CHERYL DESMIDT, LMFT

New Client Information

Patient Name Age Gender

Address

City State Zip Email

Date of Birth Social Security Number

Primary phone cell home work other Secondary cell home work other

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Primary Insurance Carrier Policy ID #

Name of Policy Holder (if not patient) Date of Birth

Secondary Insurance Carrier Policy ID#

Name of 2nd Policy Holder (if not patient) Date of Birth

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Place of Employment/School:

Occupation: Marital status:

Partner’s Name: Partner’s occupation:

If Patient is a minor: Mother’s name Father’s name

Name(s) and age(s) of siblings:

Parents’ marital status: married living together separated divorced

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Primary Care Physician Tel # Last visit

Would you describe your current physical health as: Very Good Good Average Poor	Other:

Do you have current legal difficulties? If so, please describe:

Current complaint or symptoms:

What are your expectations from this consultation?

How did you find us/who referred you?

Signature of Client: (or Guardian if client is a minor)

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Office Use Only: First Appt……………….. Last Seen…………….Date Closed…………….Date Destroyed……………..

CHERYL DESMIDT, LMFT

Authorization for Release of Information

Patient Name:

Date of Birth: SSN:

I understand that under Florida law, communications between a patient and his/her psychotherapist are privileged and may not be disclosed by the treating provider unless the patient or parent/legal guardian gives written permission. I also understand that Client Records maintained by a psychologist may not be disclosed to third parties except by my expressed written consent or through the legal process. I also understand that, in accordance with HIPAA guidelines for mental health records, in some cases I may have copies of the record for my files and may review the record with my counselor during a session specifically scheduled for this purpose.

Date:

To:

_X_ My insurance/managed care company or EAP (N/A only for private pay clients):

My primary care physician, Dr.

Phone #	Fax #

My psychiatrist, Dr.

Phone #	Fax #

My previous therapist,

Phone #	Fax #

School Official(s)

Phone #	Fax #

Other

Phone #	Fax #

I hereby authorize	Cheryl Desmidt, LMFT	to disclose, release, and/or obtain records on my behalf (or on behalf of my child ). This authorization is limited to the purpose of releasing or obtaining information relevant to my case or for purposes of evaluation and treatment. This authorization shall remain in force unless revoked by me in writing.

Patient (or Guardian)	Date

Witness	Date

CHERYL DESMIDT, LMFT

Client Consent

I hereby apply for and consent to psychological evaluation and/or treatment by Associates for Human Development, specifically	Cheryl Desmidt, LMFT	, for my child or myself. I understand that it is my responsibility to cooperate with evaluation and/or /treatment to the best of my ability. I understand Florida State, Federal law and professional ethical standards provide for the confidentiality of psychotherapist/ client communications including records. Your therapist and this office will not disclose or confirm your use of services at this office. Lawful and legally required exceptions to this privilege of confidentiality include; information of child abuse, elder abuse, the immediate physical danger to yourself or another, a lawful court order and your signed consent.

I hereby authorize the payment of health benefits to which I am entitled, to Associates for Human Development and/or	Cheryl Desmidt, LMFT	. Insurance billing is performed as a convenience to me and I understand that I am responsible for all charges not covered by my carrier. I understand that I am responsible for obtaining authorization directly from my insurance carrier, PPO, HMO, or their legal representative, when requested, or conducting communications with same to facilitate payment for services. I understand that charges and/or co-payments for all services are due and payable at the time services are rendered, or as provided by state/federal statute or regulation.

Because time has been reserved for me and/or members of my family, except in the event of a true emergency (final decision to be made by therapist), I am expected to provide at least 24 hours advanced notice if I am unable to keep a scheduled appointment. In the event that the office is closed, date and time stamped voicemail is available 24/7 and does suffice for giving adequate notice. If I miss my appointment or fail to provide such notice, my credit card will be charged $80 (insurance clients) or the full session fee (private-pay clients) for the time reserved. Insurance carriers will not pay for missed appointments and therefore cannot be billed. Also, returned checks will not be re-presented to your bank, and a fee of $25 will be assessed.

Credit card # Expiration date

CVV code Name on the card

I understand that insurance benefits, if any, will pay only for therapeutic sessions. Time spent on telephone calls, preparation of letters or reports, psychological testing, or attendance at schools, depositions, legal proceedings, or other conferences, whether for me or my child, is my financial responsibility and will be billed at the prevailing hourly rate ($130 per hour) for those services. In addition, should this account be sent to an outside Agency for collection of a balance due, the client will be responsible for all and any fees assessed.

My full signature below indicates that I have read and agree to all policies.

Signature:	Date:

CHERYL DESMIDT, LMFT

Health Insurance Portability Accountability Act (HIPAA) Client Rights & Therapist Duties

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your PHI in greater detail.

The law requires that I obtain your signature acknowledging that I have provided you with this. If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless I have taken action in reliance on it.

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communication between a patient and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary. Reasons I may have to release your information without authorization:

If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.

If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them.

If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.

If a patient files a worker's compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.

I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient's treatment:

If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the Florida Abuse Hotline. Once such a report is filed, I may be required to provide additional information.

If I know or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the Florida Abuse Hotline. Once such a report is filed, I may be required to provide additional information.

If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.

CLIENT RIGHTS AND THERAPIST DUTIES

Use and Disclosure of Protected Health Information:

For Treatment – I use and disclose your health information internally in the course of your treatment. If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.

For Payment – I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.

For Operations – I may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.

Patient's Rights:

Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.

Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. I will agree to such unless a law requires us to share that information.

Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.

Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Furthermore, there is a copying fee charge of $1.00 per page. Please make your request well in advanced and allow 2 weeks to receive the copies. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.

Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days.

Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request.

Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.

Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action.

Right to Choose – You have the right to decide not to receive services with me. If you wish, I will provide you with names of other qualified professionals.

Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. I ask that you discuss your decision with me in session before terminating, or at least contact me by phone letting me know you are terminating services.

Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.

Therapist’s Duties:

I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you with a revised notice in office during our session.

COMPLAINTS

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me, the State of Florida Department of Health, or the Secretary of the U.S. Department of Health and Human Services.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.

Client/Legal Guardian Signature	Date

Clinician Signature	Date