The PRISM Center
6750 West Loop South, Suite 950
Bellaire, TX 77401
Office: (832) 778-6750 Fax: (832) 778-6752
Psychotherapy Consultation
Adult Client Registration
Client Name: ______Date:______
Home Address: ______
Number Street City/State Zip Code
Phone Number: Home: ______Work: ______Cell: ______
Date of Birth: ______Age: _____ Sex: _____ Marital Status: _____ Race: ______
Employer: ______Occupation: ______Email: ______
Whom may we thank for referring you to The PRISM Center? ______
Emergency Contact: Name: ______Relationship to client: ______
Phone Number: Home: ______Work: ______Cell:______
What is the problem or issue for which you are seeking treatment or consultation?
______
______
Name of Primary Care Physician:______Phone: ______
Date of Last Appointment: ______Date of Next Appointment ______
Are you presently under the care of a psychiatrist? ( ) No ( ) Yes
If yes, please complete the following:
Name of Psychiatrist: ______Phone Number: ______
Date of last Appointment:______Date of Next Appointment: ______
Date first began seeing this doctor: ______
Are you presently under the care of a psychotherapist? ( ) No ( ) Yes
If yes, please complete the following:
Name of Psychotherapist: ______Phone Number: ______
Date of Last Appointment: ______Date of Next Appointment: ______
Date first began seeing this professional: ______
Current Medications
Name of Medication / Dosage / How long have you been taking this medication? / Reason for Medication / Response: Helpful?Side effects?
Please mark all of the following that apply to you today:
Behavioral Symptoms:
____Appetite disturbance ____Poor peer relationships____Impulsivity
____Parent/child conflict ____Promiscuity____Theft
____Sexual problems ____Gambling____Social isolation
____Self injuring(cutting, burning) ____Excessive use of alcohol____Marital conflict
____Acting out sexually ____Procrastinating____Financial issues
____Compulsive behavior ____Illegal drug use____Binge eating
____Abuse of prescribed meds ____Excessive absences from work____Other______
____Difficulty maintaining a clean & orderly home
Emotional symptoms:
____Irritability/Easily agitated ____Anger/resentment ____Stressed ____Sadness/grief ____Shame/guilt ____Tearful
____Anxious/panicky ____Numb____Detached
____Hopeless/Helpless ____Feelings of inferiority____Afraid
____Depressed ____Emptiness____Worthless
____Unmotivated ____Other______
Cognitive (Thought) symptoms:
____Poor concentration ____Difficulty making decisions____Unattractive
____Confused ____Nightmares____Unlovable
____Memory loss ____Overly sensitive____Racing thoughts
____Obsessive thoughts ____Distracted____Disorganized
____Paranoia ____Delusions/hallucinations____Fear of going crazy
____Worries about body image ____Fear of dying ____Other______
Physical symptoms:
Area of Physical Health / No Problem / PastProblem / Current
Problem / If a Current or Past Problem, Describe
Vision (eye sight, cataract, glaucoma)
Hearing (hearing impairment,tinnitus)
Circulatory (heart disease, migraine/headache, chest tightness,blood pressure, stroke)
Nervous System (seizures, numbness, shaking, trembling, tingling, etc.)
Muscles/Bones (breaks/sprains, muscle disease, etc.)
Digestive (stomach, bowels, IBS, GERD/reflux, vomiting, nausea, weight gain/loss, etc.)
Reproductive (STD, infertility, chills/hot flashes, pregnancy, prostate, peri-menopause, etc.)
Respiratory (lungs, TB, emphysema, etc.)
Hepatic (liver, hepatitis A, B, C)
Lymphatic (swollen glands)
Skin/Hair (rash, lesions, etc.)
Immune (HIV, cancer, frequent colds, coughs, infections, CFS, Epstein Barr)
Infectious (staph, MRSI, blood-borne)
Urinary (kidneys, bladder, etc.)
Other significant past and current medical problems not described above: ______
______
Allergies: ______
Current Pain? ( ) No ( ) Yes If yes, describe severity and location:
______
Current Treatment of Pain? ( ) Yes ( ) No Referred to Physician on ______
date
Current Sleep: ( ) No sleep disturbance ( ) Trouble falling asleep
( ) Trouble staying asleep ( ) Excessive sleep
Appetite: ( ) No appetite disturbance ( ) Loss of appetite ( ) Excessive appetite
Energy: ( ) Normal amount of energy ( ) Loss of energy ( ) Excessive energy
Suicidal Thoughts: Currently: ( ) No suicidal thoughts ( ) Suicidal thoughts
If yes, please describe: ______
Past: ( ) Never had suicidal thoughts ( ) Thoughts of suicide in past
( ) Attempted suicide in the past:
If yes, please explain (when? how?):______
Homicidal/Violence Thoughts: Currently: ( )None ( ) Yes, I have violent or
homicidal thoughts
If yes, please describe:______
Hallucinations: Check offcurrent hallucinations, if any:
( ) Visual ( ) Auditory ( ) Touch ( ) Taste ( ) Smell
Check offpast hallucinations, if any
( ) Visual ( ) Auditory ( ) Touch ( ) Taste ( ) Smell
Have you had the following abuse history, as victim or perpetrator:
Type of Abuse / Yes / No / Please describeEmotional/Verbal Abuse
Sexual Abuse
Physical Abuse
Domestic Violence/
Battering
Rape/Date Rape
Other violent crime
Substance Use:
Substance / Yes / No / Describe pattern of use / Date/Amount of last useTobacco
Alcohol
Marijuana
Cocaine/Crack
Stimulant Drugs (Ritalin, Adderal1, Speed, Methamphetamine, Crank)
Opiates (Vicodin, Oxycontin, Heroin)
Hallucinogens (XTC, PCP, LSD, Mushrooms)
Sedatives, Tranquilizers
(Xanax, Valium, sleeping pills)
Please answer yes or no to each question regarding your drug and/or alcohol use:
Question / Yes / No / Please describe/explainHave you ever felt you should cut down on your use of alcohol or drugs?
Have you ever been annoyed when people have commented on your alcohol or drug use?
Have you ever felt guilty or badly about your alcohol or drug use?
Have you ever had an “eye opener” first thing in the morning to steady your nerves, avoid withdrawal symptoms, or avoid the low feeling you get after using?
Please describe all past Outpatient Psychotherapy and/or Psychiatric Hospitalizations:
Provider of Service / Dates of Service / Reason(s) forTreatment / Was it helpful?
Financially Responsible Party (If Different Than Client)
Name: ______Home Phone #: ______Work #: ______
Cell #:______Address: ______
Number Street City Zip Code
Insurance claims
If we will be filing an insurance claim for you, (1) Please give us your insurance card to photocopy and (2) Please complete the following:
Name of Insured (if different than client): ______
Relationship to Client: ______Date of Birth: ______Social Security #:______
Insured’s Address (if different than client):______
number street city zip code
Insured’s Phone # (if different than client): ______Insured’s Employer: ______
The PRISM Center
6750 West Loop South, Suite 950
Bellaire, TX 77401
Office: (832) 778-6750 Fax: (832) 778-6752
Psychotherapy Consultation
Client’s Name ______
Welcome to The PRISM Center. Please review the following policies carefully. We will discuss our policies at any time should you have questions. We appreciate your confidence in selecting us as your service provider.
Services Provided: We provide a wide variety of psychotherapy and consulting services including, but not limited to, the following:
- Evaluations and Consultation
- Crisis Intervention and Crisis Management Services
- Intensive Outpatient Program (IOP) for Adults
- Dialectical Behavioral Therapy (DBT) for Adolescents, Parents,
and Adults. Individual DBT and DBT Skills Training Groups
- Individual, Group, Marital, and Family Therapy/Education
- Stress Management
- Individualized Chemical Dependency Assessment and Treatment
- Employee Assistance Services for Companies (EAP)
- Career Coaching and Vocational Assessment
Each of these activities is covered by the rules of practice for practitioners in the state of Texas, and is governed by the Texas State Board of Social Work Examiners and other certifying agents.
Records and Diagnosis: We are required by law to maintain records of each time we meet or talk on the phone. The records include a brief synopsis of the conversation along with any observations or plans for the next session. Your file will be kept in a locked file cabinet, and only staff members with a key will have access to records on an as needed basis. A judge can subpoena your records for a variety of reasons and, if this happens, we must comply. If we are called to testify about the contents of the records, we also must comply. Occasionally, we can negotiate with judges and attorneys to keep some information confidential.
Electronic Transmissions: Confidentiality cannot be assured using any form of electronic media communication (i.e. fax, internet communication). Email: We are a very busy practice, working with clients primarily via face-to-face therapy and via phone contact. Your individual psychotherapist or group therapist may also respond to emails, but the timeliness of response depends on the particular therapist, and some prefer not to communicate via email(unless a special circumstance occurs). Please discuss email with your therapist. There will be a charge for therapeutic/consulting activities via email.
Fees: Payment is due at time of service. We accept MasterCard, VISA, checks and cash. There is an ATM machine in the Frost Bank lobby downstairs which you are welcome to use.
Fee Schedule
Brief Session: 30 minutes $ 62.50
Standard Session: 50 minutes $125.00
Intake Evaluations and Extended Session: 75 minutes $150.00
Extended Session: 90 minutes $187.50
Extended Session: 120 minutes $ 250.00
Group Therapy (60 to 120 min.) $50 - 100 /session
DBT Group Therapy (2 to 2.25 hours) $100
Intensive Outpatient Program per Session: $150 to $207+ / session
(2.25 – 2.5 hours/session) (rates vary depending on contract with insurance company)
Professional time: for reports, court appearances, crisis telephone sessions, disability reports, responding to email communication, etc. Insurance does not pay for these extra services. $125 / hour, prorated
TimeParameters and Scheduling: We have a busy schedule, as do the majority of our clients, so we make considerable effort to run on time, unless come unforeseen crisis occurs. Since we specialize in complex care, psychiatric emergencies do occasionally happen. Routine psychotherapy sessions are scheduled for 50 minutes, unless we are advised in advance that you prefer either a brief or extended session. During the courseof a follow-up session, if you want additional time (i.e. extended session) please let the therapist know and we will be happy to accommodate you if our schedule allows.
The time allotted for your therapy session begins at the time of your scheduled appointment (e.g. 2:00 p.m. appointment means that the time from 2:00 until 2:50 p.m. has been reserved for you and will end at 2:50 p.m. regardless of your arrival time).
Cancellations: 24 hours business notification prior to scheduled appointments is required. Monday appointments must be cancelled on the preceding Friday to avoid any fee. If you fail to give 24 hours notice and/or fail to appear for a session, you will be charged the full rate of the session. Insurance companies cannot be billed for a cancelled appointment.
Absences from Group Therapy and IOP: It is expected that you attend all scheduled group therapy sessions until you are discharged. If you have to miss group therapy or IOP, please call us in advance to discuss the absence. We have limited spaces availablein our groups so, if you are a member, it is important to take advantage of your membership and attend group therapy when it is scheduled (plus, you maximize the therapeutic benefits of being in the program.)
Zero Tolerance Policy: Safety to clients and others is essential at all times. We adhere to a strict “zero tolerance” policy towards violence against people or property, and drug, alcohol, or weapons on the property. We will call the police for violations of this policy to insure safety. Neither clients nor family members are to come intoxicated or high to any therapy session.
Confidentiality: Confidentiality is a legal protection and assurance of your right to privacy within the limits of the Texas state statues and Federal HIPAA law. The attached HIPAA notice further explains our privacy practices. It is your right that all communication with us is completely private with few exceptions:
Exceptions to confidentiality:
(1) The clinicians in the practice may share information to collaborate in your care.
(2) If we consider you a danger to yourself or to others, we must inform the police or a
family member if you refuse to tell your family or seek hospitalization.
(3) If a court subpoenas your records, we must cooperate with the court order.
(4) If you are a minor and we believe that you are a victim of abuse, we must inform
Children’s Protective Services per state law.
(5) We must report abuse of disabled or aged adults to Adult Protective Services.
(6) If you want your insurance company to reimburse treatment, we must be able to
discuss your diagnosis and treatment with their representative (either verbally or in
writing).
(7) If you are under the age of 18 and your parent or legal guardian requests information
that we consider necessary to the support of your treatment, we will ask your permission to discuss such issues with them, but will do so in any case for emergencies.
(8) State and Federal Law also mandates that we may have to disclose limited health
information in matters regarding emergencies, national security, public health,
research, and other similar matters.
Client Rights and Privacy Notice: Attached are copies for your review.
Client and Family Involvement in Treatment: It is expected that all clients and applicable family members actively participate in the assessment, treatment, and discharge planning process. We want and require your input, preferences, and objections in regard to treatment.
Emergencies: One of the therapists is always on call nights and weekends for true emergencies. In addition, we encourage you to go to your nearest emergency room or psychiatric hospital for psychiatric emergencies. Our day and after-hours cell phone number is (281) 974-0691.
Notice of Termination of Services: You are not obligated to seek services here for any specified number of sessions. You are important to us, however, and if you decide to end services here, we would appreciate notification of your completion of services either in a therapy session or via a phone call.
Questions, Concerns, or Complaints: Your satisfaction with our services is very important to us. Should you have any questions, concerns, or complaints, please feel free to openly discuss them with either your therapist or Martha Fontana, LCSW.
I have reviewed and understand these policies and procedures, and agree to the terms specified above. I have also received a notice of “Privacy Practices” on this date. I understand that if I have any questions regarding the Notice of Privacy Practices or my privacy rights, I may contact Martha Fontana, Privacy Officer, at (832) 778-6750.
( ) I am consenting to an initial intake evaluation and/or continuing treatment
Initial or consultation services, for myself or my child.
Client Signature:______Date: ______
Parent Signature: (if applicable; please print): ______
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 THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.
For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization. We may use PHI to remind you of appointments, or to provide information about treatment alternatives or other health-related benefits and services.
Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:
- Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or the health department)
- Required by Court Order
- Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
Verbal Permission
We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer , Martha Fontana at 832-778-6750.
- Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.
- Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
- Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
- Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
- Right to a Copy of this Notice. You have the right to a copy of this notice.
COMPLAINTS