Assessment Form - Can Do Counseling and Hypnosis Center, LLC

Step 1 of 4

25%

Can Do Counseling Screening & Strengths Based Assessment Form

SCREENING SECTION

Name:(Required)

First Name Middle Name Last Name

What would you like to be called?

Consumer ID:

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone:(Required)

Alt Phone:

Service Carrier:(Required)

Email:(Required)

Best way to contact:

phone

txt

DOB:

Age:

Please enter a number from 1 to 200.

Gender:

Female

Male

SSN:

Provider:

Policy #:

Policy Holder:

Policy Holder Birthdate:

MM slash DD slash YYYY

PERSON RESPONSIBLE FOR CARE / EMERGENCY CONTACT

Name:

First Name Middle Name Last Name

Relationship to Patient:

Willing to participate in services?

Yes

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

(if different than above)

Phone:

Alt. Phone:

Best way to contact:

phone

txt

If not available may we leave a message with others in the home or at that number?

Yes

Responsible party DOB:

Describe Specific emotional/behavioral problems that led to your coming here today:

Do you have current thoughts of harming yourself or others or engage in risk-taking behavior?

Yes

If yes, please describe:

CONSUMER RIGHTS

Can Do Counseling / 619 W. Main / Yukon, OK 73099 / 405-435-5848

Can Do Counseling shall support and protect the fundamental human, civil, and constitutional rights of the individual consumer. Each consumer has the right to be treated with respect and dignity and will be provided the synopsis of the Bill of Rights as listed below:

Each consumer shall retain all rights, benefits, and privileges guaranteed by law except those lost through due process of law.
Each consumer has the right to receive services suited to his or her condition in a safe, sanitary and humane treatment environment regardless of race, religion, gender, ethnicity, age, degree of disability, handicapping condition or sexual orientation.
No consumer shall be neglected or sexually, physically, verbally, or otherwise abused.
Each consumer shall be provided with prompt, competent, and appropriate treatment; and an individualized treatment plan. A consumer shall participate in his or her treatment programs and may consent or refuse to consent to the proposed treatment. The right to consent or refuse to consent may be abridged for those consumers adjudged incompetent by a court of competent jurisdiction and in emergency situations as defined by law. Additionally, each consumer shall have the right to the following:

Allow other individuals of the consumer's choice participate in the consumer's treatment and with the consumer's consent;
To be free from unnecessary, inappropriate, or excessive treatment;
To participate in consumer's own treatment and discharge/transition planning;
o To receive treatment for co-occurring disorders if present;
o To not be subject to unnecessary, inappropriate, or unsafe termination from treatment; and
o To not be discharged for displaying symptoms of the consumer's disorder.

• Every consumer's record shall be treated in a confidential manner.
• No consumer shall be required to participate in any research project or medical experiment without his or her informed consent as defined by law. Refusal to participate shall not affect the services available to the consumer.
• A consumer shall have the right to assert grievances with respect to an alleged infringement on his or her rights.
• Each consumer has the right to request the opinion of an outside medical or psychiatric consultant at his or her own expense or a right to an internal consultation upon request at no expense.
• No consumer shall be retaliated against or subjected to any adverse change of conditions or treatment because the consumer asserted his or her rights.

Consumer Signature (14 or older):(Required)

Date:

Month

Day

Year

Parent/Guardian Signature:

Date:

MM slash DD slash YYYY

Staff Signature:

Title/Credentials:

Date:

MM slash DD slash YYYY

CONSENT FOR USE OF HEALTH INFORMATION

Can Do Counseling / 619 W. Main / Yukon, OK 73099 / 405.435.584

, understand that as part of my health care, Can Do Counseling originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment,
A means of communication among the health professionals who may contribute to my care,
A source of information for applying my diagnosis and treatment to my bill,
A means by which a third-party payer can verify that services billed were actually provided,
A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

(Initial):

I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax or electronic form.

(Initial):

I understand that if my partner and I are in couples counseling, nothing will be confidential between either partner.

(Initial):

Since part of the cost of your treatment may be paid by federal, state, or local sources, these sources have the right to review client files to verify that these services have been delivered appropriately. This review is done for accounting or evaluative purposes only, with no files or clinical information removed from this agency. Others having review access to your file are agency staff, consultants, and accountants.

I fully understand and

decline

the terms of this consent.

Consumer Signature (14 or older):(Required)

Date:

MM slash DD slash YYYY

Parent/Guardian Signature:

Date:

MM slash DD slash YYYY

Staff Signature:

Title/Credentials:

Date:

MM slash DD slash YYYY

CONSENT FOR TREATMENT

Can Do Counseling / 619 W. Main / Yukon, OK 73099 / 405-435-5848

(Initial):

Although the ultimate goal of therapy is for me/us to exhibit alleviated/eliminated symptoms as indicated by my/our individualized treatment plan, I/We understand that no guarantees are given by anyone as to the results that may be obtained.

(Initial):

I/We have read this Consent for Treatment, understand all of its contents and signed my/our name(s) freely, voluntarily, and without coercion.

THIS CONSENT SHALL REMAIN IN EFFECT COMMENCING ON THE DATE OF ADMISSION UNTIL THE CONSUMER HAS BEEN DISCHARGED; AND FOR THE PURPOSES OF FOLLOW-UP, UNLESS REVOKED IN WRITING AND DELIVERED TO THE AGENCY, CAN DO COUNSELING.

Consumer Signature (14 or older):(Required)

Date:

MM slash DD slash YYYY

Parent/Guardian Signature:

Date:

MM slash DD slash YYYY

Staff Signature:

Title/Credentials:

Date:

MM slash DD slash YYYY

PAYMENT AGREEMENT

I agree to pay a fee as termed by my insurance per 60 minute session or $75 hourly (Self pay consumers).

I agree to pay the deductible, copay, and/or coinsurance fees as dictated by my insurance provider.

I understand that any copay, as dictated by my insurance policy, is due at the time services are rendered. If using a credit card, I consent to an additional $3 fee being charged to my credit card on the date of each service provided to me.

I understand that I am responsible for the charges for services provided by Can Do Counseling and that my insurance provider may make payments on my account. If any part of my fees are being paid by my insurance provider or other third party, I understand that this may result in limitations to my confidentiality.

I agree to pay a 24-hour late/cancellation fee or no show fee of $75. I understand that subsequent late cancellations or no shows may result in termination of services. I may or may not receive a notification.

I agree to pay an amount of __________________________ for hypnosis. I understand that there is no guarantee that it will be 100% effective. It all depends on the attitude of the client.

Amount:

RATES

Individual and Family Sessions $75 to $120
Individual sessions are usually scheduled for 55 minutes but can be scheduled for 85 minutes if needed or requested. Family sessions are usually scheduled for 85 minutes.

Court Testimony- No staff or personnel associated with Can Do Counseling will testify in court unless required to do so by a judge signed court order or law. This includes conversations with an attorney. If compelled to testify, the rate will be $1,000 to be paid prior to me saving it on my calendar. If court date is changed, for whatever reason, 48 hours or less before the date on the subpoena, there will be an additional fee of $400 and the amount left of the $1,000 will either be given back or will be applied to when I do testify in court. This is to cover the cancelled services from the schedule that I cleared to make myself available for you. All fees, deductibles, and any amount owed must be paid prior to any testimony or conversations with attornies.

PAYMENT Payment is expected at the time of services unless other arrangements have been made. However, no one will be refused services due to inability or refusal to pay. Payment is accepted in the form of cash, check or credit card.

Consumer Signature (14 or older):(Required)

Date:
MM slash DD slash YYYY

Parent/Guardian Signature:

Date:
MM slash DD slash YYYY

Staff Signature:

Title/Credentials:

Date:
MM slash DD slash YYYY

Comments
This field is for validation purposes and should be left unchanged.