Meyer Counseling Services
2728 Asbury Rd. Suite 520
Dubuque, IA 52001
T: 563-284-2125	F: 563-583-3769

The following question will help me best meet your treatment needs. Please complete as thoroughly as possible.
CONTACT INFORMATION
Client Name ____________________________________________________________   Birth Date: ___________________ 
Address: _________________________________________________ City, State, Zip: _______________________________
Home Phone: ______________________________________ Cell Phone: _________________________________________
Social Security #_______________________________________________________________________________________
E-mail Address: _______________________________________________________________________________________
Please check ways I can communicate with you*: ☐Mail ☐Home Phone ☐Cell Phone ☐Text Message ☐Email
*Communication may involve health information, appointment reminders, etc.
PARENT/GUARDIAN INFORMATION (Skip if not applicable)
Note: The guardian who brings the child to treatment will be responsible for payments.
Mother’s Name: _____________________________________________
Address: _______________________________________________ City, State, Zip: ________________________________
Home Phone: ______________________________________ Cell Phone: _______________________________________
E-mail Address: ______________________________________________________________________________________
Please check the ways I can communicate with you: ☐Mail ☐Home Phone ☐Cell Phone ☐Text Message ☐Email

Father’s Name: _____________________________________________
Address: ________________________________________________ City, State, Zip: ________________________________
Home Phone: ______________________________________ Cell Phone: _________________________________________
E-mail Address: ________________________________________________________________________________________

Please check the ways I can communicate with you: ☐Mail ☐Home Phone ☐Cell Phone ☐Text Message ☐Email

INSURANCE & MEDICAL INFORMATION
** Please indicate if you have a Health Savings Account (HSA)
Primary Insurance Information	Secondary Insurance Information	
Insurance Company:	Insurance Company:	
Subscriber’ Name:	Subscriber’ Name:	
Subscribers DOB:	Subscribers DOB:	
Insurance Address:	Insurance Address:	
Insurance Phone:	Insurance Phone:	
Employer:	Employer:	
Employer Phone #:	Employer Phone #:	
Subscriber ID:	Subscriber ID:	
Policy #:	Policy #:	
Group #:	Group #:	
Subscriber’s Relationship to Client:
     ☐ Parent     ☐ Spouse     ☐ Other:	Subscriber’s Relationship to Client:
      ☐ Parent     ☐ Spouse     ☐ Other:	
REFERRAL AND COLLATERAL INFORMATION
Referral Source: ☐Word of Mouth ☐Advertisement ☐Web Search	
Primary Care M.D.: __________________________________________________ Phone: ___________________________
Emergency Contact: ______________________________ Relationship: __________________ Phone: __________________
ASSESSMENT INFORMATION
Please describe your reason(s) for seeking treatment at this time.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Have you ever received mental health treatment before?  If so, please list dates and provider name.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Have you ever been the victim of emotional, physical, sexual abuse or been witness to domestic violence?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Have you had previous suicidal thoughts or attempts?
_________________________________________________________________________________________________

Please list any medications you are currently taking:

SYMPTOMS CHECKLIST: Please check all that apply.
Depression				ANXIETY			ADHD
____Agitation				___Chest Tightness		___Distractible
____Change in Appetite			___Dizziness			___Easily Frustrated
____Crying Spells			___Dyspnea			___Fails to Complete Tasks
____Depressed/Sad			___Headaches		___Fidgety
____Difficulty Coping			___Irritable			___Forgetful
____Discouraged			___Palpations		___Hyperactive
____Helplessness			___Poor Sleep		___Impatient
____Hopelessness			___Restless			___Impulsive
____Irritable				___Tense Nervous		___Poor Concentration
____Loss of Concentration		___Tiredness/Fatigue	___Poorly Organized
____Loss of Energy			___Trembling			___Procrastinates
____Loss of Interest			___Worry			___Reactive
____Loss of Motivation			___Other			___Short Attention Span
____Sense of Guilt							___Working Below Capacity
____Sleep Difficulty			PANIC 			___Other
____Thinking Slowed			___Agoraphobia
____Weight Gain/Loss			___Chest Pain		ANGER/CONDUCT
____Worthlessness		___Derealization		___Aggression 
____Suicidal Ideation			___Fear of Dying		___Argues
____Other					___Palpations		___Blames Others
						___Shakes/Trembles	___Cruelty
MANIA					___Short of Breath		___Defiant
____Agitation				___Sweats			___Destructive
____Dizzy					___Nausea			___Fights
____Excessiveness			___Other			___Fire Setting
____Grandiose								___Run Away/Truant
____Minimal Sleep							___Theft
____Racing Thoughts				PTSD
____Other					___Avoidant
						___Flashbacks					
EATING DISORDERS			___Insomnia
___Binges				___Nightmares	
___Body Image Distortion		___Startles
___Fear of Weight Gain			___Trauma
___Loss of Menstrual Cycle		___Vigilante
___Purges				___Other
___Other
						OCD
						___Compulsions
						___Obsessions
						___Other		

TREATMENT PHILOSOPHY
We believe in providing goal-directed treatment.  This means that a treatment goal or several goals are established after a thorough assessment.  All treatment is then planned with the goal in mind and progress is made toward accomplishment of that goal in a time-efficient manner.
CONFIDENTIALITY
All information between provider and client is held strictly confidential unless:

•	The client authorizes release of information with his/her signature, or parent/guardian signature.
•	The client presents a physical danger to self.
•	The client presents a danger to others.
•	Child or Adult abuse/neglect is suspected.

We are required by law to inform potential victims and legal authorities of potential dangers.
FINANCIAL TERMS
Upon verification of health plan/insurance coverage and policy limits, your insurance carrier will be billed for you and we will be paid directly by the carrier.  You will be responsible for any applicable deductibles and co-payments.  Co-payments must be paid at the beginning of each session for services rendered.  If you are not eligible at the time services are rendered, you are responsible for full payment.
CANCELLED/MISSED APPOINTMENTS
A scheduled appointment means that time is reserved only for you.  If an appointment is missed or cancelled with less than twenty-four (24) hours’ notice, you may be billed $25 for the first missed appointment, $50 for the second missed appointment, and full fee for each consecutive missed appointment thereafter, within a six month period.  
EMERGENCY PROCEDURES
If you have a mental health emergency and are unable to reach me, please call the crisis hotline at 1-855-800-1239. If your mental health symptoms persist, please call 911 or go to the nearest hospital. If you have a medical or life threatening emergency, please dial 911.
RELEASE OF INFORMATION
By signing below, you authorize the release of information regarding your care to your health plan for the payment of claims, certifications/case management decisions, and other purposes related to the administration of benefits for your health plan while being seen at the Meyer Counseling Services. 

CLIENT RIGHTS AND RESPONSIBILITIES
No list of client rights can ensure the respect of those rights.  It is the intent of Meyer Counseling Services to make sure that all aspects of treatment and service reflect concern and respect for client’s rights as well as high ethical standards.

•	Each client has the right to considerate care with the client’s safety and personal dignity being of prime importance.
•	Each client shall have reasonable access to care, regardless of race, religion, gender, sexual orientation, ethnicity, age, or disability.
•	Each client has the right to have his or her cultural, psychological, spiritual and personal values, beliefs, and preferences respected.
•	Each minor client has the right to include his or her parent/family member/guardian in treatment.
•	Each client has the right to privacy, confidentiality, and security, in accordance with agency, state and federal regulations governing the confidentiality of information.  Client confidentiality will be maintained during case consultations, clinical supervision and all internal or external audits of clinical records.  All records reviewed by auditors, external entities and business associations, will be noted on the accounting summary form for HIPAA purposes.
•	Treatment services are provided regardless of whether authorization for release of information is signed.
•	Each client and when appropriate the family, has the right to complete information about treatment including, but not limited to:  Limits of confidentiality, Treatment planning, Risks of Treatment, Alternatives to Treatment, Cost of Service and/or any changes in treatment recommendations (including changes in clinical staff).
•	Each client has the right to access, request amendment to, and receive an accounting of disclosures regarding his or her own clinical/service information as permitted under applicable law.  (Please see Notice of Privacy Practices)
•	Each client who seeks services voluntarily has the right to refuse and/or terminate care, treatment or services at any time.
CONSENT FOR TREATMENT
Please read the following statement and sign below:

I authorize and request that the professional staff at the Meyer Counseling Services carry out mental health examinations, therapy, counseling, evaluations, treatments, and/or diagnostic procedures, which now or during the course of my care are advisable.  I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement.  I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable. I hereby acknowledge that I am willing and without coercion, taking part in these mental health related procedures. 

By signing below, I understand and agree to the above information as described on pages 4 and 5 of this intake packet.

______________________________________________________	     	_________________________
Client Signature							Date

______________________________________________________	     	_________________________
Parent/Guardian Signature	 (if applicable)				Date

MEYER COUNSELING SERVICES
NOTICE OF PRIVACY PRACTICES

HIPPA 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.  

Effective date: June 1, 2016
Meyer Counseling Services has been and will always be totally committed to maintaining client’s confidentiality. We will only release healthcare information about you in accordance with federal and state laws and ethics of the counseling profession.

This notice describes our policies related to the use and disclosure of your healthcare information.

Uses and disclosures of your health information for the purposes of providing services.  Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care.  State and federal laws allows us to use and disclose your health information for these purposes.

TREATMENT We may need to use or disclose health information about you to provide, manage or coordinate your care or related services.  Which could include consultants and potential referral sources.

PAYMENT Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes.  We may bill the person in your family who pays for your insurance.

HEALTHCARE OPERATIONS We may need to use information about you to review our treatment procedures and business activity. Information may be used for certification, compliance and licensing activities.

Other uses or disclosures of your information which does not require your consent there are some instances where we may be required to use and disclose information without your consent.  For example, but not limited to: Information you and/or your child or children report about physical or sexual abuse: then by Iowa State Law, we are obligated to report this to the Department of Human Services. If you provide information that informs us that you are in danger of harming yourself or others.  Information to remind you of /or to reschedule appointments or treatment alternatives. Information shared with law enforcement if a crime is committed on our premises or against our staff or as required by law such as a subpoena or court order.

Meyer Counseling Services
2728 Asbury Rd. Suite 520
Dubuque, IA 52001
T: 563-284-2125	F: 563-583-3769

PRIVACY NOTICE ACKNOWLEDGEMENY

I hereby acknowledge that Meyer Counseling Services has provided the Privacy Notice as required by the Health Insurance Portability and Accountability Act of 1996.

_________________________________________________	______________________
Client Signature					Date

_________________________________________________	______________________
Parent/Guardian Signature				Date

_________________________________________________	______________________
*Staff Signature					Date

* If client refuses to acknowledge receipt of the Privacy Notice

Meyer Counseling Services
2728 Asbury Rd. Suite 520
Dubuque, IA 52001
T: 563-284-2125	F: 563-583-3769

RELEASE FOR PRIMARY CARE PHYSICIAN

CLIENT NAME: ________________________________________      DATE OF BIRTH:   /    /____

I      DO    /    DO NOT    (Please Circle One) authorize Meyer Counseling Services staff to contact my primary care physician 
____________________________________________________________ (Physician Name) at 
____________________________________________________________ (Physician Address) to 
Provide information about my diagnosis and my treatment at Meyer Counseling Services. I understand that mental illness can have biological causes, and that it is recommended that I consult my doctor about my symptoms. To facilitate care coordination, this consent for release of the below information and subsequent verbal information remains in effect for one full year or until consent is revoked by me in writing. I understand that further written disclosure of information requires me to complete an additional authorization. This authorization is effective for 12 months (or ________________________) after the date it is signed. 

This authorization applies to information about my: (Circle yes or no for each)
Mental Health   YES   /   NO	Substance Abuse YES   /   NO	 HIV Status   YES   / NO

Client/Guardian Signature: ___________________________        Date:       /    /__   

Meyer Counseling Services
2728 Asbury Rd. Suite 520
Dubuque, IA 52001
T: 563-284-2125	F: 563-583-3769

RELEASE OF INFORMATION

CLIENT NAME: ________________________________________      DATE OF BIRTH:   /    /____

I      DO    /    DO NOT    (Please Circle One) authorize Meyer Counseling Services staff to communicate with: 
____________________________________________________________ (Name) at 
____________________________________________________________ (Address) to 
Provide information about my diagnosis, my treatment, and progress at Meyer Counseling Services. To facilitate care coordination, this consent for release of the below information and subsequent verbal information remains in effect for one full year or until consent is revoked by me in writing. I understand that further written disclosure of information requires me to complete an additional authorization. This authorization is effective for 12 months (or ________________________) after the date it is signed. 

This authorization applies to information about my: (Circle yes or no for each)
Mental Health   YES   /   NO	Substance Abuse YES   /   NO	 HIV Status   YES   / NO

Client Signature: ___________________________________        Date:       /    /__   

Client/Guardian Signature: ___________________________        Date:       /    /__