PSYCHOLOGICAL RESOURCE ASSOCIATES
479 JUMPERS HOLD ROAD - SUITE 106
SEVERNA PARK, MD 21146
(410) 647-8840
ADMINISTRATIVE USE ONLY
Acct.# ______
1ST Appt. ______
Clinician ______
Dx. ______
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Dx. ______
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Signature on File: Y N
Signed Fee Agreement Y N
Date ______
Statement to:
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HICFA to: ______
Special Instructions:
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Data Entry Date ______
By ______
Mr. Mrs. Ms. Dr. ______Sex M F
Soc. Sec. # ______
Telephone (H) ______(W) ______
Cell ______
Address ______FOR ADMINISTRATIVEUSE ONLY
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E-Mail Address ______
Date of Birth ______Place of Birth ______
Marital Status ____ Single ____ Married ____ Partnered ____Separated ____Divorced
____Widow(er)
Date of Marriage ______Previous Marriages? Y N
Children/Siblings (Please provide names and birth dates)
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Spouse/Significant Other ______
CONTACT IN CASE OF EMERGENCY: ______
Telephone (H) ______(W) ______
Religious Preference ______
Education ______Degree/Years completed______
Employer ______Position ______
How long with employer? ______
Who referred you to us? ______
Reason for referral ______
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Please describe the problem(s) for which you are seeking help.
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PSYCHOLOGICAL RESOURCE ASSOCIATES2
Primary Physician ______Specialty ______
Telephone ______Address ______
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Date of last physical ______Medications ______
Medical problems/conditions ______
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Please provide the names and telephone numbers of other healthcare providers who are actively involved with your treatment at this time. Include Rehabilitation Nurse, Physical Therapist, and any complementary medicine providers, for example, Massage Therapist and Acupuncturist.
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FAMILY HISTORY Please describe the presence of any medical or psychological problems, substance abuse (drugs, alcohol, food), physical and/or sexual abuse in your family of origin.
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Any other information you believe would be important for us to know about you? ______
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Prior experience with psychotherapy? ____ Yes ____ No. If yes, with whom and when? ______
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FINANCIAL RESPONSIBILITY FOR SERVICES (Please fill out if the financially responsible party is someone other than the patient)
Responsible Party ______Date of Birth ______
Social Security # ______
Address ______
INSURANCE INFORMATION (Please fill out if you will be utilizing insurance)If you are utilizing insurance, please make sure that your clinician or the office secretary gets a copy, front and back, of your insurance card.
Insured Party Date of Birth ______
Address (if different from patient) ______
Insured’s Employer ______
PSYCHOLOGICAL RESOURCE ASSOCIATES 3
Primary Insurance Company______
Insured’s Identification Number ______Group Number ______
Secondary Insurance Company _________ID # ______Group # ______
May we contact you in the future to follow up on your satisfaction with the services you receive through Psychological Resource Associates? Yes No
Please indicate the following Psychological Resource Associates’ services about which you would like to receive more information:
Parent Education Workshops on AD(H)D
I authorize Psychological Resource Associates to release written information and to talk with my Health Care Providers and/or Managed Care Company for purposes of coordinating my clinical treatments, and for the management of reimbursement for services. I understand that this authorization can be revoked by me in writing at any time.
Signature Date ______
C:\Data\PRA\MASTERS\PBIAdult-4-22-14