ROBERT S. SHOPE MA, LMHC

PATIENT REGISTRATION FORM

(please print legibly)

Today’s date: (signature date) / DRIVERS LICENSE #
PATIENT INFORMATION
Patient’s last name: First: middle: / Marital status (circle one)
Mr. Mrs. Miss. Ms. Dr. Single / Mar/ Div / Sep / Wid / Oth
Is this patient’s legal name?
Yes No / If not, what is patient’s legal name? (former name): / Birth date:
/ / / Age: / Sex:
M F
Social Security #: / Home phone #: / Cell phone #: / Email address (optional)
Street address: / P.O. Box:
City: / State: / ZIP code:
IN CASE OF EMERGENCY
Name of local relative or close friend: / Relationship to patient: / Home phone #: / Work phone #:
EMPLOYEER or STUDENT INFORMATION
Occupation / Employer or School (if student). / Work/School phone #:
GUARANTOR: List individual responsible to pay all charges incurred during your relationship with our office.
Person responsible for payment of all billing: / Date of birth: / Social Security #:
Home phone: / Cell phone: / Work phone:
Address: / P.O. Box: / Is this person a patient here?
Yes No
City: / State: / Zip code:
Occupation: / Employer: / Work phone no:
The above information is true to the best of knowledge. I authorize the release of any medical or other information necessary to process claims. I authorize this office and/or the provider to be my representative. I understand that I am financially responsible for any balance. I also authorize this office and/or the provider and/or insurance company to release any information required to process all personal and/or financial information.
Print Guarantors Name: / Guarantors Signature: Date:
X
PRIMARY INSURANCE INFORMATION
Is this patient covered by Insurance? Yes No / Who is bringing patient in today?
(please be specific, mother, father, etc.)
Please indicate insurance:
(Uniform Med., Regence, DSHS?) / Primary insurance: / Secondary insurance: / Third: / Fourth/Other:
Even though you presented your medical card/coupon to us, please answer all questions below
Subscribers name: (this is who holds this policy) / Subscribers Social Security Number: / Date of birth:
Patient’s ID# (patient not subscriber, if different) / Group number / Group name: / Co-pay:
Patients relationship to subscriber: / Self Spouse Child / Other (be specific)
SECONDARY INSURANCE INFORMATION
Even though you presented your medical card/coupon to us, please answer all questions below
Subscribers name: (this is who holds this policy) / Subscribers Social Security Number: / Date of birth:
Patient’s ID# (patient not subscriber, if different) / Group number / Group name: / Co-pay:
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ROBERT S. SHOPE MA, LMHC

PATIENT REGISTRATION FORM

INFORMED CONSENT FORM
Fees and Payment for Services
The initial session is $225.00 and $150.00 for each subsequent (50 minute) session. Payment or
co-payment is due at the conclusion of each session. Payments are to be made to the office manager at the front desk. Co-insurance bills will be sent to you by our office after insurance explanation of benefits has been processed by us. It is office policy to bill the lesser of, $80.00 or the amount that would have been received from the insurance billings + co-payment for no-shows or cancellations made less than 24 hours prior to an agreed appointment time. For unavoidable circumstances this fee may be reduced to $40.00. Your signature below includes your authorization for release of any medical/psychotherapy information to your insurance company(s) or others that would be necessary in the procession and collection of your account. Furthermore, you are authorizing your insurance company(s) to make payments directly to this office or provider. You are also acknowledging that you understand the content of these documents, and giving your consent for treatment.
This statement is for your information and is an agreement between you and this office or provider regarding procedures and fees. If you have any questions, please feel free to ask.
______
Patient/Parent Guardian/Guarantor Signature Date
Release of Information
I authorize the release of any medical or other information necessary to process this claim. I authorize the provider to be my personal representative, which allows the provider to: (1) submit any and all appeals when my insurance company denies me benefits to which I am entitled, (2) submit any and all requests for benefit information from my insurance company, and (3) initiate formal complaints to any state or federal agency that has jurisdiction over my benefits. I fully understand and agree that I am responsible for full payment of the medical debt if my insurance company has refused to pay 100 percent of my benefits within ninety (90) days of any and all appeals or requests for information. I also agree that any fines levied against my insurance company will be paid to the provider for acting as my personal representative.

Please place a check in the box if you give us permission to call your contact phone number in order to confirm your appointment.
______
Clients Signature Date
Confidentiality
With the exception of specific legal circumstances described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not disclose to anyone what we discuss in session, or that you are even in counseling, without your written permission.
The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I would have to put these into effect.
1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.
2. If I have good reason to believe that you are abusing and/or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services and/or Adult Protective Services.
3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.
______
Client Signature Date
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ROBERT S. SHOPE MA, LMHC

PATIENT REGISTRATION FORM

SUPPLEMENTAL INFORMATION PAGE
Family members information: (i.e. Children, parents, siblings, spouse/significant other)
Name / Age / Sex / Living / Years of Education / Marital Status
Marriage Information:
(skip if never married)
Spouses name: Birth date: / /
Employer: Work phone #:
Have you ever been divorced? Yes No Date of marriage: / /
Have you ever been separated? Yes No
Give some brief information about any previous marriage(s):
Health Information:
Rate your physical health:
Very good Good Average Declining Date of last medical exam: / /
Physician’s name:
Are you currently taking medication? Yes No
If so, what?
Prescribed by: Phone number#
Religious Background:
Denomination preference:
Church attendance per month: (circle one) 0 1 2 3 4 5 6 7 8 9 10+
Religious background of spouse: (if married)
Do you believe in a higher power? If so, type (ie: God)
Explain recent changes in your religious life, if any:
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ROBERT S. SHOPE MA, LMHC

PATIENT REGISTRATION FORM

QUESTIONAIRE PAGE
Please Answer the Following Questions:
1). What is the main problem, as you see it? (Why are you here?)
2). What have you done about it?
3). What can we do?
4). Describe your spouse’s/partner’s personality in a few words.
5). As you see it, what kind of person are you? Describe yourself.
6). Is there any other information we should know?
How were you referred? (Check all that apply)
Myself Yellow Pages Relative Friend Parent/Guardian Teen Hotline
Court/Judge/Lawyer Probation or parole officer
Doctor/Clinic/Hospital (specify)
Another Agency (specify)
Other (specify)
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ROBERT S. SHOPE MA, LMHC

PATIENT REGISTRATION FORM

THE OPTION of CHRIST CENTERED COUNSELING
God, Our Father, is a very present help in times of need. The Bible teaches us that Jesus is the Wonderful Counselor. The Father and Son have sent the Holy Spirit to help, comfort, and teach us in our personal lives while we wait for Christ to return.
Therefore, all clients are offered the opportunity to include Christian spirituality as part of the counseling process and individualized treatment plan.
If you choose this option we may regularly invite the Holy Spirit to guide us; give us wisdom; and help us weave the spiritual realities and values taught in the Bible into the counseling process.
You may be encouraged to deepen your spiritual awareness and pointed to Biblical teachings about how to develop a deeper relationship with God and how to have the spiritual values Jesus taught woven into your daily living. Spiritual and religious aspects of your life may be included in the assessment process.
This option will be included only by your signed informed consent which may be freely adopted or rescinded at any time. Generally speaking, I do not believe in any form of manipulation or coercion choices. I choose to follow His example. Your spiritual decisions are ultimately private matters between you and God. However, if you think including Christian spirituality in your counseling might benefit you, it is available for you at your request.
Please consider these options:
______I chose to include Christian spirituality as part of my counseling.
______I would like to discuss this with you as we go along. You may bring up topics of Christian
spirituality and I will decide then whether I prefer to continue along those lines of discussion or
not.
______I prefer not to include this option as part of my counseling.
______I would like to consider this option privately and let you know what I have decided later.
______I have decided I no longer wish to continue this option as part of my counseling.
______
Signature Date
______
Signature Date
______
Witness Date
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