Colleen M Pearson, PsyD, PLLC
2598 E. Sunrise Blvd Suite 210A
Fort Lauderdale, FL 33304
(754) 301-8739
CHILD INFORMATION COLLECTION FORM
CONFIDENTIAL
Patient Name:______Today’s Date:______
Address:______City/State______Zip______
Home Phone #:______Work Phone #______Cell# ______
Date of Birth: _____/_____/___ Age:_____ Gender: c Female c Male
Email Address (For Reminders) : ______
Married c Divorced c Single c Separated c Widowed c
Employed c Unemployed c Full-Time Student c Part-Time Student c
Nearest relative NOT living in home: ______Phone #:______
RESPONSIBLE PARTY: (other than insurance) if different from patient:
Name:______Date of Birth____/_____/______
Address______City/State:______Zip______
Home Phone #:______Work Phone #:______Cell/Mobile #______
RESPONSIBLE PARTY (Parent or Guardian) SIGNATURE: ______
Insurance Information:
INSURANCE CARRIER (AETNA, CIGNA, HUMANA, FLORIDA BLUE, TRICARE, MEDICARE, UNITED HEALTHCARE) :______
Policy Holder DOB:___/___/___ Policy Holder Name:______
Policy Holder Employer:______
Policy Number: ______Group Number: ______
I, the undersigned, hereby agree that, excluding Worker’s Comp and Medicaid, I will guarantee payment for services rendered by Dr. Colleen M. Pearson. I hereby authorize payment directly to same, of the benefits otherwise payable to me but not to exceed the doctor’s regular charges for this service. I understand I am financially responsible to the doctor for charges not covered by this agreement, and I agree that the bill will be paid upon receipt of a statement unless other arrangements have been made with our office. I also understand that, should a collections process become necessary, I am responsible for all expenses connected with their process. I further authorize the release of information for insurance purposes.
Signed:______Referred By:______
PATIENTS’ RIGHTS AND RESPONSIBILITIES STATEMENT
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Colleen M Pearson, PsyD, PLLC
2598 E. Sunrise Blvd Suite 210A
Fort Lauderdale, FL 33304
(754) 301-8739
STATEMENT OF PATIENTS’ RIGHTS
Patients have the right to:
Ø Be treated with dignity and respect.
Ø Fair treatment, regardless of their race, religion gender, ethnicity, age, disability, or source of payment
Ø Their treatment and other member information
kept private. Only where permitted by law,
may records be released without member
permission.
Ø Easily access timely care in a timely fashion.
Ø Know about their treatment choices. This is
regardless of cost or coverage by the member’s
benefit plan.
Ø Share in developing their plan of care.
Ø Information in a language they can understand.
Ø A clear explanation of their condition and
treatment options.
Ø Information about Magellan, its practitioners.
services and role in the treatment process.
Ø Information about clinical guidelines used in
providing and managing their care.
Ø Ask their provider about their work history and training.
Ø Give input on the Members’ Rights and
Responsibilities policy.
Ø Know about advocacy and community groups and prevention services.
Ø Freely file a complaint or appeal and to learn
how to do so.
Ø Know of their rights and responsibilities in the treatment process.
Ø Receive services that will not jeopardize their
employment.
Ø Request certain preferences in a provider.
Ø Have provider decisions about their care made without regard to financial incentives.
STATEMENT OF PATIENTS’ RESPONSIBILITIES:
Patients have the responsibility to:
Ø Treat those giving them care with dignity and
respect.
Ø Give providers information they need. This is so providers can deliver the best possible care.
Ø Ask questions about their care. This is to help them understand their care.
Ø Follow the treatment plan. The plan of care is to be agreed upon by the member and the provider.
Ø Follow the agreed upon medication plan.
Ø Tell their provider and primary care physician
about medication changes, including medications
given to them by others.
Ø Keep their appointments. Members should contact
their provider(s) as soon as they know they need to
cancel visits.
Ø Let their providers know when the treatment plan
isn’t working for them.
Ø Let their provider know about problems with
paying fees.
Ø Report abuse and fraud.
Ø Openly report concerns about the quality of care they receive.
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Colleen M Pearson, PsyD, PLLC
2598 E. Sunrise Blvd Suite 210A
Fort Lauderdale, FL 33304
(754) 301-8739
CONFIDENTIALITY, PRIVILEGED COMMUNICATION,
AND DUTY TO WARN OR PROTECT
Federal and State of Florida laws assure that everything a patient tells their mental health professional is to remain confidential and is considered privileged communication. Any information a mental health professional has regarding the patient can only be released with the signed, written consent of the patient (or patient’s parent or legal guardian in the case of a child). Thus, confidentiality and privileged communication are your rights, guaranteed under State and Federal laws.
There are, however, two exceptions in which the mental health professional’s social responsibility is given precedence over these rights. If a patient intends to harm him or herself, or another individual, the mental health professional has the responsibility and duty to protect the patient, or warn the person to whom harm is intended. Such action by the mental health professional may require that confidentiality be broken. Of course breaching confidentiality would be the last resort, occurring only after all reasonable efforts to resolve the situation had failed, and would be limited to the necessary information required to ensure safety.
State of Florida law also requires that mental health professionals report all incidents of any type of suspected child abuse to appropriate agencies.
I have read the above and understand my rights and the mental health professional’s social responsibility.
______
Signature Date
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Colleen M Pearson, PsyD, PLLC
2598 E. Sunrise Blvd. Suite 210A
Fort Lauderdale, FL 33304
(754) 301-8739
BILLING AND FINANCIAL POLICY
Diagnostic Interview - First Visit - $275.00 - based on 45-50 minutes of actual contact time, and additional time being used for developing a treatment plan, charting, reviewing records, etc.
Therapy Sessions - $200.00 - are based on one hour and defined as 50 minutes of actual contact time, with the remaining 5-10 minutes being used for charting, writing progress summaries, etc. A 45 min session is defined as 40 minutes of actual contact time. Therapy sessions which last longer than 50 minutes will be billed accordingly.
Testing and Assessment – Insurance companies do not pay for Educational or Academic testing. Those tests (IQ, Achievement, Communication, Learning Disorder) will be charged a cash fee. Any mental health assessments will be billed to the insurance company. As of 2017, Testing Fees are $2000 - $3500 depending on extent of assessments required.
Missed Appointments and Cancellations are not considered for payment by insurance companies, you are, nevertheless, responsible for paying $75 for missed appointments and cancellations if there is less than 24 hours notice. Email me for the best time stamp, I do make exceptions when there is an emergency. If you arrive late for your appointment, you will be billed for the time scheduled. The appointment will still conclude on time.
Testing Sessions: Any missed testing sessions that have been scheduled for more than 2 hours time will be billed to the responsible party at $500. This considers the amount of time blocked out for assessment.
PAYMENT: Payment in full - less the amount insurance will pay - is required at the time of service. No further services will be scheduled if your account becomes two or more payments behind (i.e., for two hours of service).INSURANCE: I will file your insurance claims only if I am a contracted provider with that company. After you have met your deductible for the year, we will accept the assignment (i.e., reimbursement directly from your insurance company). However, deductibles, co-payments and all fees not covered by your policy are still due at the time of service.
PRECERTIFICATION OF INITIAL APPOINTMENT IS YOUR RESPONSIBILITY. Your doctor will take care of any
pre-certification necessary for ongoing treatment. It is also your responsibility to know your benefits - co-pay, deductible, authorization requirements, referrals, etc. - prior to your appointment.
NOTE 1: In cases of divorce and/or separation, the parent who originally brought the child in for services is responsible for paying this office, regardless of which parent is legally responsible for insurance coverage and medical bills as established by a divorce or any other agreement. Assignment from the non-custodial parent’s insurance carrier will be accepted only after this office has his/her signature on file.
NOTE 2: Former patients returning for treatment who have had an unsatisfactory payment history or have been turned over to our collection agent will be seen on a CASH ONLY basis. We’ll be glad to give you the necessary forms for reimbursement directly from your insurance company to you.
I HAVE READ AND UNDERSTAND THE ABOVE BILLING POLICY. I AGREE TO PAY FOR SERVICES UNDER THE CONDITIONS AND SPECIFICATIONS SET FORTH IN THIS BILLING POLICY AND ACKNOWLEDGE THAT I AM RESPONSIBLE FOR PAYMENT OF ALL SERVICES PROVIDED, REGARDLESS OF INSURANCE COVERAGE, EXCLUDING MEDICAID AND WORKER’S COMPENSATION; INCLUDING COLLECTIONS/COURT COSTS SHOULD THAT PROCESS BECOME NECESSARY IN THE SETTLEMENT OF MY ACCOUNT.
Signature: ______Date:______
CONFIDENTIAL
Patient name:______Date of Birth: ______
TREATMENT CONSENT FORM
Explanation of Consent Form:
This treatment consent form covers all procedures that are not of a nature to require a special consent, and it provides protection for the procedures performed by Colleen M. Pearson, Psy.D. This form documents that the client has consented to treatment, including but not limited to psychotherapy and counseling.
This form provides evidence that no guarantee is made by any professional concerning the outcome of treatment. There is no guarantee that treatment will be successful. This form also provides evidence that consent is given only after a full explanation has been provided. If you have any questions concerning this or any other matters, it is your responsibility to ask your therapist. By signing this form, you acknowledge that you understand your consent to treatment as explained in this form.
Consent to Treatment:
I, ______, for ______
(Print your name) (Print the child’s name)
do hereby voluntarily consent to care and treatment by Dr. Colleen M. Pearson. I am aware that the practice of Clinical Psychology and Neuropsychology is not an exact science and I acknowledge that no guarantees have been made as to the result of evaluation or treatment.
I am aware that I am an active participant in the counseling process and that I share responsibility for treatment. My responsibilities in treatment include informing the therapist of any information that may be relevant to the problems or conditions being treated, assisting in setting goals for treatment, following therapeutic advice to the best of my ability, and ending treatment in a responsible way.
If I am consenting to treatment for another person, I certify that I am legally responsible for that person and am entitled to consent to treatment for them.
This form has been fully explained to me and I certify that I understand its contents. I also understand that it is my sole responsibility to ask any questions or obtain any clarification necessary to my understanding this form fully.
______
(Your Signature) (Date)
Child/Adolescent Intake Form
Name: _ Date:
PRESENTING PROBLEMS AND CONCERNS
Please circle all your child’s behaviors and symptoms that you consider problematic:
Are your child’s problems affecting any of the following?
Yes No Has your child ever had thoughts, made statements, or attempted to hurt him/herself? If yes, please describe: _ _ _ __
_ _ _ __
Yes No Has your child ever had thoughts, made statements, or attempted to hurt someone else? If yes, please describe: _ _ _ _
_ _ _ __
Yes No Has your child recently been physically hurt or threatened by someone else? If yes, please describe: _ _ __
_ _ _ __
FAMILY AND DEVELOPMENTAL HISTORY
Please check if your child has experienced any of the following types of trauma or loss:
Yes No Were there any medical problems during the pregnancy or birth of your child? If yes, please describe: _ _ __
Yes No Did the biological mother use any tobacco, medication, street drugs, or alcohol while pregnant with this child? If yes, please describes substances used, quantity, and frequency: _
_ _ _ __
Yes No Did your child have any developmental delays in early childhood (crawling, walking, talking, toileting, etc.)? If yes, please describe: _ _
_ _ _ __
PREVIOUS MENTAL HEALTH TREATMENT
Yes No Type of Treatment When? Provider/Program Reason for Treatment
Outpatient CounselingMedication (mental health)
Psychiatric Hospitalization
Drug/Alcohol Treatment
Self-help/Support Groups
SCHOOL INFORMATION
Current grade/placement: _ _
This year’s school grades: / Excellent Good / Fair / Poor
Past school grades: / Excellent Good / Fair / Poor
This year’s school behavior: / Excellent Good / Fair / Poor
Past school behavior: / Excellent Good / Fair / Poor
Has your child had any of the following difficulties at school?
Suspension Incomplete homework Learning problems Referrals or detentions Poor grades Teased or picked on Speech problems Attendance problems Gang influence
Yes No Does your child have an after-school provider? If so, who?
Yes No Has your child ever repeated or skipped a grade? If yes, which one(s)? _
Yes No Has your child ever received Special Education services? If yes, please describe services received and reason for services: _ _ _