Loree A. Johnson, Ph.D., MFT

1601 Pacific Coast Highway, Suite 290, Hermosa Beach, CA 90254

23030 Lyons Avenue, Suite 202, Newhall, CA 91321

CA License # MFC 43775

310.625.9783

Client Information

(Confidential, please print)

Date______

Name______Name______

Address______Address______

City______Zip______City______Zip______

Home phone______Home phone______

Age______Date of Birth______Age______Date of Birth______

Social Security#______Social Security#______

Driver’s License #______Driver’s License#______

Occupation______Occupation______

Employer______Employer______

Address______Employer______

City______Zip______City______Zip______

Work Phone______Work Phone______

Email______Email______

Emergency Contact

Name______Phone______

Address______Relationship______

Health Insurance Coverage

Name of Insurance Company______Phone______

Mailing Address______

Plan or Policy#______Certificate#______Individual ID#______

Name of insured if different than client______

Referred By

Name______Phone______
Address______

Is it all right to thank them? ______Yes______No

Marital Status (check one) Single Married Separated Widowed  Divorced  Cohabiting

Children or Stepchildren (indicate by C or S)

NameAgeC or SNameAgeC or S

______

______

______

Name of Primary Care Physician______

Address______Phone______

Medication List all medications you are taking

Medication and DosagePrescribed forPrescribed & Supervised by

______

______

______

Previous Therapy:  Individual  Couple  Family  Group  Inpatient  Outpatient

(check all that apply)

 MFT/MFCC  LCSW  Psychologist  Psychiatrist  Other

Name of Therapist______How long?______

For What?______Results______

Current Concerns & Goals

1.______

2.______

3.______

4.______

Loree A. Johnson, Ph.D., LMFT

Office and Financial Policy

Usual and customary rates… My fee is $175 for a session of 45 minutes in length, or the negotiated rate ($____). My practice is committed to providing the best treatment for patients and I charge what is usual and customary for this area. You are responsible for payments regardless of any insurance company’s determination of usual and customary rates.

Regarding insurance…Your insurance policy is a contract between you and your insurance company. I am not a party to that contract. As a courtesy, my office will bill your insurance company on your behalf. I do not bill secondary insurance, my office will provide a billing statement, upon request, which you can submit to your carrier for reimbursement. The balance is your responsibility whether or not your insurance company pays. If your insurance company does not pay your account in full within 45 days of the billing date, you will be billed for the remaining balance on your account, which will be charged to your credit card on file. ______(Initial)

Payment… is due at the time of service. Please have your check written prior to session in order to maximize our time in session. I accept cash, check, MasterCard, or Visa. For your convenience, a credit card will be placed on file to assist you with this process. A returned check fee of $25 will be charged. If any chargeback occurs, you will assume responsibility for the chargeback penalty and any costs incurred. Unpaid bills may be turned over to a collection agency and/or an attorney and, if so, you will also be responsible for collection and/or legal costs. ______(Initial)

Late and Missed appointments…If you are late, we will meet for the remainder of your session. If you are unable to keep your appointment, please call at least 24 hours in advance to cancel. If your appointment is on a Monday, then you must call or email to cancel no later than Friday at 12 noon. Please do not text. My policy is to charge for missed appointments at the same rate of a normal office visit. Insurance does not cover missed appointments. Please help me serve you better by keeping scheduled appointments. ______(Initial)

Informed Consent to Treatment and Release of Information

Participating in therapy can help you learn new and important things about yourself and others, as well as new and better ways of handling feelings and/or problems. While there are no guarantees, coming to therapy should help you feel better and produce beneficial results.

You know therapy is working when you feel less worried, afraid or anxious; problems are being resolved; relationships are improving or you come to feel better about yourself. Sometimes you may feel worse before you feel better. This is part of the therapeutic process and usually means you are making progress. You have the right to end therapy at any time.

Circle One:

1.YesNoI consent to the release of information in my file for insurance billing/collection of

outstanding balance purposes.

2YesNoI understand that my insurance company may require random reviews of all client clinical

records maintained by Loree A. Johnson, Ph.D., LMFT.

3.YesNoI understand that all information and records are held in strict confidence unless:

(a) YesNoA client communicates to the therapist a serious threat to harm an

identifiable person, in which case the therapist must warn that person and the police;

(b) Yes NoThe therapist suspects child abuse or neglect, or abuse of a helpless adult or

elder, at which time a report must be made to the designated agency;

(c) YesNoThe client seems dangerous to self or others or is unable to care for him/herself,

then hospitalization may be required.

(d) YesNoInformation and records – otherwise confidential – and/or testimony

concerning me and/or my family must be provided in the event of a court ordered subpoena in litigation, or in official proceedings, or for workers’ compensation cases.

4. YesNoI acknowledge that I have been provided with a copy of Dr. Johnson’s Privacy Practices.

In connection with the treatment and/or consultation in which I am participating with Dr. Loree Johnson, and after discussing these matters with my therapist, I hereby understand and consent to all of the above, including all matters pertaining to confidentiality, release of information, financial/insurance arrangements and financial responsibility. I further understand this consent covers any of my minor children involved in treatment, as well as myself, and that this consent is in effect for the duration of treatment and collection of any outstanding balance.

Client:______Date: ______Loree A. Johnson, Ph.D., LMFT: ______

Loree Johnson, Ph.D., MFT

1601 Pacific Coast Highway, Suite 290, Hermosa Beach, CA 90254 310.625.9783

23030 Lyons Avenue, Suite 202, Newhall, CA 91351

State Lic. # MFC 43775

Notice of Privacy Practices Summary

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW CAREFULLY.

I understand the importance of privacy and am committed to maintaining the confidentiality of your medical information. I make a record of the medical care I provide and may receive such records from others. I use these records to provide medical or enable other health care providers to provide medical care, to obtain payment for services provided to you as allowed by your health plan and to enable me to meet my professional and legal obligations to operate this practice properly. I am required by law to maintain the privacy of protected health information (PHI) and to provide individuals with notice of my legal duties and privacy practices with respect to protected health information. This summary of the Privacy Practices lists how I may use and disclose your medical information. It also lists your rights and my legal obligation with respect to your medical information. If you have any questions about the Notice, please feel free to ask.
A. How this Office May Use or Disclose Your Health Information
This office collects health information about you and stores it in a chart and/or computer. This is your medical record. The law permits me to use or disclose your health information for the following purposes:
  1. Treatment
  2. Payment
  3. Health Care Operations
  4. Appointment Reminders
  5. Notification and communication with family
  6. Required by law
  7. Public Health
  8. Health oversight activities
  9. Juridical and administrative proceedings
  10. Law enforcement
  11. Coroners
  12. Organ or tissue donation
  13. Public Safety
  14. Specialized government functions
  15. Workers compensation
  16. Change of ownership
B. When This Office May Not Use or Disclose Your Health Information -
Except as described in this Notice of Privacy Practices, / this practice will not use or disclose health information, which identifies you without your written authorization. If you do authorize this office to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
C. Your Health Information Rights
  1. Right to Request Special Privacy Protections
  2. Right to Request Confidential Communication
  3. Right to Inspect and Copy
  4. Right to Amend or Supplement
  5. Right to an Accounting of Disclosures
  6. You have a right to a paper copy of the complete Notice of Privacy Practices
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, you may contact this office.
D. Changes to this Notice of Privacy Practices
I reserve the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, I am required by law to comply with this notice. After an amendment is made, the revised notice will apply to all protected health information that I maintain, regardless of when it was created or received. A copy will be available.
E. Complaints
Complaints about this Notice of Privacy Practices or how this office handles your health information should be directed to the licensed healthcare professional.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:
Department of Health and Human Services
Office of Civil Rights
Room 509F HHH Building G
200 Independence Avenue, S.W.
Washington, D.C. 20201
You will not be penalized for filing a complaint

Loree A. Johnson, Ph.D., LMFT

1601 Pacific Coast Highway, Suite 290, Hermosa Beach, CA 90254

23030 Lyons Avenue, Suite 202, Newhall, CA 91321

State Lic. # MFC 43775

310.625.9783

Credit/Debit Card Payment Consent Form

Client Name: ______

I, ______(Person financially responsible for account), authorize Loree A. Johnson, Ph.D., LMFT to charge my credit/debit card for fees associated with my account.

Type of Card:MasterCardVisa

Card Number: ______-______-______-______CVV: ______

A 3-digit number in reverse italics on the back of the credit card

Expiration Date: ______

Name As It Appears On the Card: ______

Billing Address: ______

______

Signature: ______Date: ______