Rick Presley M.S, LCMFT

Rick Presley M.S, LCMFT

12710 S. Pflumm St, Suite 204

Olathe, Ks 66062

REGISTRATION FORM

(Please- print)

Today’s Date:
Patient’s last name: First: Middle: / Mr. / Miss / Marital Status:
Parents/Guardians: / Mrs. / Ms. / Single Mar Div Sep Wid 
Is this your legal name? / If not what is your legal name? / (Former name): / Birth Date: / Age: / Sex:
YesNo / MF
Street Address: / Social Security Number: / Home phone Number:
( )
EMAIL ADDRESS / Preferred Method of communication:
PHONE: 
EMAIL:  / Best time to contact:
PO Box: / City: / State: / ZIP Code:
Occupation: / Employer: / Employer’s Phone Number:
( )
Chose clinic because/referred to clinic by (please check one box) / Dr. / Insurance Plan / Hospital
Family / Friend / Close to home/work / Yellow Pages / Other (list)
Other family members seen here:
Patient’s last name: First: Middle: / Mr. / Miss / Marital Status:
Parents/Guardians: / Mrs. / Ms. / Single Mar Div Sep Wid 
Is this your legal name? / If not what is your legal name? / (Former name): / Birth Date: / Age: / Sex:
YesNo / MF
Street Address: / Social Security Number: / Home phone Number:
( )
EMAIL ADDRESS / Preferred Method of communication:
PHONE: 
EMAIL:  / Best time to contact:
PO Box: / City: / State: / ZIP Code:
Occupation: / Employer: / Employer’s Phone Number:
( )
Chose clinic because/referred to clinic by (please check one box) / Dr. / Insurance Plan / Hospital
Family / Friend / Close to home/work / Yellow Pages / Other (list)
Other family members seen here:

INSURANCE INFORMATION

(Please give your insurance card to the receptionist)

Person responsible for bill: / Date of Birth: / Address (if different): / Home phone Number:
( )
Is this person a patient here? YesNo
Occupation: / Employer: / Employer’s Phone Number:
( )
Is this person covered by insurance? YesNo
Please indicate primary insurance /  [Insurance] /  [Insurance] /  [Insurance] /  [Insurance] /  [Insurance]
 [Insurance] /  [Insurance] /  [Insurance] / Welfare (please provide coupon) / Other
Subscriber’s Name: / Subscriber’s S.S number: / Birth Date: / Group number: / Policy number: / Co-Payment
$
Patient’s Relationship to subscriber: / Self / Spouse / Child / Other
Name of secondary insurance (if applicable) / Subscriber’s Name: / Group number: / Policy number:
Patient’s Relationship to subscriber: / Self / Spouse / Child / Other

EMERGENCY INFORMATION

Name of local friend or relative (not living in same address): / Relationship to patient: / Home phone number:
( ) / Work Phone Number:
( )
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize LifelineCounselingCenter to release any information required to process my claims.
Client Signature: / Date:

Personal History Questionnaire

All questions answered in this questionnaire are strictly confidential and will not become part of your medical report

Name(last, first, M.I.) M F / DOB:
Marital Status / Single Partnered Married Separated Divorced Widowed
Primary Care Physician: / Date of last physical exam:
PCP’s Phone Number: / Release of Information Signed: 

PERSONAL HEALTH HISTORY

List any medical or physical problems, hospitalizations, and surgeries; include when they were diagnosed

List all prescription and over-the-counter drugs you are taking: Any Allergies:

HEALTH HABITS AND PERSONAL SAFETY

ALL ANSWERS WILL BE KEPT STRICTLY CONFIDENTIAL.

Exercise / Sedentary (No Exercise)
Mild exercise (i.e., climb stairs, walk three blocks, golf
Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 minutes)
Regular vigorous exercise (i.e., work or recreation, 4x/week for 30 minutes)
Diet / Are you dieting? / Yes No
If yes, are you on a physician prescribed diet? / Yes No
Number of meals you eat a day?
______
Caffeine / None / Coffee / Tea / Cola
Number of cups/cans per day?
Alcohol / Do you drink alcohol? / Yes No
If yes, what kind?
How many drinks per week? / Yes No
Are you concerned about how much you drink? / Yes No
Have you considered stopping? / Yes No
Have you ever experienced blackouts? / Yes No
Are you prone to “binge” drinking? / Yes No
Do you drive after drinking? / Yes No
Tobacco / Do you use tobacco? / Yes No
Cigarettes - pks./day / Chew - #/day / Pipe - #/day / Cigars - #/day
# of years / Or year quit
Drugs / Do you currently use recreational or street drugs? If yes, please list / Yes No
Is there a history of problems with drugs or alcohol use in your family? / Yes No
Gambling / Have you ever gambled in a casino, bet on races or sports, played cards for money or played the lottery? / Yes No
If yes what kind?
Sex / Are you sexually active? / Yes No
Do you have any concerns about your sexual activity, including sexual dysfunction, sexual orientation, birth control or infertility? / Yes No
Personal Safety / Do you have any legal concerns? / Yes No
Do you have a history of any type of abuse? Physical, sexual, emotional or neglect? / Yes No
Is there any type of abuse happening in your life now? / Yes No

FAMILY HEALTH HISTORY

AGE / Significant health problems including addictive/compulsive behaviors and mental health / AGE / Significant health problems including addictive/compulsive behaviors and mental health
Father / Children / M
F
Mother / M
F
Siblings / M
F / M
F
M
F / M
F
M
F / Grandmother
Maternal
M
F / Grandfather
Maternal
M
F / Grandmother
Paternal
M
F / Grandfather
Paternal

MENTAL HEALTH

Is stress a major problem for you? / Yes No
Do you feel depressed? / Yes No
Do you panic when stressed? / Yes No
Do you have problems with eating or your appetite? / Yes No
Do you cry frequently? / Yes No
Have you ever attempted suicide? / Yes No
Have you ever seriously thought about hurting yourself? / Yes No
Do you have trouble sleeping? / Yes No
Have you ever been to a counselor? If yes, whom? / Yes No

PRIMARY REASON (S) FOR SEEKING SERVICES

Anger Management/ Aggression / School/ Learning/ Developmental Issues / Work/ Employment Issues
Anxiety/ Fears/ Phobias / Grief/ Loss / Weight/ Eating Disorders
Depression/ Mood Problems / Family/ Marriage/ Relationship Issues / Suicidal Thoughts/ Hurting Self
Sexual Addiction or Compulsions / Parenting/ Behavioral Problems / Homicidal Thoughts/ Harming Others
Trauma / Sexual Concerns / Gambling issues
Alcohol/ Drugs/ Addictive Behaviors / Mental Confusion/ Psychosis / Other Concerns

GOALS FOR TREATMENT:

What are your personal goals for therapy?

What are your marriage goals for therapy?

What are your family goals for therapy?

Informed Consent and Therapy Contract

Rick Presley, Licensed Clinical Marriage and Family Therapist

Thank you for giving me the opportunity to serve you in your counseling needs. I pledge to give you the best care that I can and will deliver to you the highest quality of service. In order to meet your needs the following information is provided for your consideration. Please read this carefully and ask any questions that you may have.

Credentials – I am a Licensed Clinical Marriage and Family Therapist in the state of Kansas, and have a Masters of Science Degree in Family Therapy. I am not a physician and do not have authority to prescribe medication.

Confidentiality – It is my desire to protect your confidentiality rights as defined by law. You can be assured your records are being kept, handled, and monitored in the most professional way. No information from your records will be released to anyone without your prior written consent. However, there are certain situations in which I may be required by law to release information without your consent. These situations may include:

-suspected abuse or neglect of a child, the elderly, or disabled persons

-duty to warn of homicidal intent

-civil detention to prevent suicide

-when ordered by a court of law

-when either you or I initiate legal action regarding the counseling process

-when I am in a civil or criminal lawsuit pertaining to my counseling practice

-when you sign a release for disclosure of the contents of your records or of pertinent needs/progress to an person such as doctors, or other co-mental health professional, family member, or pastor

-when I bill third-party providers such as an insurance company, Employee Assistance Program (EAP), or a church

-occasional peer supervision

-licensure supervision

Please feel free to discuss issues of confidentiality with me.

Client Rights:

YOU HAVE THE RIGHT:

To be treated with consideration and respect.
To expect quality services provided by concerned, competent staff.
To a clear statement of purposes, goals, techniques, rules of procedure and limitations, as well as potential dangers of the services to be performed, plus all other information related to or likely to effect the on-going counseling relationship.
To obtain information about the case record and to have the information explained clearly and directly.
To full knowledgeable and responsible participation in the on-going treatment plan.
To expect complete confidentiality and that no information will be released without written consent.
To see and discuss charges and payment records.
To refuse any recommended services and be advised of the consequences of this action

Scheduling of Appointments – I will make every effort to schedule your appointments at times most convenient for you. My sessions last approximately 50 minutes. It is your responsibility to arrive on time. If you are running late please call and let me know. If you have not called and are not here by 15 minutes past the scheduled start time, I will cancel the appointment and bill you for the session. I must have 24 hours advance notice if you cannot attend your scheduled appointment. I do charge full price for a missed appointment. More than two missed sessions or 30 days past due on payment will result in suspension or termination of therapy sessions.

How to reach me – Should you need to reach me, please call 913-738-4757. If I do not answer, please leave a message. It may be difficult for me to return your calls if you use a call block device.

I may not immediately be able to speak with you when you try to contact me. I check my voicemail several times daily Monday through Friday and at least once daily Saturday and Sunday. I will gladly return your call as soon as I am able. My voice mails are also forwarded to my private number to ensure that I am available when you need to reach me. On occasion you may experience a time when speaking to me briefly outside a session would be helpful. As I receive notice of your need and am able to respond, I can provide at most two ten-minute phone crisis sessions per week without charge. Phone calls lasting longer than 15 min will be billed at 15 min increments at my standard hourly fee.

Children – Please do not bring your children with you to your therapy appointment unless they are part of the therapy session. As a rule, when I work with children I desire to have the parents present. Please do not leave your children in the waiting area unsupervised.

Electronic Communication - On occasion I may be asked to fax or submit via the internet, information regarding your treatment. This request could be made by an insurance company or another health care provider.

I authorize the electronic transmission of information from my records.

______

Client initialsClient initialsClient initialsClient initials

I do not authorize the electronic transmission of information from my records.

______

Client initialsClient initialsClient initialsClient initials

______

If I am away from my office, I may use a cell or cordless phone to communicate with you. These calls are not always guaranteed to be 100% secure. I need permission to talk with you on a cell or cordless phone.

I authorize phone calls via cell or cordless phone.

______

Client initials Client initials Client initials Client initials

I do not authorize phone calls via cell or cordless phone.

______

Client initials Client initials Client initials Client initials

______

Social Media – As a business owner, I do have a professional Facebook, Twitter, and Blog account. You are welcome at anytime to view these resources, however, please know that I cannot guarantee the confidentiality of these resources if you choose to join, like or sign up on any of these accounts. These resources are for the general public and when choose to associate yourself with there resources will make public your association with my business. My desire is to protect your confidentiality. The management of your confidentiality and social media sites is beyond my control.

Termination of Counseling – Counseling termination is permitted at any time. I do request that you talk with me before you terminate, and that you complete an exit session. The counseling agreement shall remain in effect until one or more of the following occurs:

You and I mutually agree that treatment goals have been met satisfactorily.
You leave counseling and do not return for three months.
You are no longer making progress in my professional opinion.
I reach the limits of my training, education, or experience. At this point I will refer you to other mental health professionals.
I am unable to counsel due to extended illness, incapacity, retirement, relocation, or job change.

Fees – My fee per session is $120 for the first session and $90 for all following sessions. If you have concerns about my fee, please discuss them with me at the beginning of our first session. Counseling fees are due and payable at the end of each session. If you desire any other arrangement, please talk to me in advance. I accept cash, check, Visa, MasterCard, American Express, and Discover. There is a $15 charge for a returned check

______

I have read the above mentioned policies and understand and agree to all of them. I agree to pay the agreed upon fee. I also agree to pay for missed appointments or for appointments I cancel without giving the required advance notice. I agree to pay $______for each session.

Client Signatures ______Date______

______Date______.

Therapist Signature ______Date______

Rick Presley, LCMFT

Rick Presley MS, LCMFT

12710 S. Pflumm St, Suite 204

Olathe, Ks 66062

913-738-4757

HIPAA CONSENT FORM

I give Richard L. Presley my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for healthcare operations like quality reviews.

I have been informed that I may review the HIPAA Notice of Privacy Practices used by Rick Presley for a more complete description of uses and disclosures before signing this consent.

I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that Richard L. Presley, and LifelineCounselingCenter is not required to agree to the request. If Richard L. Presley agrees to my requested restriction, they must follow the restrictions.

I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.

Signature:______Date: ______

If signed by patient representative, state relationship to patient:______

Rick Presley, MS. LCMFT

Waiver of Medical/Psychiatric Consultation

I understand that under the provisions of KSA 65-64040 (b) (3) my therapist is required to consult with my primary care physician or psychiatrist to determine if there my be a medical condition or medication that may be causing or contributing to any signs of a mental disorder that he may have observed while working with me or my minor children. In the event that I or my minor children do not have a primary care physician and/or psychiatrist, I acknowledge that my therapist has recommended that I seek medical consultation.

I WAIVE MY RIGHT

By signing below I am indicating that I waive my right to such consultation and that I am aware that this waiver will become part of my record.

Client Signature / Date: / Client Signature / Date
Client Signature / Date: / Client Signature / Date
Therapist Signature / Date: / Therapist Signature / Date

I DO NOT WAIVE MY RIGHT

By providing my physicians name and contact info, I am using my right for a medical consultation between my therapist and primary physician/psychiatrist.

Physician/Psychiatrist Name: ______

Office Address: ______

Phone: ______

Rick Presley MS, LCMFT

12710 S. Pflumm St, Suite 204

Olathe, Ks 66062

913-738-4757

HIPAA CONSENT FORM

I have been informed that I may review the HIPAA Notice of Privacy Practices used by Rick Presley for a more complete description of uses and disclosures before signing this consent.

I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed.

Signature:______Date: ______

If signed by patient representative, state relationship to patient:______