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Patient Information Form Date ___________
Last Name: First Name: Middle Initial:
Date of Birth: Social Security Number: _________- _________-____________
Gender: ☐ Male ☐Female ☐TG / M F ☐TG / F M
Primary Phone # ( _____)____________________________ ☐Cell ☐Home ☐Work
OK to leave message? ☐Yes ☐No OK to Text? ☐Yes ☐No
Secondary Phone # ( )______________________
☐Cell ☐Home ☐Work
OK to leave message? ☐Yes ☐No OK to Text? ☐Yes ☐ No
Email Address: ____________________________________________ @__________________________ ☐ OK to send Email
Physical Address:
City: State: Zip Code:
Mailing Address: (if different from above): ☐ Check here if you DO NOT authorize mailings from Family Centers Inc.
Occupation (if employed): ___________________________________________ ☐ Full Time ☐ Part Time ☐ N/A
School (if student) __________________________________________________ ☐ Full Time ☐ Part Time ☐ N/A
Emergency Contact Name: ________________________________________________ Relationship to Patient: ___________________
Emergency Contact Primary Phone # ____________________________☐Cell ☐Home ☐ Work OK to leave message: ☐Yes ☐ No
Secondary Phone # ___________________________________________☐Cell ☐Home ☐Work OK to leave message: ☐Yes ☐ No
Type of Residence where you live:
☐ Home/Own
☐ Rent
☐ Friends/Family
☐ Transitional
☐ Homeless
☐ Shelter
☐ Other _________________________
Public Housing ☐ Yes ☐ No
Section 8 ☐ Yes ☐ No
Do you think of yourself as:
☐Lesbian, Gay or Homosexual
☐ Straight or Heterosexual
☐ Bisexual
☐ Something Else
☐ Don’t Know
Primary/Preferred Language if other than English: __________________________________
Do you need a Translator: ☐ Yes ☐ No
Are you a veteran of one of the United States Uniformed Services? ☐ Yes ☐No
How did you hear about us?
☐Friend/Family member
☐ Media
☐ Internet
☐ Family Centers Event/Outreach
☐ Referred by other Agency:
Agency Name________________________
☐ Other:
Who referred you? ______________________
Annual Household Income: $ Number of people in the household:
Ethnicity: (Choose One)
☐ Hispanic☐Non-Hispanic
Race: (choose all that apply)
☐ White/Caucasian
☐ Black/African American
☐ Asian
☐ Native Hawaiian
☐ American Indian or Alaskan Native
☐ Other Pacific Islander
Marital Status:
☐ Single
☐ Unmarried Couple
☐ Married (Spouse Name_______________________)
☐ Separated
☐ Widowed
☐ Divorced
HEALTH INFORMATION
Revised 1/8/2018
Date: _________________
Name: ______________________________________________________ Date of Birth: ____________________________
Last First Middle
Allergy/Drug Allergy: Side Effect/Reaction:
1.
2.
3.
4.
☐ NO KNOWN DRUG ALLERGIES
Medical History Do you now or have you ever had:
☐ NONE OF THE CONDITIONS LISTED BELOW
☐ Aneurysm
☐ Atrial
Fibrillation/Flutter
☐ Convulsions
☐ Heart Attack
☐ HIV or AIDS
☐ TB (Tuberculosis)
☐ Abnormal Heart
Rhythm
☐ Acid reflux
☐ Arthritis
☐ Asthma
☐ Blood Disorder
☐ Cancer
☐ Cataracts
☐ Chronic Lung
Disease/COPD
☐ Clotting Disorder
☐ Congestive Heart
Failure
☐ Diabetes (Insulin? Y / N)
☐ Gallstones
☐ Gastrointestinal Disease
☐ Gout
☐ Headaches
☐ Heart Murmur
☐ Heart Valve Disease
☐ Hepatitis
☐ High Blood Pressure
☐ High Cholesterol
☐ Kidney Disease
☐ Kidney Stones
☐ Liver Disease
☐ Prostate Problems
☐ Rheumatic fever
☐ Sleep Apnea
☐ Stroke of TIA
☐ Thyroid Disease
☐ Ulcers
☐ Other
_______________________
Current Medications: Please include non-prescription medications, over the counter & vitamins or supplements:
Name of Drug Dose (include strength & quantity per day)
1.
2.
3.
4.
5.
☐ NOT TAKING MEDICATIONS
HEALTH INFORMATION
Revised 1/8/2018
Pain and Nutrition:
Are you experiencing in Pain? ☐ NO ☐ YES
If YES, please rate your pain on a scale of 1 to 10 with 10 being the most painful: _____________
In the past 3 months, have you had a change in appetite? ☐ NO ☐ YES
In the past 3 months, have you had a change in weight of 10 or more pounds? ☐ NO ☐ YES
In the past month, have you experienced problems with swallowing? ☐ NO ☐ YES
Treatment History: (i.e. Previous Psychiatric/Medical Hospitalizations and/or other psychiatric treatment programs) Dates:
1.
2.
3.
4.
☐ NO PREVIOUS PSYCHIATRIC TREATMENT
Date of Last Physical Exam _____________________________________________________________________________________________
Primary Medical Provider (if not Family Centers Health Care)_________________________________________________________________
Address: ___________________________________________________________ Phone__(______)__________________________________
Primary Dental Provider: (if not Family Centers Health Care)__________________________________________________________________
Address: ___________________________________________________________ Phone_(______)____________________________________
Preferred Pharmacy____________________________________________________________________________________________________
Address: ___________________________________________________________ Phone__(______)__________________________________
Client's Rights and Responsibilities
The client and the provider have a responsibility to each other to assure that the best possible service is provided and
appropriately used.
Each Client Has the Right to the Following:
• Considerate and respectful service.
• Service provided by qualified personnel.
• A reasonable response to his/her request for service and reasonable continuity of care.
• Service without discrimination as to race, religion, sex, gender identity/expression, national origin, sexual orientation,
ancestry, age, familial status, physical or mental disability or handicap, or ability to pay.
• To participate in the development of his/her treatment plan.
• To accept or reject any treatment plan.
• Family Centers Inc.'s policies such as eligibility for service, regulations, hours of service and fee information.
• Assistance in locating the appropriate service when continuity can not be provided
• To examine and receive an explanation of his/her bill for service, regardless of the payment source.
• To receive a copy of the Client's Rights and Responsibilities at the time service begins.
• To the name, title and professional credentials of any person providing or supervising his/her service.
• To review their case record in accordance with Family Centers Inc.'s policy.
It is the Client's Responsibility to:
• Accept or refuse any service.
• Direct grievances, concerns and recommendations for change to assigned staff member/supervisor and/or Program
Director
• Direct unresolved health, safety or quality-of-care concerns to The Joint Commission located at One Renaissance Blvd.,
Oakbrook Terrace, IL, 60181 and telephone number 630-792-5000.
• Keep all scheduled appointments or give 24-hour notice of cancellation.
• To inform clinician of changes in financial circumstances which may affect the fee.
In Order to Protect Your Privacy:
The Clinical Staff of Family Centers Inc. are required by law and professional ethics to maintain client confidentiality.
This is done within the context of standard agency practice. Your records are confidential and will not be
released or discussed with anyone outside of Family Centers Inc. without your written consent except as otherwise
provided by law.
Emergency/Crisis:
In the event there is an emergency or crisis outside of the agency’s business hours, (Monday - Thursday, 9 AM to 9
PM and Friday, 9 AM - 5 PM) please dial 877-349-4689 or go to your nearest hospital emergency department.
Minor Child:
The Clinical Staff of Family Centers Inc. are required to discuss and determine parental arrangements and responsibilities
for the client’s arrival and departure; procedures followed in the event of a medical emergency; inform the parent or
guardian of the clinic’s mandated reporting responsibility according to Section 17a-101 of the CT General Statutes.
The parent or guardian of a minor will sign for the child that they and the child have received and reviewed
the Client’s Rights and Responsibilities and have been explained these rights in an understandable and age
appropriate manner.
I have received and reviewed the Client's Rights and Responsibilities and I have been oriented to the
agency's policies and procedures and consent to treatment.
Client Signature___________________________________________ Date_______________________
Staff Signature ____________________________________________ Date_______________________
CONSENT TO TREAT / BILLING
1. I (patient name) give permission for Family Centers Health Care to give me medical/dental/mental health treatments.
2. I authorize Family Centers Health Care to file for insurance benefits to pay for the care I receive.
I understand that:
• Family Centers Health Care will have to send my medical/dental/mental health records information to my insurance company.
• My share is due at the time of service. • I must pay for the cost of these services if my insurance does not pay or I do not have
insurance. 3. I understand:
• I have the right to refuse any procedure or treatment. • I have the right to discuss all medical/dental/mental health treatments with my provider. • If I miss or cancel within 24 hours (Friday’s by 12pm for Monday’s appointments) 2 or
more times, I may be unable to schedule any further appointments in advance.
Patient’s Signature Date Parent or Guardian Signature Date (for children under 18) Print name Date __________________________________________ __________________ Witness Date
Family Centers Inc.
Notice of Privacy Practices Effective September 23, 2013
Your Information. Your Rights. Our Responsibilities.
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.
SUMMARY
Your Rights You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated
Your Choices You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds
Our Uses and Disclosures We may use and share your information as we:
• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government
requests
• Respond to lawsuits and legal actions
Family Centers Inc.
Notice of Privacy Practices Effective September 23, 2013
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of
our responsibilities to help you.
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information
we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request.
We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us
how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a
different address.
• We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
• You can ask us not to use or share certain health information for treatment, payment, or our operations.
We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that
information for the purpose of payment or our operations with your health insurer. We will say “yes”
unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to
the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations,
and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for
free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person
can exercise your rights and make choices about your health information.
Family Centers Inc.
Notice of Privacy Practices Effective September 23, 2013
• We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
• You can complain if you feel we have violated your rights by contacting us using the information on the
last page.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by
sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or
visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference
for how we share your information in the situations described below, talk to us. Tell us what you want us to do,
and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share
your information if we believe it is in your best interest. We may also share your information when needed to
lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
Our Uses and Disclosures
How do we typically use or share your health information? We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.
Family Centers Inc.
Notice of Privacy Practices Effective September 23, 2013
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when
necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public
good, such as public health and research. We have to meet many conditions in the law before we can share your
information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
Do research
We may use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of
Health and Human Services if it wants to see that we’re complying with federal privacy law.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual
dies.
Address workers’ compensation, law enforcement, and other government requests
Family Centers Inc.
Notice of Privacy Practices Effective September 23, 2013
We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a
subpoena.
Our Responsibilities
• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of
your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in
writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change
your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Special Rules Regarding Disclosure of Mental Health, Substance Abuse and HIV-Related Information
For disclosures concerning protected health information relating to care for mental health conditions,
substance abuse or HIV-related testing and treatment, special restrictions may apply. For example, we
generally may not disclose this specially protected information in response to a subpoena, warrant or other
legal process unless you sign a special Authorization or a court orders the disclosure.
Mental Health Information. Certain mental health information may be disclosed for treatment, payment and health care operations as permitted or required by law. Otherwise, we will only disclose such information pursuant to an authorization, court order or as otherwise required by law. For example, all communications between you and a psychologist, psychiatrist or social worker will be privileged and confidential in accordance with Connecticut and Federal law.
Substance abuse treatment information. If you are treated in a specialized substance abuse program, your permission will be needed for certain disclosures, but not emergencies, certain reporting requirements and other disclosures specifically allowed under Federal law.
HIV-related information. We will disclose HIV-related information as permitted or required by Connecticut law. For example your HIV-related protected health information, if any, may be disclosed in the event of a significant exposure to HIV-infection to personnel of Family Centers Inc., another person, or a known partner. Any use and disclosure for such purposes will be to someone able to reduce the outcome of the exposure and limited in accordance with Connecticut and Federal law.
Minors. We will comply with Connecticut law when using or disclosing protected health information of minors. For example, if you are an un-emancipated minor consenting to a health care service related to
Family Centers Inc.
Notice of Privacy Practices Effective September 23, 2013
HIV/AIDS, venereal disease, abortion, or alcohol/drug dependence, and you have not requested that another person be treated as a personal representative, you may have the authority to consent to the use and disclosure of your health information.
Changes to the Terms of this Notice We can change the terms of this notice, and the changes will apply to all information we have about you. The new
notice will be available upon request, in our office, and on our web site.
If you have any questions about this Notice or would like further information concerning your privacy rights,
please contact
Family Centers Inc.
Robert Short, HIPAA Privacy Officer
P.O. Box 7550 Greenwich, CT 06830
203 869-4848
Family Centers Inc.
Notice of Privacy Practices Effective September 23, 2013
Consent and Acknowledgment Form
I consent to the use or disclosure of my protected health information by Family Centers Inc. to any person
or organization for the purposes of carrying out treatment, obtaining payment or conducting certain healthcare
operations. I understand that further information regarding how Family Centers Inc. will use and disclose my
information can be found in Family Centers Inc.’s Notice of Privacy Practices.
By signing below, I understand and acknowledge the following:
I have read and understand this consent; and
I have received Family Centers Inc.‘s Notice of Privacy Practices currently in effect.
_____________________________________________
Print Name of Individual or Personal Representative
______________________________________________________________
_ Signature of Individual or Personal Representative
If signed by the individual’s representative, describe the legal authority of the representative to act on
behalf of the individual: ______________________________
Unable to obtain written consent and acknowledgment because:
□ Individual refused
□ Emergency treatment situation
□ Individual not able to sign due to incompetence or other medical reason
□ Other: ______________________________________
Date
________________________________
ADULT LDI
Intake__ Discharge__
Client Name:_________________________ Date:__________
This scale is intended to estimate your current level of distress with each of the eighteen areas of
your life listed below. Please circle one of the numbers (1-7) beside each area. Numbers toward
the left end of seven-unit scale indicate higher levels of distress, while numbers toward the right
end of the scale indicate lower levels of distress. Try to concentrate on how distress you
currently feel about each area.
7 = THE MOST DISTRESS I’VE EVER FELT
6 = EXTREMELY DISTRESSED
5 = VERY DISTRESSED
4 = MODERATELY DISTRESSED
3 = SOMEWHAT DISTRESSED
2 = VERY LITTLE DISTRESS
1 = NO DISTRESS
PLEASE CHECK ONE NUMBER FOR EACH ITEM AND TOTAL
MARRIAGE 7 6 5 4 3 2 1 SEX 7 6 5 4 3 2 1 RELATIONSHIP TO SPOUSE/SIGNIFICANT OTHER 7 6 5 4 3 2 1 RELATIONSHIP TO CHILDREN 7 6 5 4 3 2 1 RELATIONSHIP TO OTHER RELATIVES 7 6 5 4 3 2 1 HOUSEHOLD MANAGEMENT 7 6 5 4 3 2 1 FINANCIAL SITUATION 7 6 5 4 3 2 1 EMPLOYMENT/JOB 7 6 5 4 3 2 1 EDUCATION/SCHOOL 7 6 5 4 3 2 1 RECREATION/LEISURE 7 6 5 4 3 2 1 SOCIAL LIFE 7 6 5 4 3 2 1 RELIGION 7 6 5 4 3 2 1 MANAGEMENT OF TIME 7 6 5 4 3 2 1 PHYSICAL HEALTH 7 6 5 4 3 2 1 PERSONAL INDEPENDENCE 7 6 5 4 3 2 1 ROLE OF ALCOHOL or DRUGS IN THE HOME 7 6 5 4 3 2 1 SATISFACTION WITH LIFE 7 6 5 4 3 2 1 EXPECTATIONS FOR THE FUTURE 7 6 5 4 3 2 1 TOTAL: