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DeLuca Family Wellness Center, Inc.
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Matt
Molly
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Christina
Lisa
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Home
Therapists
Matt
Molly
Jaime
Ashley
Christina
Lisa
Forms
Services
About Us
Contact Us
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DeLuca Family Wellness Center Inc Initial Intake
Date
(Required)
MM slash DD slash YYYY
CLIENT INFORMATION AND INSURANCE:
Name
(Required)
First
Last
Birth Date
(Required)
MM slash DD slash YYYY
Sex:
(Required)
M
F
Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
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California
Colorado
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Delaware
District of Columbia
Florida
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Northern Mariana Islands
Ohio
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South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Relationship to Policy Holder
(Required)
Self
Child
Social Secuirty Number
Parent/Guardian Name
(Required)
Parent/Guardian Phone
(Required)
Parent/Guardian Email
PRIMARY HEALTH INSURANCE INFORMATION:
Name of Policy Holder
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Address of Policy Holder
(Required)
Sex
(Required)
M
F
Phone number of Policy Holder
(Required)
Primary Insurance Company Name
(Required)
Member ID #
(Required)
Employer
(Required)
Is there other health insurance coverage?
(Required)
Yes
No
SECONDARY HEALTH INSURANCE INFORMATION:
Name of Policy Holder
(Required)
Birth Date
(Required)
MM slash DD slash YYYY
Address of Policy Holder
(Required)
Sex
(Required)
M
F
Phone number of Policy Holder
(Required)
Secondary Insurance Company Name
(Required)
Secondary Insurance Company Member ID#
(Required)
Employer
(Required)
Who is legal custodian of child?
(Required)
Parents
Other
If there was a divorce which state and county has jurisdiction?:
(Required)
What type of legal custody was ordered?:
(Required)
Joint
Mother
Father
Other
If joint custody exists,
both
parents must consent to non-emergency psychological care.
Child/Adolescent Questionnaire
Client Name
(Required)
Name and relationship to client of person completing questionnaire:
(Required)
How did you learn about this practice?
(Required)
Friend
Family member
Website
Court/Lawyer
Insurance Referral
School Referral
What do you think are your child’s main struggles? (Include current concerns and stressors).
(Required)
When did you first notice these difficulties? How did these struggles come to your attention?
(Required)
MENTAL HEALTH HISTORY
Has your child been prescribed medications to manage his/her emotions or behavior?
(Required)
Yes
No
If “yes”, please state the name of each medication, reason for taking and prescribing physician.
Has your child been in counseling before?
(Required)
Yes
No
If “yes”, was that experience…
Very Positive
Somewhat Positive
Negative
Not Sure
If “yes”, please list the names of past therapists, reasons for treatment and dates seen.
Has your child made any suicide attempts in the past?
(Required)
Yes
No
Has your child engaged in any self-harm behavior (i.e. cutting or burning)?
(Required)
Yes
No
Has your child ever been hospitalized for mental health treatment?
(Required)
Yes
No
If “yes”, please list name of hospital/facility, dates of stay and reason for admission.
FAMILY HISTORY
Are the child’s parents currently….
(Required)
Living together
Married to each other
Separated
Divorced
Remarried
Widowed
Other
List the names of those currently living in your child’s household. Include age, relationship to child and occupation.
(Required)
Do any family members suffer from substance abuse or emotional problems?
(Required)
Yes
No
If “yes”, please describe.
Please describe any additional family stressors that may be contributing to your child’s struggles.
(Required)
PHYSICAL HEALTH
Name of Pediatrician:
Please describe your child’s current physical health condition.
(Required)
List your child’s current medications including name, reason for medication and name of prescribing physician.
(Required)
Does your child use tobacco products? (i.e. cigarettes, snuff, vapes, etc…)
(Required)
Yes
No
Does your child use street drugs, painkillers, tranquilizers, stimulants or sleeping pills?
(Required)
Yes
No
Has your child ever used drugs or alcohol excessively?
(Required)
Yes
No
Do you or others believe that your child has a problem with alcohol or drugs?
(Required)
Yes
No
Has your child received treatment for alcohol or drug abuse?
(Required)
Yes
No
Is your child currently facing or ever faced any criminal charges?
(Required)
Yes
No
If “yes”, please describe.
Is your child currently on probation?
(Required)
Yes
No
SCHOOL AND SOCIAL LIFE:
Current grade level
(Required)
Name of School
(Required)
Has your child been diagnosed with a learning or attention disorder?
(Required)
Yes
No
If “yes”, please describe.
Does your child currently have an IEP (Individualized Education Plan) or 504 Plan at school?
(Required)
Yes
No
Has your child ever been suspended or expelled from school for behavioral problems?
(Required)
Yes
No
Current grades
(Required)
Typical grades
(Required)
Describe your child’s socialization (check all that apply)
(Required)
is popular
makes friends easily
has many friends
has few close friends
has difficulty fitting in
is teased or bullied
is shy or awkward
chooses friends I don't approve of
difficult to get to go to school
underperforms at school
How does your child spend his/her free time? Describe any extracurricular activities and interests.
(Required)
Is your child involved in any social, religious or community organizations?
Yes
No
If “yes”, please describe.
(Required)
Please describe your child’s strengths and weaknesses.
(Required)
Contact Information Permissions:
I authorize DeLuca Family Wellness Center Inc to: (Please indicate YES or NO for each option)
Leave a message on my home telephone voicemail
(Required)
Yes
No
Leave a message on my work telephone voicemail
(Required)
Yes
No
Leave a message on my cell telephone voicemail
(Required)
Yes
No
Leave a message with a family member/friend at my home
(Required)
Yes
No
Permission to receive a reminder telephone call/text of future appointments
(Required)
Yes
No
Payment Responsibility
Name of Client
(Required)
First
Last
Date
(Required)
MM slash DD slash YYYY
Person responsible for payment and relationship to client:
(Required)
Social Security Number of Person Responsible for Payment:
(Required)
Birthdate of Person Responsible for Payment
(Required)
In signing, I agree to be responsible for all charges incurred during my time in counseling. I understand that it is my responsibility to educate myself and know the extent and limits of my insurance benefits. If my insurance does not pay these charges or any part thereof, I agree to be responsible and will pay the incurred fees in a timely fashion. I understand that a third party billing agency, in addition to collections agency services if necessary, may be processing my payments and these agencies are bound by a confidentiality agreement and will only have access to billing information. I agree to the assignment of benefits directly to the provider. Attached is a form for your credit/debit card information should you choose to set up an arrangement to have your payment automatically deducted monthly. Should you choose not to set up automatic payment, you will be responsible for payment in full, either by cash or check, prior to each visit. Visit fees are as follows: Initial session - $225.00; Individual session - $195.00; Family session - $200.00.
Futhermore, I also understand that in the event I have to miss a scheduled appointment, 24-hour notice must be given or I may be charged a $75.00 cancellation for my missed appointment.
I understand the DeLuca Family Wellness Center, Inc. makes every effort to assist in improving appointment attendance including reminder texts 24-hours prior to each appointment, however, it is my responsibility to manage my appointment times and dates. The 24-hour notice of cancellation can be achieved through telephone, fax or email. I also understand the DeLuca Family Wellness Center, Inc. may use a collection agency and credit bureau to both report and collect any balance outstanding beyond 30 days.
If you have any questions or concerns regarding any of the above, please ask prior to your therapy session beginning.
Please choose one of the following:
(Required)
Bill my credit/debit card
Cash/Check in advance of session
Agreed upon monthly payment plan amount (if necessary FOR OFFICE USE ONLY):
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Credit/Debit Card Charge Form
Date
MM slash DD slash YYYY
Client's Name
Cardholder's Name
Type of Card
Visa
MasterCard
Am Express
Discover
Card Number
Expiration Date (Month/Year)
Three / Four Digit Security Code:
Cardholder’s Address:
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Cardholder’s Phone Number Associated with card
Cardholder’s Email
Printed Name
Signature
Date
MM slash DD slash YYYY
Informed Consent to Use and Disclose Your Health Information
This form is an agreement between you,
(Required)
and the DeLuca Family Wellness Center, Inc. When the word “you” appears below, it can mean you, your child, a relative or other persons if you have written his or her name below:
(Required)
When this practice examines, tests, diagnoses, treats or refers you, it will be collecting what the law calls Protected Health Information (PHI) about you. This practice needs to use this information to decide what treatment is best for you and to provide any treatment to you. This practice may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions not limited to but including court or legal purposes. This practice may use or disclose PHI for purposes outside of treatment, payment, and health care operations when appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when asked for information for purposes outside of treatment, payment and healthcare operations, an authorization will be obtained from you before releasing this information. An authorization will also need to be obtained before releasing your psychotherapy notes. “Psychotherapy notes” are notes that have been made about your conversations during private, group, joint or family counseling sessions, which have been kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
By signing this form, you are agreeing to let this practice use your information here and send it to others. The Notice of Privacy Practices explains in more detail your rights and how this practice can use and share your information. Please read this before you sign the consent form.
If you are concerned about some of your information, you have the right to ask this practice to not use or share some of your information for treatment, payment, or administrative purposes. You will have to request what you want in writing. Although this practice will make every attempt to respect your wishes, it is not required to agree to requested limitations.
After you have signed this consent, you have the right to revoke it, in writing, and this practice will comply with your wishes about using or sharing your information from that time on considering it may already have used or shared some of your information that cannot be changed.
Signature of Client Guardian:
(Required)
Printed name of Client Guardian:
(Required)
Date
(Required)
MM slash DD slash YYYY
Relationship to Client:
(Required)
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY.
This practice is dedicated to maintaining the privacy of your PHI as part of providing professional care. This practice is required by law to keep your information private. However, this notice cannot cover all possible situations so please talk to DeLuca Family Wellness Center, Inc. about any questions or concerns.
This practice will use the information about your health that is obtained from you or from others mainly to provide you with treatment, to arrange payment for these services, and for other business activities that are called, in law, health care operations. If this practice or you want to use or disclose your information for any other purposes, this will be discussed with you and a written authorization obtained.
While this practice will keep your health information private, there are circumstances where it may disclose PHI without your consent or authorization such as:
1.
Serious Threat to Health or Safety:
Confidential information may be released to protect against a serious threat to your health or safety or the health or safety of another individual or the public.
2.
Child Abuse:
If there is reasonable cause to suspect that a child is abused or neglected or if this practice observes a child being subjected to conditions that are likely to result in abuse or neglect, it is required by law to immediately report these circumstances to the West Virginia State Department of Human Services. If it is believed that a child has suffered serious physical abuse or sexual abuse, it must in addition , be reported to a law enforcement agency.
3.
Professional Health Oversight:
If the West Virginia Board of Examiners in Counseling, its president, or the ethics coordinator issues a subpoena requesting this practice to appear before them and bring documentation, compliance is required. This could include your confidential mental health information.
4.
Judicial or Administrative Proceedings:
If you are involved in a court proceeding and a request is made regarding your evaluation, diagnosis or treatment or the records thereof, such information may be privileged under state law, and therefore generally will not be released without your written consent or court order. The privilege would not apply when you are being evaluated for a third party or where evaluation is court ordered.
Inital
(Required)
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION:
1. You can ask this practice to communicate with you about your health and related issues in a particular way or at a certain place that is more private for you. For example, you can request this practice to telephone you at home and not at work to schedule or cancel an appointment or to have your bill sent to alternate addresses.
2. You have the right to inspect or obtain a copy (or both) of PHI in your mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Access to PHI may be denied under certain circumstances and in some cases you may have this decision reviewed. On your request, the details of the request and denial process will be discussed with you.
3. If you believe the information in your record is incorrect or missing important information, you can ask this practice to make some kinds of changes (called amending) to your health information. Upon request, this practice will discuss with you the details of the amendment process.
4. This practice is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.
5. This practice reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, this practice is required to abide by the terms and conditions currently in effect.
6. If these policies and procedures are revised, you will be furnished with a revised written notice by mail within two weeks of revision.
7. If you are concerned that this practice has violated your privacy rights, or you disagree with a decision that has been made in regard to access to your records, you may contact Matthew J. DeLuca MS,LPC at 304-626-3541 for further information. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.
The effective date of this notice is: January 1st, 2016. Also, you may have other rights that are granted to you by the laws of our state and these may be the same or different from the rights described above. This practice will be happy to address these situations with you.
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Once we obtain all the information regarding your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your treatment. It is important to remember that you always have the right to pay for services yourself to avoid the problems described above.
Your signature below indicates that you have read the information in this initial packet and agree to abide by its terms during our professional relationship. Your signature or the signature of your authorized person allows release of information necessary to process insurance claims and authorizes direct payment of health insurance benefits to DeLuca Family Wellness Center, Inc. THIS INFORMATION WILL INCLUDE DIAGNOSIS, DATES OF TREATMENT, AND AT TIMES, TREATMENT PLANS.
HIPAA PATIENT ACKNOWLEDGEMENT
Your signature below indicates:
1. that you have read this Counselor-Client Services Agreement;
2. that you have read the Notice of Privacy Practices and agree to its terms;
3. that you have received copies of the Notice of Privacy Practices form;
4. that you have the right to revoke this consent, in writing, at any time by sending such written notification to this office. Your revocation will not be effective to the extent that your counselor has taken action in reliance on the authorization.
Signature of Parent/Guardian
(Required)
Date
(Required)
MM slash DD slash YYYY
Telehealth Mental Health Therapy Services Agreement
Client Name
(Required)
Birthdate
(Required)
MM slash DD slash YYYY
1. Telehealth mental health services are an alternative form of therapy with several limitations. There is a risk of misunderstanding one another resulting from the absence of visual or auditory cues as well as a risk of disruption to the service due to technical difficulties of the devices utilized. I understand these potential risks to using this technology and that my health care provider or I can discontinue the telehealth session if it is deemed that the conferencing connections are not adequate for the situation.
2. My health care provider has explained to me how the video conferencing technology will be used and it will not be the same as a direct client/provider visit due to the fact that I will not be in the same room as my health care provider. I have had the alternatives to a telehealth session explained to me.
3. I agree to inform my provider of my address/location at the beginning of each telehealth session. I understand that notifying my provider of my location is in my best interest in case of an emergency. This may include but is not limited to if I am having suicidal or homicidal ideations or plans, and/or intent to act out my plans; if I am in crisis that cannot be resolved remotely; or if my provider determines I need a higher level of care. I understand that in the event of an emergency, my provider may need to contact emergency services to further assess for safety.
4. There are limitations to confidentiality to be mindful of including that individuals near you may overhear your communications or have access to the platform that you are using. I understand that I am responsible for my surroundings and will make attempts to engage in telehealth sessions privately, in a quiet space and without distractions.
5. I agree to conduct myself in telehealth sessions as I would if in the office participating in a face-to-face session. This included wearing appropriate attire, refraining from substance use and not engaging in sessions while driving.
6. I understand that billing will occur from my provider and that the structure and cost of telehealth sessions are consistent with face-to-face sessions.
7. I agree that I will not record any telehealth sessions.
8. I have had a direct conversation with my provider during which I had the opportunity to ask questions in regard to telehealth sessions.
By signing this form, I certify:
***That I have read or had this form read and/or had this form explained to me.
***That I fully understand its contents as well as the risks and benefits of services
***That I have been given the opportunity to ask questions and that any questions have been answered to my satisfaction.
Parent/Guardian Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Witness Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
Verbal Consent Given
Verbal Consent Given
Date
MM slash DD slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Verbal Consent Witness Printed Name
Signature
Δ
