Larry Smith, Lpc

The DBT Clinic, PC 4511 SE Cesar E. Chavez Blvd.

Portland, OR 27202

Phone: (971) 285-6545

Fax; (503) 200-5550

CLIENT INFORMATION SHEET

Name: / Date:
Date of Birth: / Age: / Marital Status:
Social Security #: / Email:
Home Phone: / Cell Phone: / Fax:
Home Address: / City, State, Zip:
May I leave a message? / Yes No / May I identify myself/clinic? / Yes No
Job Title: / Employer:
Work Address:
Work Phone: / May I leave a message? / Yes No
Emergency Contact: / Relationship:
Address:
Home Phone: / Cell Phone: / Work Phone:
Physician:
Address: / Phone:
Who referred you to this office?
Address: / Phone:

Issues of Concern:

Client or authorized person’s signature: I authorize The DBT Clinic to make contact with my physician for purposes of treatment planning and coordination of care.

Signature / Date

Client or authorized person’s signature: I authorize The DBT Clinic to make contact with the referral source to thank him/her and let him/her know contact has been made.

Signature / Date

Medical Information Sheet

Client Name: / Date:

Please write down the following information in the space provided.

General medical illnesses that I have or had (for example: cancer, arthritis, heart, thyroid, neurological diseases, or other illnesses such as migraines, chronic fatigue syndrome, etc.).

Prescriptions or over-the-counter medications that I take regularly (Please include dosages, if known, and prescriber).

Allergies that I have to foods, medicines or other things.

General medical illnesses that run in my family (such as diabetes, heart disease and others).

Other notes about my health.

INSURANCE

Client’s Name: / DOB: / SS#:
Identification #: / Group #: / Gender:
Primary Insurance Holder (If different than client):
Name: / DOB: / SS #:
Identification #: / Group #:
Address: / City, State, Zip:
Phone: / Insured’s Employer:
Relationship to Client:
Insurance Company:
Address:
Phone: / Email: / Fax:
Parameters of Benefits:
Co-pay: / $ / Co-insurance:
Deductible: / $ / Deductible met? / Yes No / Remaining? / $
Unlimited visits, as long as medically necessary? / Yes No
If no, # of visits allowed per year: / # of visits used? / Renewal date:
Preauthorization required? / Yes No / Authorization #:
Limits of health benefit? / Yes No / Amount:

Insurance Notes:

The DBT Clinic, PC and its contracted billing service has my permission to bill my insurance company. I authorize The DBT Clinic, PC and its contracted billing service to release any information necessary to process claims and secure authorization for treatment. I further authorize my insurance benefits be paid directly to The DBT Clinic,PC.

Signature / Date

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Client-Therapist Agreement/Informed Consent

The DBT Clinic and its staff consider working with you a privilege and we are grateful for you trust. In effort to avoid misunderstandings and poor feelings between us, I’ve outlined below policies for conducting counseling services. Please read the following policies carefully. If anything is not clear, or if you’d like an explanation or rationale, feel free to ask. If you’re agreeable to these policies, please indicate so with your signature below.

Payment is due at time of service unless other arrangements are made. If your therapist is in-network with your insurance company, we’ll collect your deductible and co-pay and courtesy bill to your insurance company. If costs are incurred in pursuit of collection of money owed by a client, the client is responsible for those costs. Clients are responsible for tracking benefits, authorizations and eligibility. If your therapist out-of-network, full payment will be collected. We’ll courtesy bill to your insurance, which will reimburse to you the costs they cover per your plan.
Your appointment is reserved specifically for you. If you are unable to keep your scheduled appointment or need to reschedule, please give at least 24-hour or one business day notice, whichever is longer. Without this prior notice, if we cannot fill this time reserved for you to another, the client will be charged the amount the insurance company would allow, up to $100.00.
Phone contact between sessions:

If you are in a crisis (defined as having difficulty resisting urges to commit suicide or inflict tissue damage) between sessions, you are encouraged to call/text/page your individual therapist anytime of the day or night. The focus of the call will be on using skills to manage the crisis and/or to assess the appropriateness of inpatient hospitalization.

If your therapist doesn’t return your call/text within an hour or if you don’t think you can keep yourself safe before we return your call, call the Crisis Line in your community:

Mult. County: / 503 988-4888 / Wash County: / 503 291-9111
Clack. County: / 503 655-8401 / Clark County: / 360 737-1399

Or call 911 or go to an Emergency Room. Do not hurt yourself!

Confidentiality:

Communications between you and your therapist are privileged. However, there are limits to confidentiality. These limits include, but are not limited to the following: If you intend to harm yourself or others we will alert the proper authorities and attempt to warn, if possible, intended victims. If you report to us any abuse of children, the disabled or the elderly, we are mandatory reporters and must, by law, report such information to the proper agencies. If we receive a subpoena by a court, we can resist complying but may be compelled to release records and/or testify. You can waive privilege by signing a release of information, which allows us to communicate to specified persons or agencies as noted on the release. In the case of family therapy, the all parties being treated have privilege. In as much, all parties have to sign releases of information in order to send records to other parties. If you’re using insurance to pay for services, you must agree to allow me to communicate such information as is necessary to secure authorization and payment for treatment. For a more detailed list of protections and limits to your Personal Health Information, please refer to the HIPPA Act, a copy offered at intake and available at any time upon request.

If you agree to the terms outlined above, please note with your signature below:

Signature: / Date:
Printed name(s)

Informed Consent Addendum:

Policies Regarding Electronic Communications

Client confidentiality is protected by law. Communications via e-mail and text messaging can be intercepted at a number of junctures. Therefore, The DBT Clinic, PC will not communicate any clinical information via text messaging or e-mails. It is permissible to use these methods of communication to cancel or change appointments. Clients are discouraged from sharing personal information in this manner. If you have personal/clinical concerns you’d like to discuss, it’s advised you leave a voice mail message. If you prefer to e-mail or text, it’s advised to state you would like me to call you to discuss a concern, but please don’t go into specifics of what your concern is.

Client’s signature below indicates the client has been informed of this policy:

Client Signature / Date

The DBT Clinic, PC

4511 SE Cesar E. Chavez Blvd.

Portland OR 97202

(971) 285-6545

AGREEMENT TO TREAT

I, / agree to enter counseling treatment
with The DBT Clinic, PC with the following understandings:

I understand that although there is empirical evidence for the effectiveness of psychotherapy, this evidence is not presented as a guarantee either direct or implicit of the effectiveness of this treatment.

I understand each individual must independently evaluate and use his or her own judgment in choosing among treatments and therapists available.

I understand there are other therapist and treatments available to me.

By signing my name below, I understand and accept all terms of this agreement.

Client Signature / Date
Therapist Signature / Date

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Client-Therapist Agreement/Informed Consent

(Client Copy)

Payment is due at time of service unless other arrangements are made. If I’m in-network with your insurance company, I collect your deductable and co-pay and courtesy bill to your insurance company. If the insurance company does not pay for services within 60 days of the date of service, the client is responsible for the balance at that time. If costs are incurred in pursuit of collection, client is responsible for those costs. Clients are responsible for tracking benefits, authorizations and eligibility. If I’m out-of-network, full payment will be collected. I’ll courtesy bill to your insurance, who will reimburse to you the costs they cover per your plan.
Your appointment is reserved specifically for you. If you are unable to keep your scheduled appointment or need to reschedule, please give at least 24-hour or one business day notice, whichever is longer. Without this prior notice I cannot provide this time reserved for you to another, so you will be charged full rate (insurance won’t cover) for this time slot.
My hourly fee includes 50 minutes of face-to-face contact, including payment and rescheduling, and 10 minutes for charting. If you arrive late the session will end at ten of the hour. If I’m late, either the session will be extended, pro-rated or rescheduled at no charge to you.
Phone contact between sessions:

If you are in a crisis (defined as having difficulty resisting urges to commit suicide or inflict tissue damage) between sessions, you are encouraged to call/text anytime of the day or night [503-382-9654]. The focus of the call will be on using skills to manage the crisis and/or to assess the appropriateness of inpatient hospitalization.

If I don’t return your call/text within an hour or if you don’t think you can keep yourself safe before I return your call, call the Crisis Line in your community:

Mult. County: / 503 988-4888 / Wash County: / 503 291-9111
Clack. County: / 503 655-8401 / Clark County: / 360 737-1399

Or call 911 or go to an Emergency Room. Do not hurt yourself!

Confidentiality:

Communications are privileged. There are limits to confidentiality. These limits include, but are not limited to the following: Intent to harm yourself or others: I will alert the proper authorities and attempt to warn, if possible, intended victims. Reported abuse of children, the disabled or the elderly: I am a mandatory reporter and must, by law, report such information to the proper agencies. If I receive a subpoena by a judge I can resist complying but may be compelled to release records and/or testify. You can waive privilege by signing a release of information, which allows me to communicate to specified persons or agencies as noted on the release. In the case of family therapy, the “Identified client” (person the chart is under) has privilege. E-mail and text messaging are not confidential means of communicating. Please do not send, and you will not receive, clinical information via text or e-mail. If you’re using insurance to pay for services, you must agree to allow me to communicate such information as is necessary to secure authorization and payment for treatment. For a more detailed list of protections and limits to your Personal Health Information, please refer to the HIPPA Act, a copy offered at intake and available at any time upon request.

If you agree to the terms outlined above, please note with your signature below:

Signature: / Date:

Informed Consent Addendum:

Policies Regarding Electronic Communications

(Client Copy)

Client’s signature below indicates the client has been informed of this policy:

Client Signature / Date

Revised 12/02/15