Adult Patient Forms

Mind Body Connection, Inc

Consent for Treatment and Limits of Liability

Limits of Services and Assumptions of Risks:

Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions.

Limits of Confidentiality:

What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian. The following is a list of exceptions:

Duty to Warn and Protect - If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.
Duty to Warn and Protect - If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.
Prenatal Exposure to Controlled Substances - Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.
Minors/Guardianship - Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records.
Insurance Providers - Insurance companies and other third-party payers are given information that they request regarding services to the clients.

The type of information that may be requested includes: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc.

By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.

Date

HIPPA Notice of Privacy Practices for Personal Health Information

I have read the Privacy Notice of this practice and understand my rights regarding my Personal Health Information (PHI) and how this information will be used, as presented in Privacy Notice. I consent to the use and/or disclosure of my PHI for purposes of treatment, and or payment. Other uses of my PHI will require an authorization from me for the specific intention of the disclosure.

INSERT SIGNATURE OF PATIENT OR GAURADIAN

Client's Name

Date

Parent/Legal Guardian's Name

Insurance Billing Form

I agree to authorize Dr. Anu Kommu to bill my insurance company directly for the insurance portion of my session fees. I agree to pay all copays, deductibles, and/or patient portions of the fee at the time of service. I understand that if my insurance does not reimburse Dr. Kommu for the charges within 90 days, I am responsible for the unpaid balance.

I hereby authorize my insurance company to make direct payments of the medical benefits to Dr. Kommu

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New Patient Insurance Form

Full Name of Patient

DOB

Age

Gender

Home Address

Home Phone

Work Phone

Cell Phone

Referral Source

Reason for coming in

Primary Insurance

Insurance ID#

Group #

Insured's Name

DOB

SSN

Insured's Address

Number on card to call for Benefits

Secondary Insurance

Insurance ID#

Group #

Insured's Name

DOB

SSN

Insured's Address

Number on card to call for Benefits

Any other health insurance benefits?

Are you using EAP?

Date

Cancellation Policy

No Show Policy

If you are unable to attend an appointment, we request that you provide at least 24 hours advanced notice to our office. Since we are unable to use this time for another client, please note that you will be billed for HALF THE AMOUNT of the entire cost of your scheduled appointment. Unless such cancellation is due to illness or an emergency.

No Show Fee - $60.00

A "no show" is someone who misses an appointment without cancelling it within a 24-hour working day in advance. No-shows inconvenience those individuals who need access to psychological care in a timely manner.

Scheduled Appointments

We understand that delays can happen, however, we must try to keep the other clients on time, If you are running late, please notify us.

If you arrive 15 or more minutes past the scheduled appointment time without notifying your clinician that you are running late, we may have to reschedule your appointment.

For cancellations made with less than 24 hour notice (unless due to illness or an emergency) or a scheduled appointment that is completely missed, you will be mailed a bill directly for HALF THE COST of the session fee.

How to cancel your appointments

To cancel an appointment, please call our office at (540)-341-1703 or (571)-364-3095. You may also cancel via email, which can be found on our website. After two consecutive no-shows to your appointment without notification, our practice may decide to terminate its relationship with you.

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Authorization Form to Consult with PCP

If you would like me to consult with your Primary Care Provider please fill out this portion below. If this form completed and signed by you, it authorizes me to release protected information from your clinical record to the person you designate i.e. your Primary Care Provider or other (Please list the name below).

Name of Provider or of person to whom you would like to share information with.

I authorize my psychologist, Anupama Kommu, PsyD, and or her Extern/s and administrative and clinical staff

Person providing service

to release (Provide description of the information that you want disclosed. Your description should be as specific and detailed as possible)

This information should only be released to (name and address of person to whom the information is to be released)

I am requesting my psychologist to release this information for the following reasons (Consultation, Collaboration, psychological evaluation, medication management, intervention summary, treatment plan):

This authorization shall remain in effect until (fill in expiration date) or until (fill in an event that relates to the individual or the purpose of the use or disclosure or until end of treatment).

You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I am aware of my right to confidential communications under psychologist-patient privilege.

I understand that information used or disclosed pursuant to the authorization may be subject to redisclosed by the recipient of your information and no longer protected by the HIPAA Privacy Rule

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Adult Intake Form

Please provide the following information for my records. Leave blank any question you would rather not answer. The information you provide here is held to the same standards of confidentiality as our therapy.

Date

Name (Last, First, MI)

Birth Date

Age

If other, please specify

Address (Street and Number, City, State, and ZIP)

Contact Information

Home Phone

May I leave a message?

Yes No

Cell Phone

May I leave a message?

Yes No

Email address

*Please be aware that email may not be confidential

May I email you?

Yes Yes

Relationship Status

1b) If yes, for how long?

2a) Are you currently in a romantic relationship?

Yes No

2b) If yes, for how long?

2c) If yes, on a scale of 1 to 10 (great), how would you rate your romantic relationship?

Children

1a) Do you have children?

Yes No

1b) If yes, how many?

1c) Ages?

1d) Gender of Children

HEALTH INFORMATION

Current Health Information

2a) Primary Care Doctor

2b) Primary Care Doctor Number

3) Please list any chronic health problems or concerns (e.g. asthma, hypertension, diabetes, headaches, stomach pain, seizures, etc)

4) Medications

Sleep

1) Hours per night you normally sleep

2a) Are you having any problems with your sleep habits?

Yes No

2b) If yes, check where applicable

Sleeping too little

Sleeping too much

Can't fall asleep

Can't stay asleep

Exercise

1a) Do you exercise regularly?

Yes No

1b) How many times per week?

1c) For how long?

1d) What do you do?

Sleep

1a) Are you having any difficulty with appetite or eating habits?

Yes No

1b) If yes, check where applicable

Eating less

Eating more

Bingeing

Purging

2) Have you experienced significant weight change in the last 2 months?

Yes No

Alcohol and Drug Use

1a) Do you regularly use alcohol?

Yes No

2b) If you chose any other choice besides "never", which drugs do you use?

3a) Do you smoke cigarettes?

Yes No

3b) If yes, how many cigarettes per day?

4a) Do you drink caffeinated drinks?

Yes No

4b) If yes, # of sodas per day

4c) If yes, how many cups of coffee per day

Head Injury

1a) Have you ever had a head injury?

Yes No

1b) If yes, when and what happened?

PSYCHIATRIC INFORMATION

1) What prompted you to seek therapy or an assessment at the current time?

2) What are your overall goals for therapy?

3) In the last year, have you experienced any significant life changes or stressors?

4a) Have you had previous psychotherapy?

Yes No

4b) If yes, why?

4c) If yes, when?

5a) Are you currently taking prescribed medications (antidepressants or others)?

Yes No

5b) If yes, please list names and doses:

6a) If no, have you previously been prescribed psychiatric medication?

Yes No

6b) If yes, please list names and dates

7) Are you hopeful about your future?

Yes No

8b) If yes, have you done anything to hurt yourself?

Yes No

9b) If you chose any answer besides "never", when did you have those thoughts?

9c) Did you ever act on them?

Yes No

10a) Are you having current homicidal thoughts (i.e. thoughts of hurting someone else)?

Yes No

10b) Please describe

11a) Have you previously had homicidal thoughts?

Yes No

11b) If yes, when?

Are you currently experiencing:

Depressed mood or sadness

Irritability

Mood swings

Rapid speech

Racing thoughts

Anxiety

Constant worry

Panic attacks

Phobias

Sleep disturbances

Hallucinations

Paranoia

Poor concentration

Alcohol/substance abuse

Frequent body complaints (e.g. headaches)

Eating disorders

Body image problems

Repetitive thoughts (e.g. obsessions)

Repetitive behaviors (e.g. counting)

Poor impulse control (e.g . excessive spending)

Self mutilation

Sexual abuse

Physical abuse

Emotional abuse

Have you experienced in the past:

Depressed mood or sadness

Irritability/Anger

Mood swings

Rapid speech

Racing thoughts

Anxiety

Constant worry

Panic attacks

Phobias

Sleep disturbances

Hallucinations

Paranoia

Poor concentration

Alcohol/substance abuse

Frequent body complaints (e.g. headaches)

Eating disorder

Body image problems

Repetitive thoughts (e.g. obsessions)

Repetitive behaviors (e.g. counting)

Poor impulse controls (e.g. excessive spending)

Self mutilation

Sexual abuse

Physical abuse

Emotional abuse

OCCUPATIONAL, FINANCIAL, EDUCATIONAL, & LEGAL INFORMATION

1a) Are you employed?

Yes No

1b) If yes, who is your current employer/position?

1c) If yes, are you happy with your current position?

2) Please list any work-related stressors, if any:

3a) Do you have financial concerns?

Yes No

3b) If yes, please explain

4a) Are you currently in the military?

Yes No

4b) Previously?

Yes No

5) Highest level of education

6a) Do you have any legal concerns?

Yes No

6b) If yes, please explain

FAMILY HISTORY

1a) Are your parents:

Still together Divorced Remarried Unmarried Deceased

1b) If divorced, when?

1c) If deceased, whom? Age at death?

2a) Number of siblings:

2b) Ages:

3a) Do you have good family/friend support?

Yes No

3b) From whom?

FAMILY MENTAL HEALTH HISTORY

Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following? (circle any that apply and list family members, e.g. siblings, parent, uncle, etc.):

Depression

Yes No

Family members

Bipolar disorder

Yes No

Family members

Anxiety disorders

Yes No

Family members

Panic attacks

Yes No

Family members

Schizophrenia

Yes No

Family members

Alcohol/substance abuse

Yes No

Family members

Eating disorders

Yes No

Family members

Learning disabilities

Yes No

Family members

Trauma history

Yes No

Family members

Suicide attempts

Yes No

Family members

Psychiatric hospitalization

Yes No

Family members

OTHER INFORMATION

1) What role, if any, do religion and/or spirituality play in your life?

2a) Are you satisfied with your social situation/interpersonal relationships?

Yes No

2b) If no, explain why:

3) What do you consider to be your strengths? What do you like most about yourself?

4) What are effective coping strategies you use when stressed?

5) Is there anything that I did not ask about here that would be important for me to know about you?

6) How did you learn about me?

Patient Name

Copy of Insurance Card

Please upload the front image

Copy of Insurance Card

Please upload the back side of the card

Upload a copy of your Driver's License

Files

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Date

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