Psychological Resource Associates

PSYCHOLOGICAL RESOURCE ASSOCIATES

479 JUMPERS HOLD ROAD - SUITE 106

SEVERNA PARK, MD 21146

(410) 647-8840

ADMINISTRATIVE USE ONLY

Acct.# ______

1ST Appt. ______

Clinician ______

Dx. ______

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Dx. ______

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Signature on File: Y N

Signed Fee Agreement Y N

Date ______

Statement to:

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HICFA to: ______

Special Instructions:

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Data Entry Date ______

By ______

Mr. Mrs. Ms. Dr. ______Sex M F

Soc. Sec. # ______

Telephone (H) ______(W) ______

Cell ______

Address ______FOR ADMINISTRATIVEUSE ONLY

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E-Mail Address ______

Date of Birth ______Place of Birth ______

Marital Status ____ Single ____ Married ____ Partnered ____Separated ____Divorced

____Widow(er)

Date of Marriage ______Previous Marriages? Y N

Children/Siblings (Please provide names and birth dates)

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Spouse/Significant Other ______

CONTACT IN CASE OF EMERGENCY: ______

Telephone (H) ______(W) ______

Religious Preference ______

Education ______Degree/Years completed______

Employer ______Position ______

How long with employer? ______

Who referred you to us? ______

Reason for referral ______

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Please describe the problem(s) for which you are seeking help.

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PSYCHOLOGICAL RESOURCE ASSOCIATES2

Primary Physician ______Specialty ______

Telephone ______Address ______

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Date of last physical ______Medications ______

Medical problems/conditions ______

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Please provide the names and telephone numbers of other healthcare providers who are actively involved with your treatment at this time. Include Rehabilitation Nurse, Physical Therapist, and any complementary medicine providers, for example, Massage Therapist and Acupuncturist.

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FAMILY HISTORY Please describe the presence of any medical or psychological problems, substance abuse (drugs, alcohol, food), physical and/or sexual abuse in your family of origin.

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Any other information you believe would be important for us to know about you? ______

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Prior experience with psychotherapy? ____ Yes ____ No. If yes, with whom and when? ______

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FINANCIAL RESPONSIBILITY FOR SERVICES (Please fill out if the financially responsible party is someone other than the patient)

Responsible Party ______Date of Birth ______

Social Security # ______

Address ______

INSURANCE INFORMATION (Please fill out if you will be utilizing insurance)If you are utilizing insurance, please make sure that your clinician or the office secretary gets a copy, front and back, of your insurance card.

Insured Party Date of Birth ______

Address (if different from patient) ______

Insured’s Employer ______

PSYCHOLOGICAL RESOURCE ASSOCIATES 3

Primary Insurance Company______

Insured’s Identification Number ______Group Number ______

Secondary Insurance Company _________ID # ______Group # ______

May we contact you in the future to follow up on your satisfaction with the services you receive through Psychological Resource Associates? Yes No

Please indicate the following Psychological Resource Associates’ services about which you would like to receive more information:

Parent Education Workshops on AD(H)D

I authorize Psychological Resource Associates to release written information and to talk with my Health Care Providers and/or Managed Care Company for purposes of coordinating my clinical treatments, and for the management of reimbursement for services. I understand that this authorization can be revoked by me in writing at any time.

Signature Date ______

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