- Aloha Counseling Associates

1/11
Welcome to Aloha Counseling Associates, LLC (ACA, LCC). We are looking forward to meeting with you.
Before your first appointment, we would like you to read and complete the following forms in this packet:
1) Demographic Information, 2) Insurance Information, 3) Professional Fees, 4) Late Cancellation/No
Show Policy, 5) Acknowledgement of HIPPA, 6) Release of Information, 7) Treatment Guidelines, and 8)
Child/Adolesent History Form
If you have any questions, please contact your provider or staff at ACA, LCC. Mahalo for your help and
cooperation.
DEMOGRAPHIC INFORMATION
Full Name: _____________________________________________ Date of Birth: ________________
Race/Ethnicity: ____________________ Age: __________ Sex: Male/Female
Preferred Phone: _________________________ Home/Cell/ Work (circle one) ¨ Check if OK to leave message
Alternative Phone: _______________________ Home/Cell/ Work (circle one) ¨ Check if OK to leave message
Marital Status: □ Never Married □ Married/Committed Relationship □ Divorced □ Separated □ Widowed
I am presently living: □Alone □With others (please specify):_________________________________
Home Address:___________________________________________________________________________
Primary Care Physician: ___________________________________________________________________
Referred by (if different that PCP): ___________________________________________________________
INSURANCE INFORMATION
Primary Insurance Company: ___________________________ Subscriber #: ____________________________
Group #: _________________________
Sponsor SS# (Tricare Only) ______________________________
Secondary Insurance Company: _________________________ Subscriber #: ____________________________
Group#:__________________________
Signature: __________________________________________
Date: ____________________________
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
2/11
PROFESSIONAL FEES
Please check with your insurance company's mental or behavioral health plan or request a referral from your primary care
provider or referring doctor to insure that your visit is covered by your health insurance. Please see ACA, LCC staff if you
are not sure; otherwise, the patient will be financially responsible for visits/services that are not covered by your
insurance.
The hourly rate is $225.00 + tax per hour (except for testing and assessment). However, this rate will be adjusted if your
provider works for periods less than one hour.
PSYCHOTHERAPY - $225.00 + tax per 50 min. hour.***
PSYCHOLOGICAL TESTING/ASSESSMENT - $250.00 + tax per hour including administration, scoring, interpretation,
and report.***
LEGAL INVOLVEMENT - $500.00 + tax per hour. If the patient becomes involved in legal proceedings that require the
provider's participation, the patient will be expected to cover for all of the provider's professional time, including
preparation and transportation costs, including testifying in court.***
Other additional charges include report writing, telephone consults lasting 15 minutes, preparation of records and
treatment summaries, and other time used to perform services required of your provider.***
*** Indicate services that may not be covered by your health insurance.
Sliding Fee Schedule: Please contact us at 680-0558 if you have no insurance or cannot afford these fees.
LATE CANCELLATION AND "NO SHOW" POLICY
Psychotherapy is like a contract between the patient and the provider; it's an agreement that both parties will sincerely try
their best to work toward a treatment goal. To insure patients' responsibility to themselves and to the therapeutic process,
and that other patients have an opportunity to schedule an appointment when there's a cancellation, there will be a $20.00
no show or late cancellation fee starting on the first business day of January 2015. However, if they were due to
emergencies or unusual circumstances, this fee may be waived. To avoid this charge, please cancel 24 hours in advance.
Further, we will not schedule an appointment after 3 consecutive cancellations and/or no shows. If you have any questions
or concerns about this policy, please contact us or your provider.
ACKNOWLEDGEMENT OF HIPAA
I was offered a copy of the HIPAA form concerning privacy protection by a representative of Aloha Counseling
Associates, LLC or have downloaded the HIPPA form from the ACA, LCC website.
__________________________________________
Signature
___________________
Date
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
3/11
RELEASE OF INFORMATION
Patient Name: _____________________________________________________
Patient Date of Birth: ________________________________________________
Person Authorized to give permission: __________________________________
Relationship to patient: ______________________________________________
I give permission for the staff at Aloha Counseling Associates, LLC to communicate with
_______________________________________________________ (name of primary care provider) and exchange
information, if necessary, regarding medical and psychological information.
This information will be used for evaluation, treatment, or psychological consultation regarding the patient
listed above. The above permission includes oral communication and exchange of relevant patient
information, including but not limited to, summaries of treatment, copies of records, and diagnosis, when
necessary.
______________________________________________
Authorized Person Granting Permission
Signature
__________
Date
______________________________________________
Clinician Signature
__________
Date
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
4/11
TREATMENT GUIDELINES
Emergency Contact:
Dr. Valdez is not available on an emergency or “on-call” basis. Patients requiring immediate assistance must call the
Mental Health Crisis Hotline at (808) 832-3100, 911, or go to the nearest emergency room.
Limits of Treatment:
There are some circumstances in which Dr. Valdez may make the decision to end therapy. Such circumstances include,
but are not limited to:
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treatment appears to be ineffective
threats are made against the therapist or his/her family
the therapist does not believe he/she has the necessary training to address a specific problem
there is no progress with treatment
In such cases, Dr. Valdez will attempt to find a suitable referral. He cannot be responsible as to whether this referral is
accepted.
Confidentiality:
In general, the privacy of all communications between a patient and a psychologist is protected by law, and your provider
can only release information about our work to others with your written permission. But there are a few exceptions.
(Your initials indicate that you read and understood each exception.)
Legal Proceedings: If, for some reason, your provider is court ordered to testify or release information regarding your
mental health or where your emotional condition is an important issue. Initials: ____
Abuse: If you tell your provider that you or some other identifiable person is abusing a child, elderly, or disabled person,
your provider is legally mandated to file a report with the appropriate state agency. Initials: _____
Danger To Self or Others: If you tell your provider that you are threatening serious bodily harm to either yourself or
another. These actions may include notifying the potential victim, contacting the police, seeking hospitalization for the
patient, or contacting family members or others who can help provide protection. Initials: _____
These situations occur quite rarely. But, if this situation occurs, your provider will make every effort to fully discuss it
with you before taking any action.
Minors: If you are a minor, under the age of 18, please be aware that the law may provide your parents the right to
information about your treatment. For teenagers, it is the policy at ACA, LLC to request an agreement from your parents
that they be provided with only general information about our work together, unless there is a high risk that you will
seriously harm yourself or someone else. Before giving them any information, your provider will discuss the matter with
you, if possible, and do their best to address any objections you may have.
Office Sharing: Please note ACA, LLC shares an office space with West Shore Neurological Services, LLC. These are
two separate entities, however, we consult with each other if you are a patient at both clinics.
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
5/11
PROFESSIONAL RECORDS
ACA, LLC is required to keep records of its professional services, your treatment, or your work together. Our general
policy is that patients may not review them; however, we can provide a treatment summary unless it is believed that doing
so would be emotionally damaging. If that is the case, we will be happy to send the summary to another mental health
professional who is working with you.
DISPUTES
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full
disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal
proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.) neither you nor your
attorney(s) nor anyone else acting on your behalf will call on ACA, LLC provider(s) to testify in court or at any
other proceeding, nor will a disclosure of psychotherapy records be requested.
(Please initial here): _____________
CONSENT FOR TREATMENT
I authorize Dr. Jay Valdez, Psychologist at Aloha Counseling Associates, LCC, to provide
psychological evaluation and treatment to me. I have read and understood the forms in this
packet and agree to all its conditions.
__________________________________________
Signature
___________________
Date
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
6/11
Please complete to the best of your knowledge. Leave blank to those you do not know answer to.
Thank You!
CHILD/ADOLESCENT HISTORY
Patient Name: ________________________________ Today’s Date: ___________________________________
Form Completed by: ___________________________ Relationship: ____________________________________
Date of Birth: _________________________________ Race/Ethnicity: __________________________________
Referred by: __________________________________ Reason for Referral: ______________________________
Emergency Contact: ____________________________ Emergency Phone: _______________________________
PRESENTING PROBLEM
How long ago did the problem begin:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Reason(s) for seeking services:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What things have you tried to deal with these concerns:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MEDICAL HISTORY
Current Medical Conditions/Concerns:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________
Primary Care Provider: _______________________________________ Last Physical Exam: _________________
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
7/11
Are you taking any medications on an ongoing basis? Yes/No
Name of Medication
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
Dose/Frequency
____________
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____________
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Name of Prescribing Physician
____________________________
____________________________
____________________________
____________________________
____________________________
Medical Hospitalizations/Surgeries:(Please describe and include dates)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Family History of Medical Problems:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please indicate if you have had any history of the following medical problems:
Allergies
Asthma
Diabetes
Chronic Ear Infections
Headaches
Head Injuries
Hearing/Ear Problems
Loss of Consciousness
Nightmares
Nutrition Concerns
Problems with Pain
Seizures
Serious Accidents
Sleep Apnea/Snoring
Surgeries
Thyroid Difficulties
Tics/Twitching
Vision/Eye Problems
Alcohol Use/Abuse
Illicit Drug Use/Abuse
Risky Behaviors
Circle One
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Ages
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Describe
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Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
8/11
DEVELOPMENTAL HISTORY
Mother’s Age During Pregnancy: ______________________
Child’s Birth Weight: ______________________
Mother’s Health During Pregnancy: _______________________________________________________________
Use of Cigarettes During Pregnancy
Use of Alcohol During Pregnancy
Use of Drugs During Pregnancy
Use of Prescription Medication
Complications During Pregnancy
Problems at Birth
Developmental Delays/Concerns
Received Speech Therapy
Received Physical Therapy
Age Walked: ________
Yes
No
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Describe: ______________________________________
Describe: ______________________________________
Describe: ______________________________________
Name: ________________________________________
Describe: ______________________________________
Describe: ______________________________________
Describe: ______________________________________
For: ___________________________________________
For: ___________________________________________
Age Talked: ________
Age Toilet Trained: ___________
Describe Child’s Personality as a Baby/Toddler:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MENTAL HEALTH
Please check any of the following stresses that apply to you or your family and describe:
□ Major Relocations:___________________________________________________________________________
□ School/Job Change:__________________________________________________________________________
□ Deaths:____________________________________________________________________________________
□ Relational Problems:_________________________________________________________________________
□ Someone Significant Moving Out of the Area:_____________________________________________________
□ Experiencing a Traumatic Event:________________________________________________________________
□ Witnessing a Traumatic Event: _________________________________________________________________
□ Child Protective Services (CPS) or Adult Protective Services (APS) Involvement: ________________________
____________________________________________________________________________________________
Past Psychiatric Evaluation
Prior Diagnosis of a Mental Health Disorder
Prior Use of Psychiatric Medication
History of Harm to Self/Others
Circle One
Yes/No
Yes/No
Yes/No
Yes/No
Date(s): _________________________________
Diagnoses: _______________________________
Name(s): ________________________________
Who/When: ______________________________
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
9/11
History of Suicide in Your Family
Past Psychiatric Hospitalization
Yes/No
Yes/No
Who/When: ______________________________
Dates(s): _________________________________
HISTORY OF ABUSE
Emotional Abuse
Verbal Abuse
Physical Abuse
Sexual Abuse
Yes/No
Yes/No
Yes/No
Yes/No
Who/When: _________________________________________________
Who/When: _________________________________________________
Who/When: _________________________________________________
Who/When: _________________________________________________
SCHOOL HISTORY
Academic Difficulties: Elementary School
Academic Difficulties: Middle School
Academic Difficulties: High School
Yes/No
Yes/No
Yes/No
Describe: ________________________________
Describe: ________________________________
Describe: ________________________________
Behavioral Difficulties: Elementary School
Behavioral Difficulties: Middle School
Behavioral Difficulties: High School
Yes/No
Yes/No
Yes/No
Describe: ________________________________
Describe: ________________________________
Describe: ________________________________
Special Education
Gifted Classes
Graduated High School
Attended College
Grade/Age: ___________________________________________
Grade/Age: ___________________________________________
Name/Yr: _____________________________________________
Name/Yr: _____________________________________________
Yes/No
Yes/No
Yes/No
Yes/No
IMMEDIATE FAMILY HISTORY
Medical Illness
Mental Health Illness
Substance Abuse
Legal Issues (Arrests/Jail)
Learning Difficulties/Disabilities
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Diagnoses: _____________________________________
Diagnoses: _____________________________________
Type(s): _______________________________________
Type(s): _______________________________________
Diagnoses: _____________________________________
FAMILY INFORMATION
Relationship
Good Avg Poor
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Mother’s Name: ______________________________
Educational Level: ____________________________
Occupation: _________________________________
Age: _____
Living Deceased
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Father’s Name: ______________________________
Educational Level: ___________________________
Occupation: _________________________________
Age: _____
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Stepmother’s Name: __________________________
Educational Level: ___________________________
Occupation: _________________________________
Age: _____
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Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
10/11
Age: _____
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Brother’s Name/Age: _________________________
Brother’s Name/Age: _________________________
Brother’s Name/Age: _________________________
Age: _____
Age: _____
Age: _____
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Sister’s Name/Age: __________________________
Sister’s Name/Age: __________________________
Sister’s Name/Age: __________________________
Age: _____
Age: _____
Age: _____
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Stepfather’s Name: ___________________________
Educational Level: ___________________________
Occupation: _________________________________
Other People Living in the Home or Have Significant Influence:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
LEGAL HISTORY
Past Trouble with the Law
Gone to Court
Been Arrested
Yes/No
Yes/No
Yes/No
When/Why: ___________________________________________
When/Why: ___________________________________________
When/Why: ___________________________________________
SUBSTANCE USE HISTORY
Past Use of Drugs or Alcohol
Use of Drugs or Alcohol Within Past Month
Past Treatment for Drugs/Alcohol
Addicted to Eating
Addicted to Gambling
Addicted to Spending Money
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
What/When: _____________________________
What/When: _____________________________
What/When: _____________________________
When: __________________________________
When: __________________________________
When: __________________________________
SOCIAL RELATIONSHIPS
People are Supportive of You
You have People You Can Tell Personal Information
You have People to Do Things With
Yes/No
Yes/No
Yes/No
Who: _____________________________
Who: _____________________________
Who: _____________________________
EMOTIONAL AND BEHAVIORAL FUNCTIONING
Strengths
Limitations/Weaknesses
___________________________________________
______________________________________________
___________________________________________
______________________________________________
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]
11/11
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Hobbies
___________________________________________
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GOALS FOR THERAPY
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
5. __________________________________________________________________________________________
Aloha Counseling Associates, LLC
94-216 Farrington Highway, Suite A-103 Waipahu, HI 96797
Phone: (808)680-0558 Fax: (808)680-0500 E-Mail: [email protected]