Spectrum Psychiatric Associates Intake Form

Please correct the errors described below.

Welcome to Spectrum Psychiatric Associates. Spectrum and I, Truc Nguyen, ARNP, are looking forward to meeting with you for the very first time, and to providing you with the safest, most responsive and highest quality mental health care possible. This Intake Form is an important part of this process, both to gather information from you, but also to share information with you, so that you know exactly what to expect from our professional relationship. You will receive a copy of the policies below for your record in a follow-up email, but please read each carefully before signing.

There are FIVE (5) subsections of this Intake Form, and they are extensive. However, only questions marked with an asterisk (*) are required. Nonetheless, try to complete each portion, providing as much details as possible. This will allow us to make the most efficient use of our time, so that we can focus on your clinical concerns instead of administrative details.

Before beginning, you should have the following information readily available:

  • Image of active Insurance Card (front and back)
  • Image of unexpired state issued ID or Driver's License (front)
  • Pharmacy information
  • Other healthcare providers' information
  • Medication list (current and historical)
  • Credit or Debit card information

I. REGISTRATION

Patient Information

Legal | Preferred | Pronouns
Specify Cell, Work, or Home
Specify Cell, Work, or Home
Examples: Male, Female, Trans male/man, Trans female/woman, Genderqueer, Gender non-conforming

Emergency Contact

Specify Cell, Work, or Home
Specify Cell, Work, or Home

Person Responsible for Payment (If Not the Patient)

Upload Insurance Card and ID:

You will need to provide copies of your insurance card and ID -- upload a file or an image (PNG, JPEG, or PDF)

    Please upload a file
      Please upload a file
        Please upload a file

        Other Health Professionals

        Release and Assignment of Benefits

        I understand that I am responsible for all fees at the time of service and I am financially responsible for any balance due. I also authorize Spectrum Psychiatric Associates to release any information requested by my insurance provider for processing of any claims I may file with them and assign payment by my insurance carrier to Spectrum Psychiatric Associates or Bill Heusler, PsyD, LLC. I understand and accept the Release and Assignment of Benefits policy, and I consent and agree to the terms above with my initials below in place as my signature.

        Email Consent

        I give person for Spectrum Psychiatric Associates to send email reminders to the email address I entered above. I understand that I can cancel this agreement at any time and that it must be done in writing. I understand and accept the Email Consent policy, and I consent and agree to the terms above with my initials below in place as my signature.

        II. INFORMED CONSENT FOR PSYCHIATRIC SERVICES

        General Information

        This agreement outlines what you can expect from your medical medical provider who will be providing psychiatric diagnostic evaluation, medication management, and/or psychotherapy services. Given the unique nature of the patient-provider relationship, it is important for a clear understanding about how the relationship will work, and what can be expected in treatment. This consent will provide a clear framework for your work with the psychiatric provider. Please discuss any concerns with the provider prior to signing the document. Also, please read and indicate that you have reviewed this information and agree to it by filling in the signature/initial boxes at the end of each subsections of this document.

        Truc Nguyen, ARNP is a member of Spectrum Psychiatric Associates, a group practice that provides comprehensive outpatient behavioral health services in Snohomish and King county. All members of the practice will have access to files, and are bound by the same confidentiality laws discussed in the following paragraphs.

        Ethics and Professional Standards

        You will be working with Truc Nguyen, ARNP, a licensed Advanced Registered Nurse Practitioner in the State of Washington, board-certified nationally in the clinical specialty area of Psychiatric Mental Health Nurse Practitioner (PMHNP-BC). He is accountable for his work with you. lf you have any concerns about the course of treatment, please discuss them with him. Should you feel that ARNP Nguyen have been unethical or unprofessional, you may contact the Department of Licensing in Olympia (360) 753-6981. Ethical guidelines for advanced practice nurses strongly discourage dual relationships. Therefore, as a matter of policy, social or business interactions outside of the context of the agreed upon clinical services are discouraged. Intimate contact between provider and patient is always inappropriate.

        I understand and accept the Ethics and Professional Standards policy, and I consent and agree to the terms above with my initials below in place as my signature.

        The Psychiatric Treatment Process

        Psychiatric Evaluation

        Depending on the complexity of issues presented, the initial Psychiatric Evaluation appointment(s) are scheduled 60-90 minutes long each, and consist of two parts: (1) a psychiatrically-focused comprehensive medical evaluation and assessment for diagnostic clarification, and (2) a discussion of any potential diagnoses, their prognoses, and treatment recommendations, including their potential risks, benefits, and adverse effects.

        All initial appointments are considered "consults" and do not constitute an agreement for me to treat you. Any agreement to "treat" you will be discussed after the initial consultation period. It is your decision whether I am the right provider for you, and my decision if I am able/willing to become your provider.

        Follow-up Appointments

        Follow-up appointments are scheduled for 30 minutes each, and consists of discussion of medication and their intended and unintended effects, your treatment progress, and supportive psychotherapy in the context of your medical care. The frequency of follow-up visits is tailored to your individual need at the specific time, and may range from weekly to a maximum of quarterly (once every 3 months).

        Treatment recommendations are meant to help you make an informed decision regarding your healthcare, and you are free to accept or refuse these recommendations at anytime during the course of our patient-provider relationship. However, out of concern for your health and safety, I strongly advise that unless instructed, you do not precipitously and independently discontinue, start, or increase any medication that I prescribed to you without consulting with me first.

        Should you decide to work with another provider, I will be happy to provide you with referrals, or If you are unable to locate a provider on your own, I suggest consulting the local advance practice nurse or physician's referral service, your county medical society, your primary care provider, your health plan, or Psychology Today so that you may find another provider who will assume responsibility for your care. I am committed to providing ethical and professionally competent psychiatric care to you. In the event that I feel I am no longer able to meet these commitments, I will provide you with the appropriate referrals, and transfer your care to another provider who maybe better able to help you.

        I understand and accept the Psychiatric Treatment Process policy, and I consent and agree to the terms above with my initials below in place as my signature.

        Termination of Treatment

        I, Truc Nguyen, ARNP view the relationship between the patient and the psychiatric nurse practitioner as a special one that requires considerable trust and respect from both sides. As such, you will be terminated from my care if:

        • You do violence to, threaten, verbally or physically, or harass your provider or the office or ask your provider to engage in any illegal conduct; you will be unilaterally and immediately terminated from treatment. You may not bring any weapon whatsoever into the office; if you are found to have a weapon on your person we will consider that a threat. Small pocket knives or pepper spray that you leave in your bag will not be considered a threat. No referrals will be provided in that circumstance.
        • You have two consecutive "no shows" or "late cancels", or 3 unexplained missed appointments or late cancels in 1 year.
        • You falsify a prescription or engages in other fraudulent behaviors within the context of the treatment relationship.
        • You fail to disclose of other treatment you are receiving outside of my care, such as obtaining federally controlled psychiatric medications from other providers. In such cases, the other provider will also be notified, and you will be unilaterally and immediately terminated from treatment.
        • You refuse or fail to be in compliance with office policy or any treatment I recommend or prescribe to you (e.g., ignoring appointment recall requests, self-adjusting prescriptions, demanding certain types of controlled medication, not obtaining necessary lab work)
        • I, Truc Nguyen, ARNP determine, for whatever reason, I am no longer able to work with you. This is at my discretion, and although an explanation may be provided, know that it is not necessary.

        If a patient is discharged from my care, they will be informed in writing and given a 30-day grace period to find another provider. During this time, I will only respond to emergencies that arise and maintain the patient's current medications.

        I understand and accept the Termination of Treatment policy, and I consent and agree to the terms above with my initials below in place as my signature.

        Appointments

        I chose to maintain a limited daily schedule with zero "double-booking", in order to provide the highest quality healthcare to a finite number of patients. If you arrive late, you will only be able to use the remaining appointment time reserved for you. In the event that you missed a previously scheduled appointment entirely for any reason, or are unable to attend an appointment, you must provide at least 24 hours advance notice. Otherwise, you are charged a $100 Missed Appointment fee each time.

        Please respect my time as I do yours, and understand that less than 24 hours' notice will not allow me to offer the appointment time that I have reserved for you to another patient who could have used it. After two consecutive "no show" or late cancellation appointment, or 3rd within a year, you will be discharged from my care entirely, with a bridge 30-day refill of only medically necessary and appropriate prescriptions. No exceptions

        Inclement Weather

        Telehealth appointments will proceed as scheduled on extreme weather day. For in-person appointments, these will be changed to a Telehealth appointment if possible. We will notify you of any change the morning of your appointment by either text, phone, and/or email.

        Email Communication

        I will not address any specific symptoms or make medication changes through email, no exceptions. Evaluating, assessing, and providing medical advise through email is not only illegal and clinically inappropriate, for you as a patient it is also unsafe. It is not a method of healthcare delivery approved or contracted by your insurance. It is a HIPAA violation of your protected health information.

        Emails are meant to be for brief, non-urgent questions. If you have specific issues that are not brief, of an urgent nature, or requires a longer conversation about your specific treatment, please schedule a sooner appointment with me, or we can discuss it during our next scheduled visit.

        I understand and accept the Appointments and Email Communication policy, and I consent and agree to the terms above with my initials below in place as my signature.

        Prescriptions and Refills

        Prescriptions are sent electronically (eRx) to your elected pharmacy. Although this delivery method is fast, secure, and trackable, the pitfall is that "transmission error" are common. However, most often time, it is a result of pharmacy or human error on the receiving end (by either not entering the patient's information correctly or not "seeing" the order) despite a successful transmission from the originating end. Always check with your pharmacy within 24 hours of the time of your appointment to make sure they have receive your prescription from your provider. Call Spectrum to have your prescription resent if needed.

        Regular refills of your prescriptions are provided at each follow-up appointment, at which time I will always ensure that you have enough medication until the next scheduled appointment. However, it is NOT the responsibility of the provider/office staff to keep track of your medication. You are responsible for your care, by ensuring that you do not run out of medication. If you missed or cancelled your follow-up appointment, you may request a "bridge refill" only after rescheduling.

        Controlled Substances

        Stimulants (Vyvanse, Adderall, Ritalin, etc.) are Scheduled 2 drugs under the Controlled Substance Act (CSA), and may only be prescribed maximally for a total supply of 90 days each time, and "refills" are prohibited. If your bottle states "30 day supply, zero refill", and your next appointment is three months out, that means I have sent three separate 30-day prescriptions to your pharmacy.

        If you lose a controlled medication by any means (including theft, misplaced, forgot them at a hotel, etc), you will be out until next due; no exceptions.

        There will be no early refills of controlled substances for any reason (e.g. business trips, vacations, etc.); no exceptions.

        I understand and accept the Prescription and Refills policy, and I consent and agree to the terms above with my initials below in place as my signature.

        Services and Fees

        You understand very clearly without any doubts that Truc Nguyen, ARNP will only take on the responsibility of psychiatric evaluation and treatment as a 'voluntary patient'. You also acknowledge that it has been made very clear to you by ARNP Nguyen that he is not doing any forensic/ medicolegal / child custody/ disability work, and is not accepting any court referred cases.

        Psychiatric Evaluation and Supportive Psychotherapy

        We strongly recommend utilizing your behavioral health benefits available to you through your health insurance or managed care plans. Otherwise, fee for treatment is based upon the type of appointment you have scheduled. A staff person will discuss what your fee is at the time that you schedule an appointment. Your session begins at the scheduled time, not when you arrive. Rates are based on the level of medical complexity and decision-making. No billing statements will be sent or balances carried over. Hardship situations must be discussed in advance regarding a payment plan if requested.

        Some managed care plans and health insurance plans cover behavioral health services with me. In any event, you are responsible for all charges regardless of what if anything, your insurance or managed care provider pays or tells you. In some instances, your managed care provider has entered into an agreement with this provider that discourages "balance billing" for services normally covered by your managed care company. In these isolated instances, you will be held accountable for all services not covered by your plan, all deductible, co-share, or co-payment amounts. If you have any questions regarding your insurance or managed care benefits, it is your responsibility to check with your plan. Any overdue bills will be charged 1.5% per month interest. If you eventually refuse to pay your debt, we reserve the right to give your name and the amount due to a collection agency. If this becomes necessary, you will also be responsible for any additional costs incurred by Spectrum Psychiatric Associates in order to collect fees due.

        You agree to keep ARNP Nguyen aware of any person or organization that you want information about your treatment or presenting conditions disclosed to in writing.

        Telehealth Services

        Telehealth services are offered by your clinician in select circumstances and may not be paid for by your insurance company Fees are the same as face-to-face services. You are responsible for verifying telehealth is covered, although your clinician will be happy to assist in the process. We use a secure, HIPAA-compliant service (Zoom) for telehealth services. Although it is secure, there are potential risks and consequences of participating in teleservices, including, but not limited to, the possibility, despite best efforts to ensure high encryption and secure technology on the part of your clinician, that: the transmission of my information could be disrupted or distorted by technical failures; the transmission of your information could be interrupted by unauthorized persons; and/or the electronic storage of your medical information could be accessed by unauthorized persons.

        Legal Work and Courtroom Testimony

        Mr. Nguyen does not provide treatment associated with forensic issues and requests that you not include his treatment in any legal matters. You agree to discuss any legal-related issues with him prior to making a request for notes or other documents. lf you choose to engage Mr. Nguyen in any court-related matters, you agree to the following fees for his services that insurance will not reimburse for because they are not associated with medical treatment: Court appearance: $500.00 an hour with time starting from when Mr. Nguyen leaves his office to the time he returns to his office with minimum of four hour block. For such request, you will be responsible for the payment and will make a bank draft to Mr. Nguyen's office of $4,000.00 ten days in advance in order to Mr. Nguyen to accommodate such requests.

        Telephonic Communication or Meeting with attorneys: Mr. Nguyen as a policy will not be communicating with the attorneys because it is most likely non-therapeutic in nature. Instead, any clinical concerns will be shared with the patient, his/her family or relevant clinicians directly as needed. Mr. Nguyen will himself approach the concerned agency as he so feels is clinically necessary and or legally mandated. However, if you want Mr. Nguyen to communicate with an attorney, then the financial reimbursement will be borne by the undersigned, which will be $125.00 for every fifteen minutes with minimum of fifteen minutes. In view of clinical needs Mr. Nguyen responds to calls later in the evening and you will ensure that the attorney is aware of it. Mr. Nguyen will only respond to an attorney after duly signed consent form with a bank draft of $500.00 from yourself is received at Mr. Nguyen's office. Any meeting or appointment necessary with non-clinical personal will be determined by Mr. Nguyen and based on the time availability of Mr. Nguyen.

        Witten Correspondence and Forms: As medical records are legal documents, they will be available on as requested with due release of information. However, if you want Mr. Nguyen to provide any other relevant professional letter, including the completion of forms for legal and occupational purposes, you will be responsible for the time spent on it, with minimum of fifteen minute block at $125.00 per fifteen minutes which will be paid in advance and with a week advance notice.

        Miscellaneous: you will be responsible for all payment for Mr. Nguyen's professional services at a rate of $125.00 for every fifteen minutes for any other non-clinical unforeseen request made or for which my medical insurance does not cover for Mr. Nguyen's service. You agree to pay it in advance for these services before making such request. Balance left from the pre-payment will be reimbursed to me from Mr. Nguyen's office after completion of requested work and after the charges of any additional expenses incurred are deducted.

        I understand and accept the Services and Fees policy, and I consent and agree to the terms above with my initials below in place as my signature.

        Emergency Procedure and Safety Plan

        You agree, and understand, that Spectrum Psychiatric Associates ls an ambulatory, outpatient practice, operational only during regularly scheduled business hours. As such, we do not have the capacity, nor have we met the regulatory standards, to be able to provide crisis management and emergency services.

        If an urgent matter arises both during office hours and after hours, contact the Snohomish County Crisis Line at (425) 258-4357 or the King County Crisis Clinic at (866) 427-4747. In the event of an emergency, call 911. For all other non-emergency issues, schedule the soonest available appointment with me. Contact the clinic during working hours and I will try to respond within 1-2 business days during my regular office hours. The number to the National Suicide Prevention Line is 1-800-273-8255. You can also dial 211 to be connected with local resources.

        Confidentiality and Limits of Confidentiality

        General

        All information discussed or obtained during the course of psychotherapy or an assessment is privileged and confidential. This information may not be disclosed to others without your specific consent or in the event of a minor child, the consent of the legal guardian. There are exceptions to this requirement. The law permits me to provide information to other healthcare providers that I reasonably believe are providing you with services and the situation calls forth at information to be provided in order that prudent health decisions are facilitated. I am required by the Department of Health in the State of Washington to report any disclosed cases of many communicable diseases including a positive HIV status, unless your primary healthcare provider as already done so. l am required by law to report any of the following three situations: suspected abuse of a child or vulnerable adult; serious threats of suicide; or threatened harm to another: In these instances, I am required to make a report to the appropriate authorities and/or individual(s) threatened. In addition, the courts may subpoena treatment records in certain circumstances. Every effort will be made to discuss any release of confidential information with you.

        If you and Mr. Nguyen accidentally meet outside of the therapy office, he will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance, and he does not wish to jeopardize your privacy. However, if you acknowledge him first he will be more than happy to speak briefly, but feel it appropriate not to engage in any lengthy discussions in public or outside of the office.

        Professional Consultation and Supervision

        I work in conjunction with other mental health professionals and may discuss your situation with them in order to obtain consultation or advice concerning your care. Every effort is made to avoid disclosing personally identifiable information and to disguise your identity for these consultations. In the event I am leaving town or will in some way be unavailable, I will arrange for coverage with another mental health professional and, if required or indicated, may disclose confidential information to that individual so that they may reasonably provide any required assistance for you.

        Insurance and Managed Care Provider Access

        If you are planning on utilizing a healthcare benefit provided by an insurance or managed care company, be advised that many require a statement of diagnosis and the specific types of service that were provided. In addition, some require more detailed information, such as copies of any evaluative reports, progress notes, progress reports, treatment summaries, and/or any contents of your record. They may also audit records and thereby gain access to any information contained in your file. lf you wish this type of information to be provided to your insurance company, you will need to sign the additional authorization to release protected healthcare information consent form below.

        Informed Consent for Psychiatric Services

        Signing below indicates you read and understood this agreement and that you are agreeing to the terms of this agreement and authorizing your clinician to provide psychotherapy, consultation, and/or assessment services for you. If there is any part of this agreement that you do not understand, please discuss it with your provider prior to signing it. By signing below, I hereby authorize Truc Nguyen, ARNP to render psychiatric and/or psychotherapy services for me. This authorization constitutes informed consent without exception and agreement to pay all applicable fees.

        I understand and accept the Emergency Procedures policy, and the Confidentiality and Limits of Confidentiality policy, and I consent and agree to the terms above with my initials below in place as my signature.

        III. NOTIFICATION OF PRIVACY PRACTICES

        THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

        Uses and Disclosures

        Treatment.

        Your health information may be used by our clinicians and staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing mental health conditions, and providing treatment.

        Payment. Your health information may be used to seek payment from your health plan. other sources of coverage such as an automobile insurer. or credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

        Health Care Operations. Your health information may be used as necessary to support the day-to-day activities and management of Spectrum Psychological/Psychiatric Associates . For example, information on the services you received ma y be used to support budgeting and financial reporting and activities to evaluate and promote quality to ensure that our practice is meeting state and federal guidelines and laws designed to protect your health care information.

        Law Enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigations, and to comply with government mandated reporting.

        Public Health Reporting. Your health information may be disclosed to public health agencies as required by law. For example, our practice is required to report certain communicable diseases to the State of Washington Department of Health if your physician has not done so already.

        Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure that occurred before you notified us of your decision.

        Additional Uses of Information

        Appointment reminders. Our medical notes system, Office Ally, will send an email remainder providing you have given permission for an email address to be stored on file. We have deleted most identifying information to protect your privacy.

        Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may find of interest. We may also send you information describing other health-related goods and services that we believe may interest you.

        Individual Rights

        You have certain right under the Federal Privacy Standards. These include:

        The right to request restrictions on the use and disclosure of your protected health information. The right to receive confidential communications concerning your medical condition and treatment. The right to inspect and copy your protected health information. The right to request an amendment or submit corrections to your protected health information. The right to receive an accounting of how and to whom your protected health information has been dis closed. The right to receive a printed copy of this notice.

        Spectrum Psychological/Psychiatric Associates Duties. We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy policies and practices that are outlined in this notice.

        Right to Revise Privacy Practices. As permitted by law, we reserve the right to amend or modify our privacy policies and practices, these changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the rea on for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.

        Requests to Inspect Protected Health Information. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting your individual practitioner.

        I understand and accept the Notification of Privacy Practices policy, and I consent and agree to the terms above with my initials below in place as my signature.

        A copy of the INFORMED CONSENT FOR PSYCHIATRIC SERVICES and the NOTIFICATION OF PRIVACY PRACTICES will be emailed for your reference. We will need your signature and date on the acknowledgment receipt included to be returned via email or fax once this form is submitted.

        IV. CLINICAL QUESTIONNAIRE

        Chief Complaints

        Examples: exercise, therapy, breathing techniques, talking to a friend, Post-it notes, etc.
        Include any details, such as start date, side effects, if it's helping, etc.

        Medical History

        Examples: contraceptives, IUD, gastric surgery, not able to swallow large pills, etc.

        Developmental History

        Family History

        For example: 'Paternal uncle, anger problems, might've been prescribed something'

        Current Situation

        Substance History

        How Often Do You Use:

        V. FINALIZING

        I understand by typing my name below that I am agreeing to the above treatment, and the information I provided is accurate. I understand that my typed name represents my signature and agreement to become a patient of Truc Nguyen, ARNP for psychiatric care.

        Type your full name below:

        Once you press submit, you will receive a follow up email within 2 business days. You will need to create a password and then complete the following forms:

        A final copy of the INFORMED CONSENT FOR PSYCHIATRIC SERVICES and the NOTIFICATION OF PRIVACY PRACTICES will be securely emailed to you. We will need your signature and date on the acknowledgment receipt included to be returned via email or fax once this form is submitted.

        A CREDIT CARD AUTHORIZATION FORM will also be attached to (B) above, requesting your authorization for Spectrum to keep this information on your file for future transactions regarding your account for the following purposes: to settle any co-payment amounts, outstanding balances owed, and/or fees resultant of a no-show or late cancellation appointment.

        Thank you.

        Your information will be encrypted.

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