is committed to upIaolcIioamp Those tipIs indude bull The right to RJqUCSl RSbidioos OIl some ofthe waysSest Life CDftM5dl~ usesdi9cl6suns JOUI information
Best Life ~ may DOl always IIJPC ID imp or these additional restridioas bull The rigbt to l1XlCiw confidential COO-bullbullicItions WIUIeSest Life ~ QIIIIGI promise ID communicate
ill every possible way requested 1K wiD wort willi to find lIIICIccptablc WIIJ to QIImnfidcntjaIly bull The rigbt to inspect and get copies ofheaIdt ce iuiNiiiiIliIIo held by Ee5t Life CDw~ by making a
request in writing Best Life ~ bowewr may ctrc a aurabIc_ to covcr only the cOst of providing this infiJrmIItioo
bull The right 10 request Ee5t Life ~ amend 01 conect infiItUllllliua about)OlL To make bull dBIge will be nquiml to nqucst in writinamp indIidiog die RBJll you MIll JOUI raunI dwnppI Sest Life ~ may not always agnc to suck nquesIS
The rigbl to a list ofSest ufe ~ disclosuns that wac not auIborilJId by you and the discIosuns wac unrelated to bCllbOCDl or opendions Ifyou have any questions _ alIIIpIaiDIs about the WIIJSest Life ~~ JOUI aIICdod QR
information or if belieyene your privacy right have beat vioIaIaI COI1Iad the sest Life ~ PrMcy Officer (Heather Pugb CAP LMHC SAP) III 727-S46-64000I inpcrson Voucan aIsoCODlaltheSectday oftbc US DepaatnllCOl ofHealth and HUDIIID SeIYica Please DOII ~will be 110 maJiatioa filing a complaint 01 making rcquem rcgadiog your beabh care iDfonnIIIion _ for dis8gmeinamp withSest Life ~~ shyrelated decisions
Notice ofPrivacy Practices Ackftowkdarme ofRaxipt I received copy of~t Life CDft~ s Notice of Privacy PIadices I uadaSUIMI that ifsest Life ~
uses my personal hcaIdI information in a IIIIIIIIlCr IhIIl is diftilCIIl dtaaibcrcl by the NCJIia ~ Life CDftseli~
must Iirsl get my permission in writing I am aaepIing this Notice OIl behIIIfof o Myself o Another person as his _ her personal representalive (perent guardian family member de)
PritNPa~_____________________________________________________
Prit NuIe fPet ~ (ifapplicable)_______________________________
Sipaanfll~ 111_____________________IWe~________
Ptgtt Li(t ~
Best Life Counseling Adult Personal History
Client ~--_____________ Date _____
First MI Phone ~______ Cell phone-_______
Address--____________________ City State___ Zip____
Social Searity Number_____ SpouseISignificont other Social SearitY----shyBirthplace Spouses Birthploce ____ [)ate of Birth Spouses dote of Birth--____ Email Address____________________ Why are you seeking counseling_________________________
MaritallFamily
of Full Siblings of Half Siblings __ Birth order Age _--_
Single ~ Married Separated DWorced _ Widowed Living Together Caucasian African-American HispanicILatin t-taaiianlPacific Islander
Multi-Rocial ~ Asian Other Native American- Hetro-Sexuol Homosexual ampi-Sexual Other Mother OcalpCltion________________
Age Is there CI contoct__ History of Mental Iliness__________________________ History of AlcoholDrug ______--____________________
Camments_______________________________
Father ____________ O~ion----------------
Age_____ Is there a contoct __ History of Mental Iliness__________________________ History of AlcoholDrug ___________________________
COm~--_________________________________
CurTcnt Si1uation
Who do you ive with____________________________ Where do you work ________ Whot is yCQ job_______________ Where does Spouse work_________________ What is there job____ Full or Port time____________ What other jobs have you had_________________________
A~~k~b~----------------------------
Have you lived anywhere else other than your curnnt residence If so please explainlt--_______
Family History
Do you hcIft any children or stepchildren If $0 pIeast give names and ~~____________
Lowe Socioeconomic Class Middlt Closs Upper Closs Alcoholic OIootic Distant Abusivle Controlling
Family Mental HeolthlAddictionlAlcoholiSlft History ____________________
Is there anyone in yow fCllftily you do not ~ contact with If $0 with whom___________
Who was in your fCllftily while you where growing up___________________
Wh~~~MW---------------------------------------
Educatianal I Social HistaI
Eosily forms friendships Attatcis social functions Needs social inta-oction Maintains friendships o Avoids social functions
00 Supportive Fritmds No close friends
How close friends do you ~____ Eementcry 0 Middlt School - High School Bochelor [)octorol ampED
0Some College Good Student IeGrrUng DtSobilities-____ ExtroaaTiculor Activities Avg Student Poor Student Regular Special Education0
Sports Advanced CIossa School Behavicrs (Childhoad)
Tnxny Argumentative Fighting with Peers Poor Effort Attenfive Repeated Grades Expulsions Susplmsions00
Difficulty with Peers Who do you turn to for support in your lif8______________________
~-----------------------------------------
Ctrrenf Employu______________________
GoodWorkHx PoorWorkHx On Sick leove
What is your financial situotion _____________________________
Military History
No Military Hx Spouse in Militcry Raised in Military Family Army Navy Air Force Marines Other _____________
Dotes of 5avice I I to I I Honorablt Dishonorable Medicof Service Related Disability AWOL Txt at VA Hospital
ComrRellts (list combat dates if opplicabI-)___________---___________
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
Best Life Counseling Financial Policy
The therapist at the Best Life Counselina wouJd like to welcome you to our PractKe We strive to provide you with excellent care and our goal is to IDIke your visits bull productive bull possible
By sipl below yOll COlI dult yoa bYe read tltis poIIcJ a Itt
bull It is your responsibility to inform our office ofany address or telepbone nmnber changes bull Your account is to be kept current - accordingly all self-pay or insunnce co-paymenII and deductibles
win be collected It the TIME OF SERVICE Payable by casb cbeck Viii MasteICanI Discover or American Expras-
bull Ifyou do not have your payment (5) your appointmcat may be resdIeduIecI NO SHOW FEES are $4000
bull A mumcd check will result in a S2S service cbarp and AU future peymeuIS beina required in the fonn ofcash or credit card and the payment ofthe monies owed You may recciw reftmds ifyou have a credit balance
bull You will only be sent a staIanCnt Ifyou are owed 1JIOIJeY reftmds will be issuod within 4-6 weeks fiom the date requested ifthere are DO pendina insurance claims
bull There is a In cbarae for Ibe completion ofpaperwork(ex disability FMLA etc) This needs to be paid prior to paperwork beina done
bull Any unpaid baIances older than 30 days may be subject to 1S percent interest per moodt bull Ifyour ICCOUIIt is turned over to a collection agency you will be responsible for any cosII incurred in
collection ofsaid balance which may include collection agency fees up to 60 penent ofyour outstandina balance court costs and aUomey fees
bull Ifl need to go to court the fee is SISO per hoW and may be billed It that nde as well We require a retainer fee ofSI 00 up fiont
bull [fphone calls beyond 1S minutes you will be billed for a tbenpy sessioa
Iya Yruce ccwerqe
We wiD submit your claims however we ell tItat latl pnwlden oar Ip II witll yoa I5Il YOllr iasaruee eompaay Althouah we attempt to veritY yourbeuefits with your insurance policy please be advised this is only an estinude ofyour coverage tscd OIl the information given to 111 at tile time of the inquiJy By sip below ya COlI tllat yCHI ulldentalld bull It is your responsibility to inform 111 ofany cbanps to your insunnce policy so that your coverage caD be reshy
verified prior to your appointment bull Ifyour insunInce poJicy requires a referral ampom your prinwy care physic_ it is your responsibiJity to have
that referral faxed to our office prior to your appointment bull Not ail services are covered beDefi1l with a1J insurance p bull It is your responsibility to be aware ofwhat service (s) is beinsprovided to you and if it is a covered benefit
We realize dull temporary financial problans may affect timely payment ofyow account Ifsuch problems do arise we urge you to CODtICt us promptly for assistance in tile IIIIIIIpIDCIIt o(your accoUnt Ifyou have any questions about the above information PLEASE do DOt hesnre to ask We are here co heiR you
I have read and understand the above FillMCiai Policy and agree to meet all financial obliptions
Patient Name (PRINn Patient SipllUre
Responsible Party (PRJNn Responsible Party Signature
Therapist Name (PRlNn Therapist Signature Date
Client Intt)mlalion and Consent
rherapist
Ih~ undersigrnd is a licenSld Mental Jlealtb professional or chemical dejlndency counselor in priate practice proiding mental health care srvices to clients directly and as iUI indcpt-ndent contmclorpro iJer ti)r aril1us managed care -I1tiries In addition the undersigned thempist provides all mental health serv ices through Rest life (middotounseling
While il may not be easy to scek help from a mental health professional it is hoJkd that you will he bener ahle to UikJerstand your situation and feelings and move fi)foard resolving lour difficulties (he therapist using her knowledge of human developmtI1t and behavior wilJ make obsenations about situations as well as suggestions for new ways 10 approach them It will be important for you to explore your own feelings and thOUghts and to try new approaches in order for change to occur You may bring OIber tamily members to a therapy session if yuu teel it would be helpful or ifthis is recommended by your thempist
AppoiRttReDts
Appoinbnents are made by calling (727) 5~ Monday through friday between the hours uf900 am and 500pm Please call to cancel or reschedule at 1east4 hours in advance or yuu will be charged tor the missed appointment Third-party payments will not usually cover or reimburse for missed appointments rhe NO SHOW fee is $4000 We require a cmJit card rhat will be billed ifyou do not show for your
appointment
Number or Visits
The number ofsesions nceded depends on many factors and will be discussed by the therapist
Length or Visits
l1Jerapy sessions are 45 minutes in lengthThe initial therapy session is I liz - 2 hours
Relatioasbip
Your relationship with the therapist is a professional and therapeutic relationship In order to preserve this relationship it is imperative rhat the therapist not have any other type of relationship with )011 Personal mdor business relationships undermine the effectiveness ufthe therapeutic relationship The therapist cares about helping you bul is not in a positioo to be your ftiend or tu have a social or personal relationship ~ith you
Gills bart~ring and trclding srvices are nut appropriate iUId should not ~ shared bctw-gten you and lhe thempist
Cancellations
(an~dlations must be nlcid af least ~4 hours bertFe our sheduled appuintment othcise yOU WIU BE tUARGIO the cUSlonlaJ) fe ofstoOO lOr (hal missed appointment You are r-(loosible It calling tn cancel or reschedule your appointment We will give OU 24 hours after the NO SHOW to call and give the rcaooning tOr (he NO SII()W bciraquore charging )(JU
Pa~ment ror ~nkes
If )OU -cllpa) the charge fUr our inilial sion is SI2500 and Ilk charge liw an qucnt 4-ions is
bull
$10000 The undersigned therapist does accept assignment of insurance ~nctits The undersigned therapist ill look to )0 ou for full paYffiCnt ofour account and you 0 ill ~ responsible for paymlnt ofall charges DifTen-nt co-pa)-ffiCnts are Rquired by arious group coverage plans Your co-pa)-ment is based 1Il the mental health policy selected by your employer or purchased by ou In addition the co-pay portion dfthe undersigned therapists charges for services at the time ofsenHCS are provided It is recommended that you detennine your co-pa ments before your tirst visit by calling yout ~fits ofttce or insurdnce company
lthough it is the goal ofthe undersigned therapist to protect the confidentiality ofour records there may ~ times when disclosure ofyour records or testimony will be compelled by law Confidentiality and exceptions to confidenliality are discussed below In the event disclosure ofyour records or testimony is required by law you will be responsible for and shall pay the (osts involved in producing the records and the thlrapists nonnal hourly rate tOr the time involved in preparing for and giving testimony Such pay ments are to be made at the time or prior to the time the services are rendered by the therapist
Conrldentiality
Discussions between a therapist and a client are confidential No information will be released without the clients written consent unless mandated by law Possible exceptions to confidentiality include but are not limited to the following situations Child abuse abuse of the elderly or disabled abuse ofcriminal prosecutions child custody cases suits in which the mental health ofa party is in issue situations where the therapist has a duty to disclose or where in the therapists judgment it is necessary to wam or disclose fee disputes between the therapist and the client a negligence suit brought by the client against the therapist or the filing ofa complaint with the licensing board Ifyou have any questions regarding confidentiality you should bring them to the attention ofthe therapist when you and the therapist discuss this matter further By signing this intOrmation and consent form you are giving your consent to the tmdersigned therapist to share confidential infonnation with all persons mandated by law and with the agency that refernd you and the managed care companyandor insurance carrier responsible for providing your mental health careservices and payment for those services and you are also releasing and holding harmless the undersigned therapist 1T0m any departure from your right to confidentiality that may result In couples or family therapy confidentiality does not apply and the thenipist will use there clinical judgment when sharing infonnation
You have the right to review your chart according toState Law
If I see in the community I wiIJ not approach you (as ifcould breach confidentiality) Ifyou want to say hello please feel free to approach me However please understand I will probably not he able to spend much time talking to you Thanks for your consideration In addition you may bump into someone you know in the waiting room This may be unavoidable Please let me know if this occurs and how you feel about it
If you cannot he reached a message will be left such as - This is Heather fiom Heather PupS otTree and I m oalling formiddotmiddot Your Name Please initial the circumstance under whichou wish to he contacted
00 not contact me under any circumstances Yes )oU may contact me a described above YS contact me but only under these circumstances
Please describe conditions
IIndcrslmd (he ilhove intOrmatilaquom - - - --- -~
Signature ofPatientParent Date
Duty to Warn
to myselfor another person I ipaifically consent for the therapist to wam the person in danger and (0
wntact6 the following persons in aJdition to m~tIical and law enf(rc~t pelStmnc
~rME TELEPHONE NUMBER
I consent t(lr the undersigned therapist to communicate with me by mail and by phone at the following addresses and phone numbers and I will IMMEOIATELY advise the lherdpist in the event ofany changtS
ADDRESS fELEPHONE NUMBER
Risks of Thenpy
Therctpy is the Greek woro tor change You may learn things about yourself that you dont like Often growth cannot occur until you experience and confront issues that induce you to feel sadness sorrow anx iety or pain The success ofour work togedter depends on the quality of the efforts on both our parts and the alization that you are ~ible for lifestyle choiceschanges that may result fiom lhcrapy Specifically one risk ofmartial dterapy is fhe possibility ofexercising the divorre option - shy
Completion ofassignmentsreadings ~een therapy sessions will help therapy be more effective In addition within a reasonable period oftime after beginning treatmentbull I will discuss with you my unders1anding of the problem treatment Ifyou have any unanswered questions about any of the procedures used in the course of therapy their possible risks please ask and you will be answered fully You also have the right to ask about other treabneflts for your condition and their risks and benelits Ifyou could benefit from any treatment thai I do not provide I have an ethical obligalion to assist you in obtaining those treatments
Atlr the lirst couple meeting I will assess if I can be of benefit to you I do not accept clients who in m) )pinion I cannot help In such a case I will give you a number of referrals that you can contactI Ifat any point during ps)chotherclpY I assess that I am not being effective in helping you reach the cherapeutic goals am obligated to discuss it with you and ifappropriate to terminate treatment In such a case I till give )OU a number ofrcfcrrals that may be of help to you (f)ou quest it and authorize it in wriling
flu-Houn Fmergendes
A mental health professional or ()ur therapist is on call when your therapists otTrce is closed and can be reached for emergencitS on a twenty-ftlUf huur seven days plr wtCk basis by calling (727) 7middotU-8u6 fmrgencitS are urgent issues requiring immediate ion Please call 91 I or go to the Emergency Room if uicidal or homicidal
If the therapist does ntCd to return our phone and the call goes beyond 15 minutes you will be billed flr a therclp) session Ifit is not an emergency you may email the OllCf Heat~-r Pugh CAP SAP IMHC at
I admm Itdgc that in the cImiddotnl Ihe unckrsigncd Ihtmpsl -lUnKS incltlpacilatCI fir dies it ill htlumc
n~cSsaJ) tor anoth~r therapist to take possession ofmy tile and recurus 8) signing this information imJ consent fonn I give my consent to allo~ing another licensed mntal heahh professional selected by the undersigned titerdpist to take possession ofmy tile and records and provide me ~ith copitos upon request or ro deliver tikm to a tikrapist of my choice
llisputn
11 disputes arising out ofor in relation to this agreement to provide ps)chothcrapy services shall first be referred to mediation before and as a precondition of the initiation ofarbitration rhe mediator shall he neutral party chosen by agreement oHleather Pugh MACAP tMUG ()tner and client (s) rhe cost of I~iation bull ifany shall be split equally unless otherwise ~ed
Consenl to TreatlR~Dt
I voluntarily agree to receive Mental Health assessment care tniltment or services and authorize the undersigned therapist to provide such care treatment or services as are considered necessary and advisable
I unJerstand and agree that I will participate in the planning ofmy care lrealment or services and that I rna) stop such care treatment or services that I receive through the undersigned therapist at any time
R) signing this Client Information and Consent Fnnn I the undersigned client acknowledge that I have been both read and understood all the terms and infonnation contained herein Ample opportunity has been otTered to me to ask questions and seek clarification ofanything unclear to me
ClientiParent Date
-~----------------------------____------------------- ----_ _--__--shySocial Security Number and Address
As witnessed by
--
Tikrapists Name
Best Life Counseling Notice ofPrivacy Practices
THIS NOTICE DESCTIBES HOW UElJlCAL INFORMATION ABOUT rouJlArBE USED AND DISCLOSED AND HOW YOU CAN GETACC~TO THIS INFORMATION PlEASEREYlEW ITCAREFUUY
USt Life Ccu~ is ftqUired by Jaw to maiDIaiD the prMcyofarIaiII balIh QR infCW1Dlldioo about our pIIlients The Law RICpIifts be notified ofthese sIaidads As a part ofoufday-fo-day activities Boest Life ~ay need to use and disclose (sI8e) )OUr protected health
QIC irtfiJrm8Ja SCVCDI purposes witbouI6ntJOUI writIalllplllOftl 11IoIe pIII)ICIIICS iodade bull Boest Life cOampuueUM9 opaaliuns F_eaapIe_ Boest Life CDw~SIIIf_disuss)OUr
conditian in onIer to pnwide proper iii bull est Life ~ ayCODIalupoa JOUI Ilaquodtd balIh cm ida FarcumpIc ~t
Life ~may cd to amage JOUI pnwide with iDfia IRaIIPlt benefits and services that ~ aYaiIabIe to you
amptst Life CDft-seli~ may provide inNuU8Iion to govcmmcnt omaJs who owrsee health care _ thtaIIs to public
safety
No other uses and disdosuns of)OUr)llUkctal haIIIII cc infiIIwiD occur without your wriUaJ autborizIItion Moroovcr ifyou sign such IIIICI audIorizaIioo you have the right to ameI it111 any time YOfU6z- I yftIllalalHallllCMIIIIJM t UodIpoundthelawyoubaYcsevcndrigbls ~t
Ltfe ~ is committed to upIaolcIioamp Those tipIs indude bull The right to RJqUCSl RSbidioos OIl some ofthe waysSest Life CDftM5dl~ usesdi9cl6suns JOUI information
Best Life ~ may DOl always IIJPC ID imp or these additional restridioas bull The rigbt to l1XlCiw confidential COO-bullbullicItions WIUIeSest Life ~ QIIIIGI promise ID communicate
ill every possible way requested 1K wiD wort willi to find lIIICIccptablc WIIJ to QIImnfidcntjaIly bull The rigbt to inspect and get copies ofheaIdt ce iuiNiiiiIliIIo held by Ee5t Life CDw~ by making a
request in writing Best Life ~ bowewr may ctrc a aurabIc_ to covcr only the cOst of providing this infiJrmIItioo
bull The right 10 request Ee5t Life ~ amend 01 conect infiItUllllliua about)OlL To make bull dBIge will be nquiml to nqucst in writinamp indIidiog die RBJll you MIll JOUI raunI dwnppI Sest Life ~ may not always agnc to suck nquesIS
The rigbl to a list ofSest ufe ~ disclosuns that wac not auIborilJId by you and the discIosuns wac unrelated to bCllbOCDl or opendions Ifyou have any questions _ alIIIpIaiDIs about the WIIJSest Life ~~ JOUI aIICdod QR
information or if belieyene your privacy right have beat vioIaIaI COI1Iad the sest Life ~ PrMcy Officer (Heather Pugb CAP LMHC SAP) III 727-S46-64000I inpcrson Voucan aIsoCODlaltheSectday oftbc US DepaatnllCOl ofHealth and HUDIIID SeIYica Please DOII ~will be 110 maJiatioa filing a complaint 01 making rcquem rcgadiog your beabh care iDfonnIIIion _ for dis8gmeinamp withSest Life ~~ shyrelated decisions
Notice ofPrivacy Practices Ackftowkdarme ofRaxipt I received copy of~t Life CDft~ s Notice of Privacy PIadices I uadaSUIMI that ifsest Life ~
uses my personal hcaIdI information in a IIIIIIIIlCr IhIIl is diftilCIIl dtaaibcrcl by the NCJIia ~ Life CDftseli~
must Iirsl get my permission in writing I am aaepIing this Notice OIl behIIIfof o Myself o Another person as his _ her personal representalive (perent guardian family member de)
PritNPa~_____________________________________________________
Prit NuIe fPet ~ (ifapplicable)_______________________________
Sipaanfll~ 111_____________________IWe~________
Ptgtt Li(t ~
Best Life Counseling Adult Personal History
Client ~--_____________ Date _____
First MI Phone ~______ Cell phone-_______
Address--____________________ City State___ Zip____
Social Searity Number_____ SpouseISignificont other Social SearitY----shyBirthplace Spouses Birthploce ____ [)ate of Birth Spouses dote of Birth--____ Email Address____________________ Why are you seeking counseling_________________________
MaritallFamily
of Full Siblings of Half Siblings __ Birth order Age _--_
Single ~ Married Separated DWorced _ Widowed Living Together Caucasian African-American HispanicILatin t-taaiianlPacific Islander
Multi-Rocial ~ Asian Other Native American- Hetro-Sexuol Homosexual ampi-Sexual Other Mother OcalpCltion________________
Age Is there CI contoct__ History of Mental Iliness__________________________ History of AlcoholDrug ______--____________________
Camments_______________________________
Father ____________ O~ion----------------
Age_____ Is there a contoct __ History of Mental Iliness__________________________ History of AlcoholDrug ___________________________
COm~--_________________________________
CurTcnt Si1uation
Who do you ive with____________________________ Where do you work ________ Whot is yCQ job_______________ Where does Spouse work_________________ What is there job____ Full or Port time____________ What other jobs have you had_________________________
A~~k~b~----------------------------
Have you lived anywhere else other than your curnnt residence If so please explainlt--_______
Family History
Do you hcIft any children or stepchildren If $0 pIeast give names and ~~____________
Lowe Socioeconomic Class Middlt Closs Upper Closs Alcoholic OIootic Distant Abusivle Controlling
Family Mental HeolthlAddictionlAlcoholiSlft History ____________________
Is there anyone in yow fCllftily you do not ~ contact with If $0 with whom___________
Who was in your fCllftily while you where growing up___________________
Wh~~~MW---------------------------------------
Educatianal I Social HistaI
Eosily forms friendships Attatcis social functions Needs social inta-oction Maintains friendships o Avoids social functions
00 Supportive Fritmds No close friends
How close friends do you ~____ Eementcry 0 Middlt School - High School Bochelor [)octorol ampED
0Some College Good Student IeGrrUng DtSobilities-____ ExtroaaTiculor Activities Avg Student Poor Student Regular Special Education0
Sports Advanced CIossa School Behavicrs (Childhoad)
Tnxny Argumentative Fighting with Peers Poor Effort Attenfive Repeated Grades Expulsions Susplmsions00
Difficulty with Peers Who do you turn to for support in your lif8______________________
~-----------------------------------------
Ctrrenf Employu______________________
GoodWorkHx PoorWorkHx On Sick leove
What is your financial situotion _____________________________
Military History
No Military Hx Spouse in Militcry Raised in Military Family Army Navy Air Force Marines Other _____________
Dotes of 5avice I I to I I Honorablt Dishonorable Medicof Service Related Disability AWOL Txt at VA Hospital
ComrRellts (list combat dates if opplicabI-)___________---___________
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
Client Intt)mlalion and Consent
rherapist
Ih~ undersigrnd is a licenSld Mental Jlealtb professional or chemical dejlndency counselor in priate practice proiding mental health care srvices to clients directly and as iUI indcpt-ndent contmclorpro iJer ti)r aril1us managed care -I1tiries In addition the undersigned thempist provides all mental health serv ices through Rest life (middotounseling
While il may not be easy to scek help from a mental health professional it is hoJkd that you will he bener ahle to UikJerstand your situation and feelings and move fi)foard resolving lour difficulties (he therapist using her knowledge of human developmtI1t and behavior wilJ make obsenations about situations as well as suggestions for new ways 10 approach them It will be important for you to explore your own feelings and thOUghts and to try new approaches in order for change to occur You may bring OIber tamily members to a therapy session if yuu teel it would be helpful or ifthis is recommended by your thempist
AppoiRttReDts
Appoinbnents are made by calling (727) 5~ Monday through friday between the hours uf900 am and 500pm Please call to cancel or reschedule at 1east4 hours in advance or yuu will be charged tor the missed appointment Third-party payments will not usually cover or reimburse for missed appointments rhe NO SHOW fee is $4000 We require a cmJit card rhat will be billed ifyou do not show for your
appointment
Number or Visits
The number ofsesions nceded depends on many factors and will be discussed by the therapist
Length or Visits
l1Jerapy sessions are 45 minutes in lengthThe initial therapy session is I liz - 2 hours
Relatioasbip
Your relationship with the therapist is a professional and therapeutic relationship In order to preserve this relationship it is imperative rhat the therapist not have any other type of relationship with )011 Personal mdor business relationships undermine the effectiveness ufthe therapeutic relationship The therapist cares about helping you bul is not in a positioo to be your ftiend or tu have a social or personal relationship ~ith you
Gills bart~ring and trclding srvices are nut appropriate iUId should not ~ shared bctw-gten you and lhe thempist
Cancellations
(an~dlations must be nlcid af least ~4 hours bertFe our sheduled appuintment othcise yOU WIU BE tUARGIO the cUSlonlaJ) fe ofstoOO lOr (hal missed appointment You are r-(loosible It calling tn cancel or reschedule your appointment We will give OU 24 hours after the NO SHOW to call and give the rcaooning tOr (he NO SII()W bciraquore charging )(JU
Pa~ment ror ~nkes
If )OU -cllpa) the charge fUr our inilial sion is SI2500 and Ilk charge liw an qucnt 4-ions is
bull
$10000 The undersigned therapist does accept assignment of insurance ~nctits The undersigned therapist ill look to )0 ou for full paYffiCnt ofour account and you 0 ill ~ responsible for paymlnt ofall charges DifTen-nt co-pa)-ffiCnts are Rquired by arious group coverage plans Your co-pa)-ment is based 1Il the mental health policy selected by your employer or purchased by ou In addition the co-pay portion dfthe undersigned therapists charges for services at the time ofsenHCS are provided It is recommended that you detennine your co-pa ments before your tirst visit by calling yout ~fits ofttce or insurdnce company
lthough it is the goal ofthe undersigned therapist to protect the confidentiality ofour records there may ~ times when disclosure ofyour records or testimony will be compelled by law Confidentiality and exceptions to confidenliality are discussed below In the event disclosure ofyour records or testimony is required by law you will be responsible for and shall pay the (osts involved in producing the records and the thlrapists nonnal hourly rate tOr the time involved in preparing for and giving testimony Such pay ments are to be made at the time or prior to the time the services are rendered by the therapist
Conrldentiality
Discussions between a therapist and a client are confidential No information will be released without the clients written consent unless mandated by law Possible exceptions to confidentiality include but are not limited to the following situations Child abuse abuse of the elderly or disabled abuse ofcriminal prosecutions child custody cases suits in which the mental health ofa party is in issue situations where the therapist has a duty to disclose or where in the therapists judgment it is necessary to wam or disclose fee disputes between the therapist and the client a negligence suit brought by the client against the therapist or the filing ofa complaint with the licensing board Ifyou have any questions regarding confidentiality you should bring them to the attention ofthe therapist when you and the therapist discuss this matter further By signing this intOrmation and consent form you are giving your consent to the tmdersigned therapist to share confidential infonnation with all persons mandated by law and with the agency that refernd you and the managed care companyandor insurance carrier responsible for providing your mental health careservices and payment for those services and you are also releasing and holding harmless the undersigned therapist 1T0m any departure from your right to confidentiality that may result In couples or family therapy confidentiality does not apply and the thenipist will use there clinical judgment when sharing infonnation
You have the right to review your chart according toState Law
If I see in the community I wiIJ not approach you (as ifcould breach confidentiality) Ifyou want to say hello please feel free to approach me However please understand I will probably not he able to spend much time talking to you Thanks for your consideration In addition you may bump into someone you know in the waiting room This may be unavoidable Please let me know if this occurs and how you feel about it
If you cannot he reached a message will be left such as - This is Heather fiom Heather PupS otTree and I m oalling formiddotmiddot Your Name Please initial the circumstance under whichou wish to he contacted
00 not contact me under any circumstances Yes )oU may contact me a described above YS contact me but only under these circumstances
Please describe conditions
IIndcrslmd (he ilhove intOrmatilaquom - - - --- -~
Signature ofPatientParent Date
Duty to Warn
to myselfor another person I ipaifically consent for the therapist to wam the person in danger and (0
wntact6 the following persons in aJdition to m~tIical and law enf(rc~t pelStmnc
~rME TELEPHONE NUMBER
I consent t(lr the undersigned therapist to communicate with me by mail and by phone at the following addresses and phone numbers and I will IMMEOIATELY advise the lherdpist in the event ofany changtS
ADDRESS fELEPHONE NUMBER
Risks of Thenpy
Therctpy is the Greek woro tor change You may learn things about yourself that you dont like Often growth cannot occur until you experience and confront issues that induce you to feel sadness sorrow anx iety or pain The success ofour work togedter depends on the quality of the efforts on both our parts and the alization that you are ~ible for lifestyle choiceschanges that may result fiom lhcrapy Specifically one risk ofmartial dterapy is fhe possibility ofexercising the divorre option - shy
Completion ofassignmentsreadings ~een therapy sessions will help therapy be more effective In addition within a reasonable period oftime after beginning treatmentbull I will discuss with you my unders1anding of the problem treatment Ifyou have any unanswered questions about any of the procedures used in the course of therapy their possible risks please ask and you will be answered fully You also have the right to ask about other treabneflts for your condition and their risks and benelits Ifyou could benefit from any treatment thai I do not provide I have an ethical obligalion to assist you in obtaining those treatments
Atlr the lirst couple meeting I will assess if I can be of benefit to you I do not accept clients who in m) )pinion I cannot help In such a case I will give you a number of referrals that you can contactI Ifat any point during ps)chotherclpY I assess that I am not being effective in helping you reach the cherapeutic goals am obligated to discuss it with you and ifappropriate to terminate treatment In such a case I till give )OU a number ofrcfcrrals that may be of help to you (f)ou quest it and authorize it in wriling
flu-Houn Fmergendes
A mental health professional or ()ur therapist is on call when your therapists otTrce is closed and can be reached for emergencitS on a twenty-ftlUf huur seven days plr wtCk basis by calling (727) 7middotU-8u6 fmrgencitS are urgent issues requiring immediate ion Please call 91 I or go to the Emergency Room if uicidal or homicidal
If the therapist does ntCd to return our phone and the call goes beyond 15 minutes you will be billed flr a therclp) session Ifit is not an emergency you may email the OllCf Heat~-r Pugh CAP SAP IMHC at
I admm Itdgc that in the cImiddotnl Ihe unckrsigncd Ihtmpsl -lUnKS incltlpacilatCI fir dies it ill htlumc
n~cSsaJ) tor anoth~r therapist to take possession ofmy tile and recurus 8) signing this information imJ consent fonn I give my consent to allo~ing another licensed mntal heahh professional selected by the undersigned titerdpist to take possession ofmy tile and records and provide me ~ith copitos upon request or ro deliver tikm to a tikrapist of my choice
llisputn
11 disputes arising out ofor in relation to this agreement to provide ps)chothcrapy services shall first be referred to mediation before and as a precondition of the initiation ofarbitration rhe mediator shall he neutral party chosen by agreement oHleather Pugh MACAP tMUG ()tner and client (s) rhe cost of I~iation bull ifany shall be split equally unless otherwise ~ed
Consenl to TreatlR~Dt
I voluntarily agree to receive Mental Health assessment care tniltment or services and authorize the undersigned therapist to provide such care treatment or services as are considered necessary and advisable
I unJerstand and agree that I will participate in the planning ofmy care lrealment or services and that I rna) stop such care treatment or services that I receive through the undersigned therapist at any time
R) signing this Client Information and Consent Fnnn I the undersigned client acknowledge that I have been both read and understood all the terms and infonnation contained herein Ample opportunity has been otTered to me to ask questions and seek clarification ofanything unclear to me
ClientiParent Date
-~----------------------------____------------------- ----_ _--__--shySocial Security Number and Address
As witnessed by
--
Tikrapists Name
Best Life Counseling Notice ofPrivacy Practices
THIS NOTICE DESCTIBES HOW UElJlCAL INFORMATION ABOUT rouJlArBE USED AND DISCLOSED AND HOW YOU CAN GETACC~TO THIS INFORMATION PlEASEREYlEW ITCAREFUUY
USt Life Ccu~ is ftqUired by Jaw to maiDIaiD the prMcyofarIaiII balIh QR infCW1Dlldioo about our pIIlients The Law RICpIifts be notified ofthese sIaidads As a part ofoufday-fo-day activities Boest Life ~ay need to use and disclose (sI8e) )OUr protected health
QIC irtfiJrm8Ja SCVCDI purposes witbouI6ntJOUI writIalllplllOftl 11IoIe pIII)ICIIICS iodade bull Boest Life cOampuueUM9 opaaliuns F_eaapIe_ Boest Life CDw~SIIIf_disuss)OUr
conditian in onIer to pnwide proper iii bull est Life ~ ayCODIalupoa JOUI Ilaquodtd balIh cm ida FarcumpIc ~t
Life ~may cd to amage JOUI pnwide with iDfia IRaIIPlt benefits and services that ~ aYaiIabIe to you
amptst Life CDft-seli~ may provide inNuU8Iion to govcmmcnt omaJs who owrsee health care _ thtaIIs to public
safety
No other uses and disdosuns of)OUr)llUkctal haIIIII cc infiIIwiD occur without your wriUaJ autborizIItion Moroovcr ifyou sign such IIIICI audIorizaIioo you have the right to ameI it111 any time YOfU6z- I yftIllalalHallllCMIIIIJM t UodIpoundthelawyoubaYcsevcndrigbls ~t
Ltfe ~ is committed to upIaolcIioamp Those tipIs indude bull The right to RJqUCSl RSbidioos OIl some ofthe waysSest Life CDftM5dl~ usesdi9cl6suns JOUI information
Best Life ~ may DOl always IIJPC ID imp or these additional restridioas bull The rigbt to l1XlCiw confidential COO-bullbullicItions WIUIeSest Life ~ QIIIIGI promise ID communicate
ill every possible way requested 1K wiD wort willi to find lIIICIccptablc WIIJ to QIImnfidcntjaIly bull The rigbt to inspect and get copies ofheaIdt ce iuiNiiiiIliIIo held by Ee5t Life CDw~ by making a
request in writing Best Life ~ bowewr may ctrc a aurabIc_ to covcr only the cOst of providing this infiJrmIItioo
bull The right 10 request Ee5t Life ~ amend 01 conect infiItUllllliua about)OlL To make bull dBIge will be nquiml to nqucst in writinamp indIidiog die RBJll you MIll JOUI raunI dwnppI Sest Life ~ may not always agnc to suck nquesIS
The rigbl to a list ofSest ufe ~ disclosuns that wac not auIborilJId by you and the discIosuns wac unrelated to bCllbOCDl or opendions Ifyou have any questions _ alIIIpIaiDIs about the WIIJSest Life ~~ JOUI aIICdod QR
information or if belieyene your privacy right have beat vioIaIaI COI1Iad the sest Life ~ PrMcy Officer (Heather Pugb CAP LMHC SAP) III 727-S46-64000I inpcrson Voucan aIsoCODlaltheSectday oftbc US DepaatnllCOl ofHealth and HUDIIID SeIYica Please DOII ~will be 110 maJiatioa filing a complaint 01 making rcquem rcgadiog your beabh care iDfonnIIIion _ for dis8gmeinamp withSest Life ~~ shyrelated decisions
Notice ofPrivacy Practices Ackftowkdarme ofRaxipt I received copy of~t Life CDft~ s Notice of Privacy PIadices I uadaSUIMI that ifsest Life ~
uses my personal hcaIdI information in a IIIIIIIIlCr IhIIl is diftilCIIl dtaaibcrcl by the NCJIia ~ Life CDftseli~
must Iirsl get my permission in writing I am aaepIing this Notice OIl behIIIfof o Myself o Another person as his _ her personal representalive (perent guardian family member de)
PritNPa~_____________________________________________________
Prit NuIe fPet ~ (ifapplicable)_______________________________
Sipaanfll~ 111_____________________IWe~________
Ptgtt Li(t ~
Best Life Counseling Adult Personal History
Client ~--_____________ Date _____
First MI Phone ~______ Cell phone-_______
Address--____________________ City State___ Zip____
Social Searity Number_____ SpouseISignificont other Social SearitY----shyBirthplace Spouses Birthploce ____ [)ate of Birth Spouses dote of Birth--____ Email Address____________________ Why are you seeking counseling_________________________
MaritallFamily
of Full Siblings of Half Siblings __ Birth order Age _--_
Single ~ Married Separated DWorced _ Widowed Living Together Caucasian African-American HispanicILatin t-taaiianlPacific Islander
Multi-Rocial ~ Asian Other Native American- Hetro-Sexuol Homosexual ampi-Sexual Other Mother OcalpCltion________________
Age Is there CI contoct__ History of Mental Iliness__________________________ History of AlcoholDrug ______--____________________
Camments_______________________________
Father ____________ O~ion----------------
Age_____ Is there a contoct __ History of Mental Iliness__________________________ History of AlcoholDrug ___________________________
COm~--_________________________________
CurTcnt Si1uation
Who do you ive with____________________________ Where do you work ________ Whot is yCQ job_______________ Where does Spouse work_________________ What is there job____ Full or Port time____________ What other jobs have you had_________________________
A~~k~b~----------------------------
Have you lived anywhere else other than your curnnt residence If so please explainlt--_______
Family History
Do you hcIft any children or stepchildren If $0 pIeast give names and ~~____________
Lowe Socioeconomic Class Middlt Closs Upper Closs Alcoholic OIootic Distant Abusivle Controlling
Family Mental HeolthlAddictionlAlcoholiSlft History ____________________
Is there anyone in yow fCllftily you do not ~ contact with If $0 with whom___________
Who was in your fCllftily while you where growing up___________________
Wh~~~MW---------------------------------------
Educatianal I Social HistaI
Eosily forms friendships Attatcis social functions Needs social inta-oction Maintains friendships o Avoids social functions
00 Supportive Fritmds No close friends
How close friends do you ~____ Eementcry 0 Middlt School - High School Bochelor [)octorol ampED
0Some College Good Student IeGrrUng DtSobilities-____ ExtroaaTiculor Activities Avg Student Poor Student Regular Special Education0
Sports Advanced CIossa School Behavicrs (Childhoad)
Tnxny Argumentative Fighting with Peers Poor Effort Attenfive Repeated Grades Expulsions Susplmsions00
Difficulty with Peers Who do you turn to for support in your lif8______________________
~-----------------------------------------
Ctrrenf Employu______________________
GoodWorkHx PoorWorkHx On Sick leove
What is your financial situotion _____________________________
Military History
No Military Hx Spouse in Militcry Raised in Military Family Army Navy Air Force Marines Other _____________
Dotes of 5avice I I to I I Honorablt Dishonorable Medicof Service Related Disability AWOL Txt at VA Hospital
ComrRellts (list combat dates if opplicabI-)___________---___________
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
bull
$10000 The undersigned therapist does accept assignment of insurance ~nctits The undersigned therapist ill look to )0 ou for full paYffiCnt ofour account and you 0 ill ~ responsible for paymlnt ofall charges DifTen-nt co-pa)-ffiCnts are Rquired by arious group coverage plans Your co-pa)-ment is based 1Il the mental health policy selected by your employer or purchased by ou In addition the co-pay portion dfthe undersigned therapists charges for services at the time ofsenHCS are provided It is recommended that you detennine your co-pa ments before your tirst visit by calling yout ~fits ofttce or insurdnce company
lthough it is the goal ofthe undersigned therapist to protect the confidentiality ofour records there may ~ times when disclosure ofyour records or testimony will be compelled by law Confidentiality and exceptions to confidenliality are discussed below In the event disclosure ofyour records or testimony is required by law you will be responsible for and shall pay the (osts involved in producing the records and the thlrapists nonnal hourly rate tOr the time involved in preparing for and giving testimony Such pay ments are to be made at the time or prior to the time the services are rendered by the therapist
Conrldentiality
Discussions between a therapist and a client are confidential No information will be released without the clients written consent unless mandated by law Possible exceptions to confidentiality include but are not limited to the following situations Child abuse abuse of the elderly or disabled abuse ofcriminal prosecutions child custody cases suits in which the mental health ofa party is in issue situations where the therapist has a duty to disclose or where in the therapists judgment it is necessary to wam or disclose fee disputes between the therapist and the client a negligence suit brought by the client against the therapist or the filing ofa complaint with the licensing board Ifyou have any questions regarding confidentiality you should bring them to the attention ofthe therapist when you and the therapist discuss this matter further By signing this intOrmation and consent form you are giving your consent to the tmdersigned therapist to share confidential infonnation with all persons mandated by law and with the agency that refernd you and the managed care companyandor insurance carrier responsible for providing your mental health careservices and payment for those services and you are also releasing and holding harmless the undersigned therapist 1T0m any departure from your right to confidentiality that may result In couples or family therapy confidentiality does not apply and the thenipist will use there clinical judgment when sharing infonnation
You have the right to review your chart according toState Law
If I see in the community I wiIJ not approach you (as ifcould breach confidentiality) Ifyou want to say hello please feel free to approach me However please understand I will probably not he able to spend much time talking to you Thanks for your consideration In addition you may bump into someone you know in the waiting room This may be unavoidable Please let me know if this occurs and how you feel about it
If you cannot he reached a message will be left such as - This is Heather fiom Heather PupS otTree and I m oalling formiddotmiddot Your Name Please initial the circumstance under whichou wish to he contacted
00 not contact me under any circumstances Yes )oU may contact me a described above YS contact me but only under these circumstances
Please describe conditions
IIndcrslmd (he ilhove intOrmatilaquom - - - --- -~
Signature ofPatientParent Date
Duty to Warn
to myselfor another person I ipaifically consent for the therapist to wam the person in danger and (0
wntact6 the following persons in aJdition to m~tIical and law enf(rc~t pelStmnc
~rME TELEPHONE NUMBER
I consent t(lr the undersigned therapist to communicate with me by mail and by phone at the following addresses and phone numbers and I will IMMEOIATELY advise the lherdpist in the event ofany changtS
ADDRESS fELEPHONE NUMBER
Risks of Thenpy
Therctpy is the Greek woro tor change You may learn things about yourself that you dont like Often growth cannot occur until you experience and confront issues that induce you to feel sadness sorrow anx iety or pain The success ofour work togedter depends on the quality of the efforts on both our parts and the alization that you are ~ible for lifestyle choiceschanges that may result fiom lhcrapy Specifically one risk ofmartial dterapy is fhe possibility ofexercising the divorre option - shy
Completion ofassignmentsreadings ~een therapy sessions will help therapy be more effective In addition within a reasonable period oftime after beginning treatmentbull I will discuss with you my unders1anding of the problem treatment Ifyou have any unanswered questions about any of the procedures used in the course of therapy their possible risks please ask and you will be answered fully You also have the right to ask about other treabneflts for your condition and their risks and benelits Ifyou could benefit from any treatment thai I do not provide I have an ethical obligalion to assist you in obtaining those treatments
Atlr the lirst couple meeting I will assess if I can be of benefit to you I do not accept clients who in m) )pinion I cannot help In such a case I will give you a number of referrals that you can contactI Ifat any point during ps)chotherclpY I assess that I am not being effective in helping you reach the cherapeutic goals am obligated to discuss it with you and ifappropriate to terminate treatment In such a case I till give )OU a number ofrcfcrrals that may be of help to you (f)ou quest it and authorize it in wriling
flu-Houn Fmergendes
A mental health professional or ()ur therapist is on call when your therapists otTrce is closed and can be reached for emergencitS on a twenty-ftlUf huur seven days plr wtCk basis by calling (727) 7middotU-8u6 fmrgencitS are urgent issues requiring immediate ion Please call 91 I or go to the Emergency Room if uicidal or homicidal
If the therapist does ntCd to return our phone and the call goes beyond 15 minutes you will be billed flr a therclp) session Ifit is not an emergency you may email the OllCf Heat~-r Pugh CAP SAP IMHC at
I admm Itdgc that in the cImiddotnl Ihe unckrsigncd Ihtmpsl -lUnKS incltlpacilatCI fir dies it ill htlumc
n~cSsaJ) tor anoth~r therapist to take possession ofmy tile and recurus 8) signing this information imJ consent fonn I give my consent to allo~ing another licensed mntal heahh professional selected by the undersigned titerdpist to take possession ofmy tile and records and provide me ~ith copitos upon request or ro deliver tikm to a tikrapist of my choice
llisputn
11 disputes arising out ofor in relation to this agreement to provide ps)chothcrapy services shall first be referred to mediation before and as a precondition of the initiation ofarbitration rhe mediator shall he neutral party chosen by agreement oHleather Pugh MACAP tMUG ()tner and client (s) rhe cost of I~iation bull ifany shall be split equally unless otherwise ~ed
Consenl to TreatlR~Dt
I voluntarily agree to receive Mental Health assessment care tniltment or services and authorize the undersigned therapist to provide such care treatment or services as are considered necessary and advisable
I unJerstand and agree that I will participate in the planning ofmy care lrealment or services and that I rna) stop such care treatment or services that I receive through the undersigned therapist at any time
R) signing this Client Information and Consent Fnnn I the undersigned client acknowledge that I have been both read and understood all the terms and infonnation contained herein Ample opportunity has been otTered to me to ask questions and seek clarification ofanything unclear to me
ClientiParent Date
-~----------------------------____------------------- ----_ _--__--shySocial Security Number and Address
As witnessed by
--
Tikrapists Name
Best Life Counseling Notice ofPrivacy Practices
THIS NOTICE DESCTIBES HOW UElJlCAL INFORMATION ABOUT rouJlArBE USED AND DISCLOSED AND HOW YOU CAN GETACC~TO THIS INFORMATION PlEASEREYlEW ITCAREFUUY
USt Life Ccu~ is ftqUired by Jaw to maiDIaiD the prMcyofarIaiII balIh QR infCW1Dlldioo about our pIIlients The Law RICpIifts be notified ofthese sIaidads As a part ofoufday-fo-day activities Boest Life ~ay need to use and disclose (sI8e) )OUr protected health
QIC irtfiJrm8Ja SCVCDI purposes witbouI6ntJOUI writIalllplllOftl 11IoIe pIII)ICIIICS iodade bull Boest Life cOampuueUM9 opaaliuns F_eaapIe_ Boest Life CDw~SIIIf_disuss)OUr
conditian in onIer to pnwide proper iii bull est Life ~ ayCODIalupoa JOUI Ilaquodtd balIh cm ida FarcumpIc ~t
Life ~may cd to amage JOUI pnwide with iDfia IRaIIPlt benefits and services that ~ aYaiIabIe to you
amptst Life CDft-seli~ may provide inNuU8Iion to govcmmcnt omaJs who owrsee health care _ thtaIIs to public
safety
No other uses and disdosuns of)OUr)llUkctal haIIIII cc infiIIwiD occur without your wriUaJ autborizIItion Moroovcr ifyou sign such IIIICI audIorizaIioo you have the right to ameI it111 any time YOfU6z- I yftIllalalHallllCMIIIIJM t UodIpoundthelawyoubaYcsevcndrigbls ~t
Ltfe ~ is committed to upIaolcIioamp Those tipIs indude bull The right to RJqUCSl RSbidioos OIl some ofthe waysSest Life CDftM5dl~ usesdi9cl6suns JOUI information
Best Life ~ may DOl always IIJPC ID imp or these additional restridioas bull The rigbt to l1XlCiw confidential COO-bullbullicItions WIUIeSest Life ~ QIIIIGI promise ID communicate
ill every possible way requested 1K wiD wort willi to find lIIICIccptablc WIIJ to QIImnfidcntjaIly bull The rigbt to inspect and get copies ofheaIdt ce iuiNiiiiIliIIo held by Ee5t Life CDw~ by making a
request in writing Best Life ~ bowewr may ctrc a aurabIc_ to covcr only the cOst of providing this infiJrmIItioo
bull The right 10 request Ee5t Life ~ amend 01 conect infiItUllllliua about)OlL To make bull dBIge will be nquiml to nqucst in writinamp indIidiog die RBJll you MIll JOUI raunI dwnppI Sest Life ~ may not always agnc to suck nquesIS
The rigbl to a list ofSest ufe ~ disclosuns that wac not auIborilJId by you and the discIosuns wac unrelated to bCllbOCDl or opendions Ifyou have any questions _ alIIIpIaiDIs about the WIIJSest Life ~~ JOUI aIICdod QR
information or if belieyene your privacy right have beat vioIaIaI COI1Iad the sest Life ~ PrMcy Officer (Heather Pugb CAP LMHC SAP) III 727-S46-64000I inpcrson Voucan aIsoCODlaltheSectday oftbc US DepaatnllCOl ofHealth and HUDIIID SeIYica Please DOII ~will be 110 maJiatioa filing a complaint 01 making rcquem rcgadiog your beabh care iDfonnIIIion _ for dis8gmeinamp withSest Life ~~ shyrelated decisions
Notice ofPrivacy Practices Ackftowkdarme ofRaxipt I received copy of~t Life CDft~ s Notice of Privacy PIadices I uadaSUIMI that ifsest Life ~
uses my personal hcaIdI information in a IIIIIIIIlCr IhIIl is diftilCIIl dtaaibcrcl by the NCJIia ~ Life CDftseli~
must Iirsl get my permission in writing I am aaepIing this Notice OIl behIIIfof o Myself o Another person as his _ her personal representalive (perent guardian family member de)
PritNPa~_____________________________________________________
Prit NuIe fPet ~ (ifapplicable)_______________________________
Sipaanfll~ 111_____________________IWe~________
Ptgtt Li(t ~
Best Life Counseling Adult Personal History
Client ~--_____________ Date _____
First MI Phone ~______ Cell phone-_______
Address--____________________ City State___ Zip____
Social Searity Number_____ SpouseISignificont other Social SearitY----shyBirthplace Spouses Birthploce ____ [)ate of Birth Spouses dote of Birth--____ Email Address____________________ Why are you seeking counseling_________________________
MaritallFamily
of Full Siblings of Half Siblings __ Birth order Age _--_
Single ~ Married Separated DWorced _ Widowed Living Together Caucasian African-American HispanicILatin t-taaiianlPacific Islander
Multi-Rocial ~ Asian Other Native American- Hetro-Sexuol Homosexual ampi-Sexual Other Mother OcalpCltion________________
Age Is there CI contoct__ History of Mental Iliness__________________________ History of AlcoholDrug ______--____________________
Camments_______________________________
Father ____________ O~ion----------------
Age_____ Is there a contoct __ History of Mental Iliness__________________________ History of AlcoholDrug ___________________________
COm~--_________________________________
CurTcnt Si1uation
Who do you ive with____________________________ Where do you work ________ Whot is yCQ job_______________ Where does Spouse work_________________ What is there job____ Full or Port time____________ What other jobs have you had_________________________
A~~k~b~----------------------------
Have you lived anywhere else other than your curnnt residence If so please explainlt--_______
Family History
Do you hcIft any children or stepchildren If $0 pIeast give names and ~~____________
Lowe Socioeconomic Class Middlt Closs Upper Closs Alcoholic OIootic Distant Abusivle Controlling
Family Mental HeolthlAddictionlAlcoholiSlft History ____________________
Is there anyone in yow fCllftily you do not ~ contact with If $0 with whom___________
Who was in your fCllftily while you where growing up___________________
Wh~~~MW---------------------------------------
Educatianal I Social HistaI
Eosily forms friendships Attatcis social functions Needs social inta-oction Maintains friendships o Avoids social functions
00 Supportive Fritmds No close friends
How close friends do you ~____ Eementcry 0 Middlt School - High School Bochelor [)octorol ampED
0Some College Good Student IeGrrUng DtSobilities-____ ExtroaaTiculor Activities Avg Student Poor Student Regular Special Education0
Sports Advanced CIossa School Behavicrs (Childhoad)
Tnxny Argumentative Fighting with Peers Poor Effort Attenfive Repeated Grades Expulsions Susplmsions00
Difficulty with Peers Who do you turn to for support in your lif8______________________
~-----------------------------------------
Ctrrenf Employu______________________
GoodWorkHx PoorWorkHx On Sick leove
What is your financial situotion _____________________________
Military History
No Military Hx Spouse in Militcry Raised in Military Family Army Navy Air Force Marines Other _____________
Dotes of 5avice I I to I I Honorablt Dishonorable Medicof Service Related Disability AWOL Txt at VA Hospital
ComrRellts (list combat dates if opplicabI-)___________---___________
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
to myselfor another person I ipaifically consent for the therapist to wam the person in danger and (0
wntact6 the following persons in aJdition to m~tIical and law enf(rc~t pelStmnc
~rME TELEPHONE NUMBER
I consent t(lr the undersigned therapist to communicate with me by mail and by phone at the following addresses and phone numbers and I will IMMEOIATELY advise the lherdpist in the event ofany changtS
ADDRESS fELEPHONE NUMBER
Risks of Thenpy
Therctpy is the Greek woro tor change You may learn things about yourself that you dont like Often growth cannot occur until you experience and confront issues that induce you to feel sadness sorrow anx iety or pain The success ofour work togedter depends on the quality of the efforts on both our parts and the alization that you are ~ible for lifestyle choiceschanges that may result fiom lhcrapy Specifically one risk ofmartial dterapy is fhe possibility ofexercising the divorre option - shy
Completion ofassignmentsreadings ~een therapy sessions will help therapy be more effective In addition within a reasonable period oftime after beginning treatmentbull I will discuss with you my unders1anding of the problem treatment Ifyou have any unanswered questions about any of the procedures used in the course of therapy their possible risks please ask and you will be answered fully You also have the right to ask about other treabneflts for your condition and their risks and benelits Ifyou could benefit from any treatment thai I do not provide I have an ethical obligalion to assist you in obtaining those treatments
Atlr the lirst couple meeting I will assess if I can be of benefit to you I do not accept clients who in m) )pinion I cannot help In such a case I will give you a number of referrals that you can contactI Ifat any point during ps)chotherclpY I assess that I am not being effective in helping you reach the cherapeutic goals am obligated to discuss it with you and ifappropriate to terminate treatment In such a case I till give )OU a number ofrcfcrrals that may be of help to you (f)ou quest it and authorize it in wriling
flu-Houn Fmergendes
A mental health professional or ()ur therapist is on call when your therapists otTrce is closed and can be reached for emergencitS on a twenty-ftlUf huur seven days plr wtCk basis by calling (727) 7middotU-8u6 fmrgencitS are urgent issues requiring immediate ion Please call 91 I or go to the Emergency Room if uicidal or homicidal
If the therapist does ntCd to return our phone and the call goes beyond 15 minutes you will be billed flr a therclp) session Ifit is not an emergency you may email the OllCf Heat~-r Pugh CAP SAP IMHC at
I admm Itdgc that in the cImiddotnl Ihe unckrsigncd Ihtmpsl -lUnKS incltlpacilatCI fir dies it ill htlumc
n~cSsaJ) tor anoth~r therapist to take possession ofmy tile and recurus 8) signing this information imJ consent fonn I give my consent to allo~ing another licensed mntal heahh professional selected by the undersigned titerdpist to take possession ofmy tile and records and provide me ~ith copitos upon request or ro deliver tikm to a tikrapist of my choice
llisputn
11 disputes arising out ofor in relation to this agreement to provide ps)chothcrapy services shall first be referred to mediation before and as a precondition of the initiation ofarbitration rhe mediator shall he neutral party chosen by agreement oHleather Pugh MACAP tMUG ()tner and client (s) rhe cost of I~iation bull ifany shall be split equally unless otherwise ~ed
Consenl to TreatlR~Dt
I voluntarily agree to receive Mental Health assessment care tniltment or services and authorize the undersigned therapist to provide such care treatment or services as are considered necessary and advisable
I unJerstand and agree that I will participate in the planning ofmy care lrealment or services and that I rna) stop such care treatment or services that I receive through the undersigned therapist at any time
R) signing this Client Information and Consent Fnnn I the undersigned client acknowledge that I have been both read and understood all the terms and infonnation contained herein Ample opportunity has been otTered to me to ask questions and seek clarification ofanything unclear to me
ClientiParent Date
-~----------------------------____------------------- ----_ _--__--shySocial Security Number and Address
As witnessed by
--
Tikrapists Name
Best Life Counseling Notice ofPrivacy Practices
THIS NOTICE DESCTIBES HOW UElJlCAL INFORMATION ABOUT rouJlArBE USED AND DISCLOSED AND HOW YOU CAN GETACC~TO THIS INFORMATION PlEASEREYlEW ITCAREFUUY
USt Life Ccu~ is ftqUired by Jaw to maiDIaiD the prMcyofarIaiII balIh QR infCW1Dlldioo about our pIIlients The Law RICpIifts be notified ofthese sIaidads As a part ofoufday-fo-day activities Boest Life ~ay need to use and disclose (sI8e) )OUr protected health
QIC irtfiJrm8Ja SCVCDI purposes witbouI6ntJOUI writIalllplllOftl 11IoIe pIII)ICIIICS iodade bull Boest Life cOampuueUM9 opaaliuns F_eaapIe_ Boest Life CDw~SIIIf_disuss)OUr
conditian in onIer to pnwide proper iii bull est Life ~ ayCODIalupoa JOUI Ilaquodtd balIh cm ida FarcumpIc ~t
Life ~may cd to amage JOUI pnwide with iDfia IRaIIPlt benefits and services that ~ aYaiIabIe to you
amptst Life CDft-seli~ may provide inNuU8Iion to govcmmcnt omaJs who owrsee health care _ thtaIIs to public
safety
No other uses and disdosuns of)OUr)llUkctal haIIIII cc infiIIwiD occur without your wriUaJ autborizIItion Moroovcr ifyou sign such IIIICI audIorizaIioo you have the right to ameI it111 any time YOfU6z- I yftIllalalHallllCMIIIIJM t UodIpoundthelawyoubaYcsevcndrigbls ~t
Ltfe ~ is committed to upIaolcIioamp Those tipIs indude bull The right to RJqUCSl RSbidioos OIl some ofthe waysSest Life CDftM5dl~ usesdi9cl6suns JOUI information
Best Life ~ may DOl always IIJPC ID imp or these additional restridioas bull The rigbt to l1XlCiw confidential COO-bullbullicItions WIUIeSest Life ~ QIIIIGI promise ID communicate
ill every possible way requested 1K wiD wort willi to find lIIICIccptablc WIIJ to QIImnfidcntjaIly bull The rigbt to inspect and get copies ofheaIdt ce iuiNiiiiIliIIo held by Ee5t Life CDw~ by making a
request in writing Best Life ~ bowewr may ctrc a aurabIc_ to covcr only the cOst of providing this infiJrmIItioo
bull The right 10 request Ee5t Life ~ amend 01 conect infiItUllllliua about)OlL To make bull dBIge will be nquiml to nqucst in writinamp indIidiog die RBJll you MIll JOUI raunI dwnppI Sest Life ~ may not always agnc to suck nquesIS
The rigbl to a list ofSest ufe ~ disclosuns that wac not auIborilJId by you and the discIosuns wac unrelated to bCllbOCDl or opendions Ifyou have any questions _ alIIIpIaiDIs about the WIIJSest Life ~~ JOUI aIICdod QR
information or if belieyene your privacy right have beat vioIaIaI COI1Iad the sest Life ~ PrMcy Officer (Heather Pugb CAP LMHC SAP) III 727-S46-64000I inpcrson Voucan aIsoCODlaltheSectday oftbc US DepaatnllCOl ofHealth and HUDIIID SeIYica Please DOII ~will be 110 maJiatioa filing a complaint 01 making rcquem rcgadiog your beabh care iDfonnIIIion _ for dis8gmeinamp withSest Life ~~ shyrelated decisions
Notice ofPrivacy Practices Ackftowkdarme ofRaxipt I received copy of~t Life CDft~ s Notice of Privacy PIadices I uadaSUIMI that ifsest Life ~
uses my personal hcaIdI information in a IIIIIIIIlCr IhIIl is diftilCIIl dtaaibcrcl by the NCJIia ~ Life CDftseli~
must Iirsl get my permission in writing I am aaepIing this Notice OIl behIIIfof o Myself o Another person as his _ her personal representalive (perent guardian family member de)
PritNPa~_____________________________________________________
Prit NuIe fPet ~ (ifapplicable)_______________________________
Sipaanfll~ 111_____________________IWe~________
Ptgtt Li(t ~
Best Life Counseling Adult Personal History
Client ~--_____________ Date _____
First MI Phone ~______ Cell phone-_______
Address--____________________ City State___ Zip____
Social Searity Number_____ SpouseISignificont other Social SearitY----shyBirthplace Spouses Birthploce ____ [)ate of Birth Spouses dote of Birth--____ Email Address____________________ Why are you seeking counseling_________________________
MaritallFamily
of Full Siblings of Half Siblings __ Birth order Age _--_
Single ~ Married Separated DWorced _ Widowed Living Together Caucasian African-American HispanicILatin t-taaiianlPacific Islander
Multi-Rocial ~ Asian Other Native American- Hetro-Sexuol Homosexual ampi-Sexual Other Mother OcalpCltion________________
Age Is there CI contoct__ History of Mental Iliness__________________________ History of AlcoholDrug ______--____________________
Camments_______________________________
Father ____________ O~ion----------------
Age_____ Is there a contoct __ History of Mental Iliness__________________________ History of AlcoholDrug ___________________________
COm~--_________________________________
CurTcnt Si1uation
Who do you ive with____________________________ Where do you work ________ Whot is yCQ job_______________ Where does Spouse work_________________ What is there job____ Full or Port time____________ What other jobs have you had_________________________
A~~k~b~----------------------------
Have you lived anywhere else other than your curnnt residence If so please explainlt--_______
Family History
Do you hcIft any children or stepchildren If $0 pIeast give names and ~~____________
Lowe Socioeconomic Class Middlt Closs Upper Closs Alcoholic OIootic Distant Abusivle Controlling
Family Mental HeolthlAddictionlAlcoholiSlft History ____________________
Is there anyone in yow fCllftily you do not ~ contact with If $0 with whom___________
Who was in your fCllftily while you where growing up___________________
Wh~~~MW---------------------------------------
Educatianal I Social HistaI
Eosily forms friendships Attatcis social functions Needs social inta-oction Maintains friendships o Avoids social functions
00 Supportive Fritmds No close friends
How close friends do you ~____ Eementcry 0 Middlt School - High School Bochelor [)octorol ampED
0Some College Good Student IeGrrUng DtSobilities-____ ExtroaaTiculor Activities Avg Student Poor Student Regular Special Education0
Sports Advanced CIossa School Behavicrs (Childhoad)
Tnxny Argumentative Fighting with Peers Poor Effort Attenfive Repeated Grades Expulsions Susplmsions00
Difficulty with Peers Who do you turn to for support in your lif8______________________
~-----------------------------------------
Ctrrenf Employu______________________
GoodWorkHx PoorWorkHx On Sick leove
What is your financial situotion _____________________________
Military History
No Military Hx Spouse in Militcry Raised in Military Family Army Navy Air Force Marines Other _____________
Dotes of 5avice I I to I I Honorablt Dishonorable Medicof Service Related Disability AWOL Txt at VA Hospital
ComrRellts (list combat dates if opplicabI-)___________---___________
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
n~cSsaJ) tor anoth~r therapist to take possession ofmy tile and recurus 8) signing this information imJ consent fonn I give my consent to allo~ing another licensed mntal heahh professional selected by the undersigned titerdpist to take possession ofmy tile and records and provide me ~ith copitos upon request or ro deliver tikm to a tikrapist of my choice
llisputn
11 disputes arising out ofor in relation to this agreement to provide ps)chothcrapy services shall first be referred to mediation before and as a precondition of the initiation ofarbitration rhe mediator shall he neutral party chosen by agreement oHleather Pugh MACAP tMUG ()tner and client (s) rhe cost of I~iation bull ifany shall be split equally unless otherwise ~ed
Consenl to TreatlR~Dt
I voluntarily agree to receive Mental Health assessment care tniltment or services and authorize the undersigned therapist to provide such care treatment or services as are considered necessary and advisable
I unJerstand and agree that I will participate in the planning ofmy care lrealment or services and that I rna) stop such care treatment or services that I receive through the undersigned therapist at any time
R) signing this Client Information and Consent Fnnn I the undersigned client acknowledge that I have been both read and understood all the terms and infonnation contained herein Ample opportunity has been otTered to me to ask questions and seek clarification ofanything unclear to me
ClientiParent Date
-~----------------------------____------------------- ----_ _--__--shySocial Security Number and Address
As witnessed by
--
Tikrapists Name
Best Life Counseling Notice ofPrivacy Practices
THIS NOTICE DESCTIBES HOW UElJlCAL INFORMATION ABOUT rouJlArBE USED AND DISCLOSED AND HOW YOU CAN GETACC~TO THIS INFORMATION PlEASEREYlEW ITCAREFUUY
USt Life Ccu~ is ftqUired by Jaw to maiDIaiD the prMcyofarIaiII balIh QR infCW1Dlldioo about our pIIlients The Law RICpIifts be notified ofthese sIaidads As a part ofoufday-fo-day activities Boest Life ~ay need to use and disclose (sI8e) )OUr protected health
QIC irtfiJrm8Ja SCVCDI purposes witbouI6ntJOUI writIalllplllOftl 11IoIe pIII)ICIIICS iodade bull Boest Life cOampuueUM9 opaaliuns F_eaapIe_ Boest Life CDw~SIIIf_disuss)OUr
conditian in onIer to pnwide proper iii bull est Life ~ ayCODIalupoa JOUI Ilaquodtd balIh cm ida FarcumpIc ~t
Life ~may cd to amage JOUI pnwide with iDfia IRaIIPlt benefits and services that ~ aYaiIabIe to you
amptst Life CDft-seli~ may provide inNuU8Iion to govcmmcnt omaJs who owrsee health care _ thtaIIs to public
safety
No other uses and disdosuns of)OUr)llUkctal haIIIII cc infiIIwiD occur without your wriUaJ autborizIItion Moroovcr ifyou sign such IIIICI audIorizaIioo you have the right to ameI it111 any time YOfU6z- I yftIllalalHallllCMIIIIJM t UodIpoundthelawyoubaYcsevcndrigbls ~t
Ltfe ~ is committed to upIaolcIioamp Those tipIs indude bull The right to RJqUCSl RSbidioos OIl some ofthe waysSest Life CDftM5dl~ usesdi9cl6suns JOUI information
Best Life ~ may DOl always IIJPC ID imp or these additional restridioas bull The rigbt to l1XlCiw confidential COO-bullbullicItions WIUIeSest Life ~ QIIIIGI promise ID communicate
ill every possible way requested 1K wiD wort willi to find lIIICIccptablc WIIJ to QIImnfidcntjaIly bull The rigbt to inspect and get copies ofheaIdt ce iuiNiiiiIliIIo held by Ee5t Life CDw~ by making a
request in writing Best Life ~ bowewr may ctrc a aurabIc_ to covcr only the cOst of providing this infiJrmIItioo
bull The right 10 request Ee5t Life ~ amend 01 conect infiItUllllliua about)OlL To make bull dBIge will be nquiml to nqucst in writinamp indIidiog die RBJll you MIll JOUI raunI dwnppI Sest Life ~ may not always agnc to suck nquesIS
The rigbl to a list ofSest ufe ~ disclosuns that wac not auIborilJId by you and the discIosuns wac unrelated to bCllbOCDl or opendions Ifyou have any questions _ alIIIpIaiDIs about the WIIJSest Life ~~ JOUI aIICdod QR
information or if belieyene your privacy right have beat vioIaIaI COI1Iad the sest Life ~ PrMcy Officer (Heather Pugb CAP LMHC SAP) III 727-S46-64000I inpcrson Voucan aIsoCODlaltheSectday oftbc US DepaatnllCOl ofHealth and HUDIIID SeIYica Please DOII ~will be 110 maJiatioa filing a complaint 01 making rcquem rcgadiog your beabh care iDfonnIIIion _ for dis8gmeinamp withSest Life ~~ shyrelated decisions
Notice ofPrivacy Practices Ackftowkdarme ofRaxipt I received copy of~t Life CDft~ s Notice of Privacy PIadices I uadaSUIMI that ifsest Life ~
uses my personal hcaIdI information in a IIIIIIIIlCr IhIIl is diftilCIIl dtaaibcrcl by the NCJIia ~ Life CDftseli~
must Iirsl get my permission in writing I am aaepIing this Notice OIl behIIIfof o Myself o Another person as his _ her personal representalive (perent guardian family member de)
PritNPa~_____________________________________________________
Prit NuIe fPet ~ (ifapplicable)_______________________________
Sipaanfll~ 111_____________________IWe~________
Ptgtt Li(t ~
Best Life Counseling Adult Personal History
Client ~--_____________ Date _____
First MI Phone ~______ Cell phone-_______
Address--____________________ City State___ Zip____
Social Searity Number_____ SpouseISignificont other Social SearitY----shyBirthplace Spouses Birthploce ____ [)ate of Birth Spouses dote of Birth--____ Email Address____________________ Why are you seeking counseling_________________________
MaritallFamily
of Full Siblings of Half Siblings __ Birth order Age _--_
Single ~ Married Separated DWorced _ Widowed Living Together Caucasian African-American HispanicILatin t-taaiianlPacific Islander
Multi-Rocial ~ Asian Other Native American- Hetro-Sexuol Homosexual ampi-Sexual Other Mother OcalpCltion________________
Age Is there CI contoct__ History of Mental Iliness__________________________ History of AlcoholDrug ______--____________________
Camments_______________________________
Father ____________ O~ion----------------
Age_____ Is there a contoct __ History of Mental Iliness__________________________ History of AlcoholDrug ___________________________
COm~--_________________________________
CurTcnt Si1uation
Who do you ive with____________________________ Where do you work ________ Whot is yCQ job_______________ Where does Spouse work_________________ What is there job____ Full or Port time____________ What other jobs have you had_________________________
A~~k~b~----------------------------
Have you lived anywhere else other than your curnnt residence If so please explainlt--_______
Family History
Do you hcIft any children or stepchildren If $0 pIeast give names and ~~____________
Lowe Socioeconomic Class Middlt Closs Upper Closs Alcoholic OIootic Distant Abusivle Controlling
Family Mental HeolthlAddictionlAlcoholiSlft History ____________________
Is there anyone in yow fCllftily you do not ~ contact with If $0 with whom___________
Who was in your fCllftily while you where growing up___________________
Wh~~~MW---------------------------------------
Educatianal I Social HistaI
Eosily forms friendships Attatcis social functions Needs social inta-oction Maintains friendships o Avoids social functions
00 Supportive Fritmds No close friends
How close friends do you ~____ Eementcry 0 Middlt School - High School Bochelor [)octorol ampED
0Some College Good Student IeGrrUng DtSobilities-____ ExtroaaTiculor Activities Avg Student Poor Student Regular Special Education0
Sports Advanced CIossa School Behavicrs (Childhoad)
Tnxny Argumentative Fighting with Peers Poor Effort Attenfive Repeated Grades Expulsions Susplmsions00
Difficulty with Peers Who do you turn to for support in your lif8______________________
~-----------------------------------------
Ctrrenf Employu______________________
GoodWorkHx PoorWorkHx On Sick leove
What is your financial situotion _____________________________
Military History
No Military Hx Spouse in Militcry Raised in Military Family Army Navy Air Force Marines Other _____________
Dotes of 5avice I I to I I Honorablt Dishonorable Medicof Service Related Disability AWOL Txt at VA Hospital
ComrRellts (list combat dates if opplicabI-)___________---___________
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
Best Life Counseling Notice ofPrivacy Practices
THIS NOTICE DESCTIBES HOW UElJlCAL INFORMATION ABOUT rouJlArBE USED AND DISCLOSED AND HOW YOU CAN GETACC~TO THIS INFORMATION PlEASEREYlEW ITCAREFUUY
USt Life Ccu~ is ftqUired by Jaw to maiDIaiD the prMcyofarIaiII balIh QR infCW1Dlldioo about our pIIlients The Law RICpIifts be notified ofthese sIaidads As a part ofoufday-fo-day activities Boest Life ~ay need to use and disclose (sI8e) )OUr protected health
QIC irtfiJrm8Ja SCVCDI purposes witbouI6ntJOUI writIalllplllOftl 11IoIe pIII)ICIIICS iodade bull Boest Life cOampuueUM9 opaaliuns F_eaapIe_ Boest Life CDw~SIIIf_disuss)OUr
conditian in onIer to pnwide proper iii bull est Life ~ ayCODIalupoa JOUI Ilaquodtd balIh cm ida FarcumpIc ~t
Life ~may cd to amage JOUI pnwide with iDfia IRaIIPlt benefits and services that ~ aYaiIabIe to you
amptst Life CDft-seli~ may provide inNuU8Iion to govcmmcnt omaJs who owrsee health care _ thtaIIs to public
safety
No other uses and disdosuns of)OUr)llUkctal haIIIII cc infiIIwiD occur without your wriUaJ autborizIItion Moroovcr ifyou sign such IIIICI audIorizaIioo you have the right to ameI it111 any time YOfU6z- I yftIllalalHallllCMIIIIJM t UodIpoundthelawyoubaYcsevcndrigbls ~t
Ltfe ~ is committed to upIaolcIioamp Those tipIs indude bull The right to RJqUCSl RSbidioos OIl some ofthe waysSest Life CDftM5dl~ usesdi9cl6suns JOUI information
Best Life ~ may DOl always IIJPC ID imp or these additional restridioas bull The rigbt to l1XlCiw confidential COO-bullbullicItions WIUIeSest Life ~ QIIIIGI promise ID communicate
ill every possible way requested 1K wiD wort willi to find lIIICIccptablc WIIJ to QIImnfidcntjaIly bull The rigbt to inspect and get copies ofheaIdt ce iuiNiiiiIliIIo held by Ee5t Life CDw~ by making a
request in writing Best Life ~ bowewr may ctrc a aurabIc_ to covcr only the cOst of providing this infiJrmIItioo
bull The right 10 request Ee5t Life ~ amend 01 conect infiItUllllliua about)OlL To make bull dBIge will be nquiml to nqucst in writinamp indIidiog die RBJll you MIll JOUI raunI dwnppI Sest Life ~ may not always agnc to suck nquesIS
The rigbl to a list ofSest ufe ~ disclosuns that wac not auIborilJId by you and the discIosuns wac unrelated to bCllbOCDl or opendions Ifyou have any questions _ alIIIpIaiDIs about the WIIJSest Life ~~ JOUI aIICdod QR
information or if belieyene your privacy right have beat vioIaIaI COI1Iad the sest Life ~ PrMcy Officer (Heather Pugb CAP LMHC SAP) III 727-S46-64000I inpcrson Voucan aIsoCODlaltheSectday oftbc US DepaatnllCOl ofHealth and HUDIIID SeIYica Please DOII ~will be 110 maJiatioa filing a complaint 01 making rcquem rcgadiog your beabh care iDfonnIIIion _ for dis8gmeinamp withSest Life ~~ shyrelated decisions
Notice ofPrivacy Practices Ackftowkdarme ofRaxipt I received copy of~t Life CDft~ s Notice of Privacy PIadices I uadaSUIMI that ifsest Life ~
uses my personal hcaIdI information in a IIIIIIIIlCr IhIIl is diftilCIIl dtaaibcrcl by the NCJIia ~ Life CDftseli~
must Iirsl get my permission in writing I am aaepIing this Notice OIl behIIIfof o Myself o Another person as his _ her personal representalive (perent guardian family member de)
PritNPa~_____________________________________________________
Prit NuIe fPet ~ (ifapplicable)_______________________________
Sipaanfll~ 111_____________________IWe~________
Ptgtt Li(t ~
Best Life Counseling Adult Personal History
Client ~--_____________ Date _____
First MI Phone ~______ Cell phone-_______
Address--____________________ City State___ Zip____
Social Searity Number_____ SpouseISignificont other Social SearitY----shyBirthplace Spouses Birthploce ____ [)ate of Birth Spouses dote of Birth--____ Email Address____________________ Why are you seeking counseling_________________________
MaritallFamily
of Full Siblings of Half Siblings __ Birth order Age _--_
Single ~ Married Separated DWorced _ Widowed Living Together Caucasian African-American HispanicILatin t-taaiianlPacific Islander
Multi-Rocial ~ Asian Other Native American- Hetro-Sexuol Homosexual ampi-Sexual Other Mother OcalpCltion________________
Age Is there CI contoct__ History of Mental Iliness__________________________ History of AlcoholDrug ______--____________________
Camments_______________________________
Father ____________ O~ion----------------
Age_____ Is there a contoct __ History of Mental Iliness__________________________ History of AlcoholDrug ___________________________
COm~--_________________________________
CurTcnt Si1uation
Who do you ive with____________________________ Where do you work ________ Whot is yCQ job_______________ Where does Spouse work_________________ What is there job____ Full or Port time____________ What other jobs have you had_________________________
A~~k~b~----------------------------
Have you lived anywhere else other than your curnnt residence If so please explainlt--_______
Family History
Do you hcIft any children or stepchildren If $0 pIeast give names and ~~____________
Lowe Socioeconomic Class Middlt Closs Upper Closs Alcoholic OIootic Distant Abusivle Controlling
Family Mental HeolthlAddictionlAlcoholiSlft History ____________________
Is there anyone in yow fCllftily you do not ~ contact with If $0 with whom___________
Who was in your fCllftily while you where growing up___________________
Wh~~~MW---------------------------------------
Educatianal I Social HistaI
Eosily forms friendships Attatcis social functions Needs social inta-oction Maintains friendships o Avoids social functions
00 Supportive Fritmds No close friends
How close friends do you ~____ Eementcry 0 Middlt School - High School Bochelor [)octorol ampED
0Some College Good Student IeGrrUng DtSobilities-____ ExtroaaTiculor Activities Avg Student Poor Student Regular Special Education0
Sports Advanced CIossa School Behavicrs (Childhoad)
Tnxny Argumentative Fighting with Peers Poor Effort Attenfive Repeated Grades Expulsions Susplmsions00
Difficulty with Peers Who do you turn to for support in your lif8______________________
~-----------------------------------------
Ctrrenf Employu______________________
GoodWorkHx PoorWorkHx On Sick leove
What is your financial situotion _____________________________
Military History
No Military Hx Spouse in Militcry Raised in Military Family Army Navy Air Force Marines Other _____________
Dotes of 5avice I I to I I Honorablt Dishonorable Medicof Service Related Disability AWOL Txt at VA Hospital
ComrRellts (list combat dates if opplicabI-)___________---___________
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
Best Life Counseling Adult Personal History
Client ~--_____________ Date _____
First MI Phone ~______ Cell phone-_______
Address--____________________ City State___ Zip____
Social Searity Number_____ SpouseISignificont other Social SearitY----shyBirthplace Spouses Birthploce ____ [)ate of Birth Spouses dote of Birth--____ Email Address____________________ Why are you seeking counseling_________________________
MaritallFamily
of Full Siblings of Half Siblings __ Birth order Age _--_
Single ~ Married Separated DWorced _ Widowed Living Together Caucasian African-American HispanicILatin t-taaiianlPacific Islander
Multi-Rocial ~ Asian Other Native American- Hetro-Sexuol Homosexual ampi-Sexual Other Mother OcalpCltion________________
Age Is there CI contoct__ History of Mental Iliness__________________________ History of AlcoholDrug ______--____________________
Camments_______________________________
Father ____________ O~ion----------------
Age_____ Is there a contoct __ History of Mental Iliness__________________________ History of AlcoholDrug ___________________________
COm~--_________________________________
CurTcnt Si1uation
Who do you ive with____________________________ Where do you work ________ Whot is yCQ job_______________ Where does Spouse work_________________ What is there job____ Full or Port time____________ What other jobs have you had_________________________
A~~k~b~----------------------------
Have you lived anywhere else other than your curnnt residence If so please explainlt--_______
Family History
Do you hcIft any children or stepchildren If $0 pIeast give names and ~~____________
Lowe Socioeconomic Class Middlt Closs Upper Closs Alcoholic OIootic Distant Abusivle Controlling
Family Mental HeolthlAddictionlAlcoholiSlft History ____________________
Is there anyone in yow fCllftily you do not ~ contact with If $0 with whom___________
Who was in your fCllftily while you where growing up___________________
Wh~~~MW---------------------------------------
Educatianal I Social HistaI
Eosily forms friendships Attatcis social functions Needs social inta-oction Maintains friendships o Avoids social functions
00 Supportive Fritmds No close friends
How close friends do you ~____ Eementcry 0 Middlt School - High School Bochelor [)octorol ampED
0Some College Good Student IeGrrUng DtSobilities-____ ExtroaaTiculor Activities Avg Student Poor Student Regular Special Education0
Sports Advanced CIossa School Behavicrs (Childhoad)
Tnxny Argumentative Fighting with Peers Poor Effort Attenfive Repeated Grades Expulsions Susplmsions00
Difficulty with Peers Who do you turn to for support in your lif8______________________
~-----------------------------------------
Ctrrenf Employu______________________
GoodWorkHx PoorWorkHx On Sick leove
What is your financial situotion _____________________________
Military History
No Military Hx Spouse in Militcry Raised in Military Family Army Navy Air Force Marines Other _____________
Dotes of 5avice I I to I I Honorablt Dishonorable Medicof Service Related Disability AWOL Txt at VA Hospital
ComrRellts (list combat dates if opplicabI-)___________---___________
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
Family History
Do you hcIft any children or stepchildren If $0 pIeast give names and ~~____________
Lowe Socioeconomic Class Middlt Closs Upper Closs Alcoholic OIootic Distant Abusivle Controlling
Family Mental HeolthlAddictionlAlcoholiSlft History ____________________
Is there anyone in yow fCllftily you do not ~ contact with If $0 with whom___________
Who was in your fCllftily while you where growing up___________________
Wh~~~MW---------------------------------------
Educatianal I Social HistaI
Eosily forms friendships Attatcis social functions Needs social inta-oction Maintains friendships o Avoids social functions
00 Supportive Fritmds No close friends
How close friends do you ~____ Eementcry 0 Middlt School - High School Bochelor [)octorol ampED
0Some College Good Student IeGrrUng DtSobilities-____ ExtroaaTiculor Activities Avg Student Poor Student Regular Special Education0
Sports Advanced CIossa School Behavicrs (Childhoad)
Tnxny Argumentative Fighting with Peers Poor Effort Attenfive Repeated Grades Expulsions Susplmsions00
Difficulty with Peers Who do you turn to for support in your lif8______________________
~-----------------------------------------
Ctrrenf Employu______________________
GoodWorkHx PoorWorkHx On Sick leove
What is your financial situotion _____________________________
Military History
No Military Hx Spouse in Militcry Raised in Military Family Army Navy Air Force Marines Other _____________
Dotes of 5avice I I to I I Honorablt Dishonorable Medicof Service Related Disability AWOL Txt at VA Hospital
ComrRellts (list combat dates if opplicabI-)___________---___________
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
SpirituatRampfigiaus
What is your Spiritual Bockground_________ How important to you ore spiritual motters__ Not __ little __Moderate __Much Are you affiliated with a spiritual or religious group __No __Yes (describe)_________ Were you raised within a spiritual or religious group __No __Yes (describe) _________
Would you like yota spiritualreligious beliefs incorporated into the counseling __No __Yes (describe)
Current Status Divorce Pending Child custody Dispute ________________ Do you have any currentpost legal problems eM i ests etc________________
Are you presently on probation or parole __No __Yes If yes p~ describe______________________________
Past History
Traffic VIOlations __No __Yes DWIDUI etc No __Yes Criminal involvement __No __Yes Civil involvernent __No ---Yes If you responded yes to any of the above please fill in the following information
lciSlrClRecrecrti Describe special areas of interest or hobbies (eg crt books crafts physical fitness sports outdoor activities church activities walking exercising dietlhmlth hunting fishing bowting tlGveling etc) Activity How often rrarn How often in the post
Check all that apply AIDS Constipation Hepatitis Sore throat Alcoholism Chicken Pox High Blood Pressure Scarlet Fever Abdominal pain Dental Problems Kidney problems Sinusitis Abortion(-l Diabetes Measles Small Pox Allergies Diarrhea Monomucleosis Stroke Anelftia Dizziness Mumps Sexual Problems Appendicitis Drug abuse Menstrual Poin Tonsillitis Asthma Ear infection Neurological disorders Toothache Bronchitis Eating problems Nausea Thyroid problems Bed wetting Fainting Nose Bleeds Vision problems Cancer Fatigue Pneumonia Vomiting Chest Poin F~ urination Rheumatic fewr Whooping cough Chronic Pain Headaches L-migraines) Sexually Transrn~ Diseases ColdsCoughs Hearing problems Sleeping Disorders Other (describel-)______________________
Please check if there have been any recent changes in the following _Sleep petta ns _Eating petta 1L9 _Behawior _Energy IeveJ _Physical activity level _General disposition _Weight _Nenousnessten5ion
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
Describe changes in areas in which you check obove___________________
List any CUTent health concerns__________________________
List any recent health or physical chonge$--______________________
Nutrition
Meal He often (times per wk) __ WeekBreakfast -No_ u~ _High
Lunch ---Week ~_u _Mcd -High_No_ u ____J-fighDinner ---Week
SnGc1cs ----Week ~_u -IMd -High
Current Prescribed Medications Dose Dotes Purpose Side Affects
Current over-counter Meds Side Affects Vitamins or Herbs
family History of Medical Problems________________________
Are you allergic to any medications or drugs _No _Yes (describe dosogeOIROCAIt per dayL)______
Are you sexually active _No Yes Are you on birth control _ No _ Yes (if yes what type of method do you usc__________ HIV tested _No _ Yes (if yes what are the resutsL________________
Last physicol Exam Last doctors visit
Last denta exam Most recent surgery Other slIgeIy Upcoming surgery
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
Chemical Usc History
Method ofUsamp
Frequency Age of 1st USC Age of last Used in last -18 hours YesNo
Used in last 3Odays YeslNo
Alcohol
Barbiturates
VaJiuntlUbri
Cocaineend
HeroinOpiates
Marijuana
PCPJLSI)Mescaline
Inhalants
Coffeine
Nicotine
or the Counter
Prescriptions ~
OtherDrugs
Substance of Preference 3-____________________________1 2 ~-----------------------------Describe when and where you typically use substonces _______________________
Describe any changes in yocr use pcrtterrI _________________________
Describe how your use has affected yocr family or friends (include thpoundir perceptions of your use)
Reason(s) for use _Addicted _Build confidence _Escape _Self-mediCGtion _Socialization _Taste _Other (specifyl-)___________________ How do you believe yow substance use affects yBlF life_______________________
Who or what has helped you in stopping or limiting yow- use1_______________________
Does (has) someone in ycxr family (past~) hove (hod) a problem with drugs or alcohol __Nb __Yes(~be~)_________________________________________________
Have you hod withdrawal symptoms when trying to stop using drugs or alcohol _No _Yes (describe)
Have you ht adverse reactions or ova-dose to drugs or alcohol _No _Y~ (describel-l__________
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
Does your body temperature change whEn you drink _No _Yes (describell--__________
Have drugs or alcohol created G problem for your job _No _Yes (describel-___________
No Yu When Where YOIII reaction to owraIl experience
CounselinglPsychiatric treatment
Suicidal thoughtsattempts
DrugAlcohol Treatment
Hospitalimtions
Involvement llith self-help groups
Hove family or Significant others had counseling or treGflftent _No _Yes (descnbe6-l________
Please check behoYiors and symptoms that ocar to you more often than you would like to toke place middot Aggression Dizziness Irritobili1y Speech problems
Alcohol dependence Drug dependence Judgment enor$ Suicidal thoughts Anger Eating disorder Memory impairment Thoughts disorganized
middot Antisocial Behavior EkMrted mood Mood shifts Trembling Anxia1y fatigue Panic attacks Withdrcawing Avoiding People Gambling Phobiasfears Worrying Chest Poin Hallucinations RearMng thoughts Others describe) _____ Cyber addiction Heart palpitations Sexual addictions Depression High blood pressure Sexual difficulties
middot Disorientation Hopelessness Sick Often DiStractibility Impulsivity Sleeping problems
Any camprrent suicidal thoughtsplan _No _Yes (if yes what is the plon6-)_______-----shy
Any history of SUicidal attempts__________________________ Current health issucs ______________________________
Briefly discuss how the ~ symptoms impair YOlF obili1y to function effectively __________
Any additional information that would ClSSist us in understanding yotr concerns or problems _______
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
FOR STAFF use ONY
Therapists SignatureCredentials Dote
Cotnments
Supervisors SignatureCredentials
PhYSician ExClt1 Release of Information _Required _Not Required _On File _Signed amp bated
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date
--------------------------------------------------
--------------------------------------------
No-Show Form Best Life Counseling
10707 66th St No Ste6
Pinellas P~ FL 33782
DECLARATION OF AGREEMENT REGARDING MISSED OR CANCELED APPOINTMENT
1 It is my responsibility to notify
Name
Phone number
24 hours prior to the scheduled appointment if I am unable to keep the scheduled appointment
2 I agree that I wiIJ be billed the $4000 fee in the event that I miss an appointment or fail to cancel 24 hours prior to the scheduled appointment
Patient
Practitioner
Date