Client Intake Sheet

Kentucky Psychological Services

P.O. Box 554 Berea, KY 40403
Phone (859) 200-1990
FAX (843) 986-0544

Client Name:

Today's Date:

Sex:

Male

Female

Client's Date of Birth:

Client Social Security #:

Custodial Parent(s) Name if Client is a Child (Otherwise enter "N/A"):

Street Address:

City, Zip Code:

Is the Client Employed?

Yes No

Occupation:

List client's employer if employed:

Marital Status:

Single Married Divorced Widowed Separated

Name of Spouse if Married:

Add new emergency contact:

Referred by:

Reason for seeking treatment:

Contact Preference:

Phone Text Message Email

Email address

Phone to Text or Call:

Insurance Information (if Applicable)

Add new insurance information:

Medical Problems (if applicable):

Release of Information and Confidentially of Records

By checking this box, I authorize the release of information to my Primary Care Physician, other healthcare providers, institutions, and referral sources for the purpose of diagnosis, treatment, consultation, and professional communication. If I am an insured client, I further authorize the release of information for claims, certification, case management, quality improvement, benefits administration, and other purposes related to my health plan.

Payment and Insurance Reimbursement

If your services are covered by insurance, by checking this box, you agree to be responsible for obtaining prior authorization for treatment from your insurance carrier. Kentucky Psychological Services will bill your insurance company; however, you are responsible for co-payment amounts and deductibles as set by your benefit plan. Clients are expected to pay any fees due at the beginning of the assessment. I agree to alert Kentucky Psychological Services immediately should my insurance status change at any time while I am enrolled. If I am not insured or become uninsured, I agree to pay all the charges incurred for services received.

Cancellation Policy

Since scheduling an appointment involved the reservation of time specifically for you, a minimum of 24 hours’ cancellation notice is helpful for rescheduling or canceling an appointment. If no prior notice of cancelation is received, we cannot guaranteed any future appointment.

Type Name:

By typing my name, I confirm that the foregoing information is correct to the best of my knowledge and agree with the responsibilities stated above.

HIPAA Authorization to Release and/or Exchange Information

NOTE: This authorization complies with the requirements of the HIPAA Privacy Act

Client Name:

Date of Birth:

Street Address:

City:

Zip Code:

Add new emergency contact:

Add another provider:

The purpose for which the information will be used or disclosed: (the purpose may be stated as “at the request of the individual” if the individual initiates this authorization and does not provide a statement of purpose)

Authorization Expiration Date:

This authorization will expire on date given above or continue for the duration of treatment at Kentucky Psychological Services. I understand that I may revoke this authorization at any time, except to the extent the person/organization obtaining the authorization has already acted in reliance on it by contacting Kentucky Psychological Services in writing to express such revocation. By signing below, I acknowledge that I have read and understood this authorization and that it will continue for the duration of my treatment with Kentucky Psychological Services

Your information will be encrypted.

Client Intake Sheet

Kentucky Psychological Services

Kentucky Psychological Services

Annette Freel

Licensed Psychological Practitioner