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Psychotherapy Packet for New Patients

PLEASE COMPLETE AND BRING WITH YOU TO FIRST APPT

First Visit: Plan on a session of approximately 1 hour. Sometimes it will be slightly beyond that if there is

a lot of information to obtain and no patient is scheduled in the next hour. In this session we will identify

what problems exist, and begin to create treatment goals. If for some reason during this first session you

decide this isn’t the best fit, we can look together for practitioners in the area that might be a better

match. We want the patient happy with their provider(s).

*All subsequent sessions are 45-53 minutes and not a full hour.

Patient Information:

Name_____________________________________________________ Gender_____________________

Mailing Address __________________________________________________________

__________________________________________________________

__________________________________________________________

Phone:

Home: ________________________ Work/Cell__________________________

Message OK?: Home: _______________ Work/Cell:____________________

Age: ________ Date of Birth (MM/DD/YYYY): ____________________

Social Security #:_____________________

Referral: ☐ Yes ☐ No Name of Referring Provider:____________________________

E-mail: ______________________________

Work Status: ☐ Employed ☐ Full-Time Student ☐ Part-Time Student

Relationship Status: ☐ Single ☐ Married ☐ Other:______________________

Are you employed but unable to work? ☐Y ☐N From (MM/DD/YY):_________ To:_____________

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Insurance Information

Insurance Provider: _______________________________________________________________

Insurance Plan Name/ Program Name:_______________________________________

Policy #:____________________________ Group #:______________________

What is your relationship to the insurance holder: ☐ Self ☐ Spouse ☐ Child ☐ Other_____________

Insurance Holder’s Name:___________________________________ Gender: ☐ M ☐ F

Insurance Holders Address:_______________________________________________________________

_____________________________________________________________________________________

Insurance Holder’s Phone Number:________________________

Insurance Holder’s Date of Birth (MM/DD/YYYY):_____________________

Are you enrolled in another health insurance policy? This includes having a plan under another

insurance company or second coverage within your current insurance company. ☐ Yes ☐ No

Full name:________________________________________________

Secondary insurance company:_______________________________________________________

Policy number:_________________________________ Group number:____________________

Date of Birth:_________________________ Gender: ☐ M ☐ F

Employer or school name (circle which):____________________________________________

Secondary insurance plan/program name:___________________________________________________

Do you plan to utilize more than one insurance plan (such as for multiple coverage)?

☐ Yes ☐ No

Policy holder of other insurance:________________________________________________

Relationship to other insured: ☐ Self ☐ Spouse ☐ Child ☐ Other_____________

Other insured’s insurance company:_______________________________________________________

Other insured’s Secondary insurance plan/program name:_____________________________________

Other insured’s Policy number:_________________________________ Group number:______________

Other insured’s Date of Birth:_________________________ Gender: ☐ M ☐ F

Other insured’s Employer or school name (circle which):________________________________________

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Primary Care Physician: __________________________________________________________

Employer/School Information:

Occupation:__________________________________________________________________________

Employer: ____________________________________________________________________________

Highest Grade Completed: _________

Current School (if a student______________________________________________________________

Therapy information

Why are you currently seeking therapy?

Was your condition related to any of the following:

Employment (current or previous) ☐ Yes ☐ No

Auto Accident (If yes, which state did it occur in?) ☐ Yes ☐ No State:_______________

Other Accident ☐ Yes ☐ No

What is the estimated date that your symptoms began (in regards to the condition for which you are

currently seeking treatment)?_____________________

Have you had the same or similar condition before? If yes, please list the estimated date of when your

symptoms began:_____________________

Please list any psychological/psychiatric treatment you have had in the past, including approximate

dates and provider name (include inpatient treatment).

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Current Medications and dosages (please include over-the-counter medications and herbal

supplements)

Who Prescribes Your Medications? Please provide full name, address, fax, and phone of physician

below:

Have you ever had any suicidal feelings or thoughts? If so, when?

Have you ever attempted suicide? If so, when, and were you treated?

Have you ever had any homicidal feelings or thoughts?

Have you ever been abused (verbally, physically, sexually?) If so, please describe below:

Have you ever experienced any other trauma? Please describe below.

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Please check any symptoms you’ve experienced in the last 2 weeks

☐ Irritability/easily annoyed

☐ Sadness

☐ Crying easily

☐ Loss of interest/pleasure

☐Hopelessness

☐ Worthlessness

☐ Low self-confidence

☐ Feeling confused

☐Feeling inferior

☐Low energy level

☐ Difficulty making decisions

☐ Thoughts of suicide

☐ Feeling tense

☐ Feeling fearful

☐ Worrying too much

☐ Startle easily

☐ Panic attacks

☐ Trauma/abuse

☐ Being scared for no reason

☐ Worrying what others think about me

☐ Having to redo things or check things

☐ Doing things very slowly to make sure they are correct

☐ Unwanted thoughts

☐ Avoiding things I am afraid of

☐ Asking others for reassurance

☐ Couples problems

☐ Family problems

☐ Problems with children

☐ Withdrawing

☐ Difficulty making friends

☐ Loneliness

☐ Work/ school problems

☐ Financial problems

☐ Sexual problems

☐ Infertility

☐ Trouble concentrating

☐ Easily distracted

☐ Memory problems

☐ Racing thoughts

☐ Procrastination

☐ Careless mistakes

☐Start but don't finish tasks

☐ Increased sleep

☐ Decreased sleep

☐ Nightmares

☐ Problems falling asleep

☐ Problems staying asleep

☐ Fatigue/feeling tired

☐ Appetite change

☐ Self-injury

☐ Excessive spending

☐ Impulsivity

☐ Hyperactivity

☐ Seeing/hearing things that other people don't see or hear

☐ Feeling something is wrong with your mind

☐ Feeling disoriented

☐ Mood swings

☐ Feeling high without being on drugs

☐ Feeling numb

☐ My feelings being easily hurt

☐ Difficulty controlling thoughts

☐ Difficulty controlling actions

☐ Being suspicious of others

☐ Someone's death

☐ My weight

☐ My eating

☐ Purging (vomiting, laxatives, excessive exercise)

☐ Food restrictions

☐ Bingeing

☐ Body image problems

☐ Hair-pulling

☐ Skin-picking

☐ Sexual addiction

☐ Internet addiction

☐ Gambling problems

☐ Chronic pain

☐ Upset stomach

☐ Headaches

☐ Being violent

☐ Anger

☐ Homicidal thoughts

☐ Other:

Client name:_____________________________________________________________________

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Do you have any personal concerns about your safety currently?

Please describe any health conditions you have below:

Please list any allergies including to medications:

Family mental health history:

Please identify below if there is a family history of any of the following. If yes, please write the

person’s relationship to you in the space provided (e.g. mother, uncle, grandfather, etc)

____________________________________________________________________________

Please Circle List Family Member

Anxiety yes/no ________________________

Depression yes/no ________________________

Eating Disorders yes/no ________________________

Alcohol/Substance abuse yes/no ________________________

Bipolar Disorder yes/no ________________________

Schizophrenia yes/no ________________________

Other: yes/no ________________________

What is your present living situation? Where do you live and with whom?

Please list partner, children (with ages) below:

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Are you currently in a romantic relationship? If so, for how long?

Do you have friends?________ Acquaintances?______________

What do you do for leisure:

Please list the highest degree/education attained (school/college):

Do you enjoy your work? __________________________________________________________

Please describe any legal problems below, as well as any anticipated legal issues below (impending

divorce, etc.)

Please describe any significant life changes or stressful events which you have recently experienced:

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Please describe substance use below (include everything…past and present….cigarettes, coffee, alcohol,

marijuana, etc.) Please describe how often you use them and how much. Please talk about how long you

have been using these. Have you ever been in treatment for a substance addiction? Have others told

you they worry about your use? Please list any DUI’s, etc. below:

Do you have problems with food? Do you consider yourself obese? Any history of an eating disorder?

Please list any religious preferences below, if any:

Please discuss any issues with gender identity/roles/sexual orientation/gender expression below:

Please bring a photocopy of your insurance card with you to the first

appointment.

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I, ______________________

(Patient Name) Patient Date of Birth: ___________

authorize

do not authorize Vaitkus Psychological Services LLC (VPS to release information contained in my patient record to my Primary Care Physician (PCP) and for my PCP to release information to . The information to be disclosed will be your initial diagnosis used for insurance billing as well as the type of therapy you will be receiving (individual vs. group for example), and also the expected time to be in treatment. This consent will terminate 6 months after the discharge date for services from VPS LLC. I understand that my consent to release information will include sending of the information below to my PCP, as well as discharge information which may be necessary to coordinate treatment at VPS LLC

Patient Signature (or parent/guardian)

Date Signed

Witness (Melody Vaitkus Ph.D.)

Date Witnessed

PCP Name: Dr. ___________________________ PCP Address: ______________________________ ______________________________ ______________________________ ______________________________ Phone: ______________________________ Fax: ______________________________

VAITKUS PSYCHOLOGICAL SERVICES LLC WILL COMPLETE THIS GREY AREA Initial Patient Care Communication to PCP Assessment Date _________ DSM-V Diagnosis:

Type of therapy: CBT (cognitive Exposure therapy Solution Other behavioral) focused

Modality: Individual Group Couples Family

Estimated Treatment Completion Date:__________________

Please contact me with any questions and comments

Melody Vaitkus Ph.D. (419) 270-2490 info@vaitkuspsychologicalservices.com

Date: _______________

NO ACTION IS REQUIRED BY PHYSICIAN’S OFFICE

This information is for continuation of care

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NOTICE OF PRIVACY PRACTICES

Notice of Psychologists: Policies and Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU OR YOUR

CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE

READ THIS CAREFULLY.

1. Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose the protected health information (PHI), of you or your child for treatment,

payment, and health care operations purposes with your consent. To help understand these terms,

please see the following definitions:

PHI: Refers to information in your health record that could identify you or your child.

Treatment, Payment and Health Care Operations:

o Treatment is when I provide, coordinate or manage the health care of you or your

child and other services related to the health care of you or your child. An example

of treatment would be when I consult with another health care provider, such as

your family physician or another psychologist.

o Payment is when I obtain reimbursement for the healthcare of you or your child.

Examples of payment are when I disclose the PHI of you or your child to your health

insurer to obtain reimbursement for that care or to determine eligibility or

coverage.

o Health Care Operations are activities that relate to the performance and operation

of my practice. Examples of health care operations are quality assessment and

improvement activities, business-related matters such as audits and administrative

services, and case management and care coordination.

Use: Applies only to activities within my office such as sharing, employing, applying, utilizing,

examining, and analyzing information that identifies you or your child.

Disclosure: Applies to activities outside of my office, such as releasing, transferring, or

providing access to information about you or your child to other parties.

2. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, and health care operations

when your appropriate authorization is obtained. An authorization is written permission above and

beyond the general consent that permits only specific disclosures. In those instances when I am

asked for information for purposes outside of treatment, payment and health care operations, I will

obtain an authorization from you before releasing this information.

You may revoke all such authorizations at any time, provided each revocation is in writing. You may

not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the

authorization was obtained as a condition of obtaining insurance coverage, and the law provides the

insurer the right to contest the claim under the policy.

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3. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse: If I know, or have reasonable cause to suspect, that a child is abused,

abandoned, or neglected by a parent, legal custodian, caregiver or other person

responsible for the child’s welfare, the law requires that I report such knowledge or

suspicions to the proper authorities.

Adult and Domestic Abuse: If I know, or have reasonable cause to suspect, that a

vulnerable adult (disabled or elderly) has been or is being abused, neglected, or

exploited, I am required by law to immediately report such knowledge or suspicion.

Health Oversight: If a complaint is filed against me with the Ohio Board of Psychology,

the Board has the authority to subpoena confidential mental health information from

me relevant to that complaint. My malpractice insurance agency and any attorney I hire

would also likely need this confidential information.

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a

request is made for information about you or your child’s diagnosis or treatment and

the records thereof, such information is privileged under state law, and I will not release

information without the written authorization of you or your legal representative, or a

subpoena of which you have been properly notified and you have failed to inform me

that you are opposing the subpoena or a court order. The privilege does not apply when

you are being evaluated for a third party or where the evaluation is court ordered. You

will be informed in advance if this is the case.

Serious Threat to Health or Safety: When you or your child present a clear and

immediate probability of physical harm to yourself (or in the case of your child, to

himself/herself), to other individuals, or to society, I may communicate relevant

information concerning this to the potential victim, appropriate family member, or law

enforcement or other appropriate authorities.

Worker’s Compensation: If you file a worker’s compensation claim, I must, upon

request of your employer, the insurance carrier, an authorized qualified rehabilitation

provider, or the attorney for the employer or insurance carrier, furnish your relevant

records to those persons. There may be additional disclosures of PHI that I am required

or permitted by law to make without your consent or authorization, however the

disclosures listed above are the most common.

4. Patient’s Rights and Psychologist’s Duties

Patient’s Rights:

Right to Request Restrictions: You have the right to request restrictions on certain uses and

disclosures of protected health information about you or your child. However, I am not

required to agree to a restriction you request

Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in

my mental health and billing records used to make decisions about you or your child for as

long as the PHI is maintained in the record. On your request, I will discuss with you the

details of the request process.

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Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is

maintained in the record. I may deny your request. On your request, I will discuss with you

the details of the amendment process.

Psychologist’s Duties:

I am required by law to maintain the privacy of PHI and to provide you with a notice of my

legal duties and privacy practices with respect to PHI.

I reserve the right to change the privacy policies and practices described in this notice.

Unless I notify you of such changes, however, I am required to abide by the terms currently

in effect.

If I revise my policies and practices such that a change to the notice is required, I will

provide you with a revised notice of my policies and practices at your next appointment

immediately following the date of such a revision.

5. Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to your

records, or have other concerns about your privacy rights, you may contact Melody Vaitkus

Ph.D. at (419) 270-2490 for further information. You can also mail a written complaint to Vaitkus

Psychological Services, LLC at 615 Kingsbury St., Maumee, OH 43537. You can also e-mail your

concerns to Info@vaitkuspsychologicalservices.com

6. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on September 1st, 2016. I reserve the right to change the terms of

this notice and to make the new notice provisions effective for all PHI that I maintain. I will

provide you with a revised notice by providing you with a copy of the revised notice at your next

appointment immediately following such a revision.

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PSYCHOTHERAPY CONSENT FORM

This form will provide information about my services and about your rights and responsibilities as a

patient. Please be sure to discuss any questions with Dr. Vaitkus. Your signature at the bottom indicates

that you understand the information and freely consent to participate in psychotherapy.

CONFIDENTIALITY:

The information obtained via psychotherapy is confidential and will not be released to any person or

organization without your written permission. The only exceptions to this policy are rare situations in

which we are required by law to release information without your permission. These are noted in the

attached Notices of Privacy Practices…see section 3. Uses and Disclosures with Neither Consent nor

Authorization. We will go over all of these circumstances in the first session together.

RECORD KEEPING:

I keep very brief records, noting only that you have been here, what interventions happened in session,

and the topics we discussed. I maintain your records in a secure location that cannot be accessed by

anyone else.

LITIGATION LIMITATION/FEES:

Due to the nature of the therapeutic process and the fact that it often involves disclosing matters that

could potentially be judged as negative if seen by others, and there is no guarantee how such

information will be evaluated, it is agreed that, should there be legal proceedings (such as but not

limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor

anyone else acting on your behalf will call on Melody Vaitkus, Ph.D. or Vaitkus Psychological Services LLC

to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be

requested.

Several things should be kept in mind in the event a subpoena issued by a court forces me to perform

services. First, any letter written describing therapy will only include sessions attended, date ranges of

services, and the diagnosis I used to bill the insurance company. Second, the patient will be financially

responsible for any and all costs related to the legal activities. For example, insurance companies pay for

the therapy session, but do not cover time spent by a psychologist writing letters, speaking to attorneys

on the phone, e-mailing attorneys, copying records, mileage driving to court, time spent in court waiting

and testifying, etc. The patient shall be responsible for all of these costs at a rate of $160 per hour.

These fees will be collected by the patient prior to the service being delivered. In cases where an exact

time isn’t known, a reasonable guess will be made and the patient will be responsible for that fee. After

the service is rendered, if the time was overestimated, a refund will be issued to the patient.

DIAGNOSIS:

If a third party such as an insurance company is paying for part of your bill, I am normally required to

give a diagnosis to that third party in order to be paid. Diagnoses are technical terms that describe the

nature of your problems and something about whether they are short-term or long-term problems. If I

do use a diagnosis, I will discuss it with you.

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OTHER RIGHTS:

You have the right to ask questions about anything that happens in therapy. I'm always willing to discuss

how and why I've decided to do what I'm doing, and to look at alternatives that might work better. You

can feel free to ask me to try something that you think will be helpful. You can ask me about my training

for working with your concerns, and can request that I refer you to someone else if you decide I'm not

the right psychologist for you.

MANAGED MENTAL HEALTH CARE:

If your therapy is being paid for in full or in part by a managed care firm, there are usually further

limitations to your rights as a client imposed by the contract of the managed care firm. These may

include their decision to limit the number of sessions available to you, to decide the time period within

which you must complete your therapy with me, or to require you to use medication if their reviewing

professional deems it appropriate. They may also decide that you must see another therapist in their

network rather than me, if I am not on their list. Such firms also usually require some sort of detailed

reports of your progress in therapy, and on occasion, copies of your case file, on a regular basis. I do not

have control over any aspect of their rules. However, I will do all that I can to maximize the benefits you

receive by filing necessary forms and gaining required authorizations for treatment, and assist you in

advocating with the MC company as needed.

FEE AND PAYMENT POLICY: Cash/Check/MasterCard/Visa

The standard fee for psychotherapy for private pay patients (people who choose to not use their

insurance or no mental health services covered in their policies) is as follows: $150 (CPT code 90791),

$130 (CPT code 90837), $100 (CPT code 90834), and $75 (CPT code 90832). Fees or copays are due at

the beginning of session. There will be a charge of $50.00 for returned checks. We reserve the right to

use a collection agency for unpaid balances. If for any reason an insurance carrier denies claims, the

patient is responsible for payment. Therefore it is extremely important that patients let us know BEFORE

services are provided of any insurance changes. It is also the patient’s responsibility to understand what

their deductible is, as well as copay information.

Many people are not aware of what their deductible is for behavioral health services. Young people

often have high deductibles because they do not seek health care as often as older individuals. Often, a

person’s behavioral health deductibles/copays are different than their standard medical care ones.

Therefore, when calling your insurance company to verify benefits, we recommend using the following

script:

“Hi, my name is Mary and my member number is XYZ….. I am about to see one of your in network

providers for behavioral health services. The provider is Melody Vaitkus PhD, Vaitkus Psychological

Services LLC and they will be using CPT code 90791 for my first visit. Once again, this is for mental health

services and NOT medical services so please tell me what deductible I have (if any) that needs to be

satisfied before my copay kicks in.”

Insurance companies can quote incorrectly, so if the patient verifies insurance and our practice does

also, this will lead to fewer mistakes later on, as we will make sure both parties have been given the

same information.

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FEES NOT COVERED BY INSURANCE COMPANIES:

Your insurance company is only paying for counseling. They do not pay for a psychologist’s time filling

out paperwork or speaking to people on the phone or reading/answering e-mails from bosses, spouses,

or other approved entities. These fees are the responsibility of the patient, and are due prior to the

services rendered. The charge per hour for these services is $160, and will be prorated. Because this

often comes up with new patients, a separate consent form is included later regarding the patient’s

responsibility for payment, as well as informing me at the start of therapy that such services will be

necessary.

EMERGENCIES/CRISIS CALLS:

Because I am not part of a group practice, I do not have 24 hour coverage, I cannot conduct

psychotherapy with patients who have had frequent bouts with suicidal behavior. We can talk about this

in the first session to determine if my practice will be sufficient for you. I am available for brief between

session phone calls but do charge for these at the same rate as sessions but will prorate them based on

the length of the call. I do not charge for phone calls involving rescheduling or questions about

upcoming appointment times. If you are experiencing an emergency that is life threatening, please have

someone take you to the nearest emergency room or call 911.

ELECTRONIC COMMUNICATION (E-MAIL, SMART PHONES, COMPUTERS, ETC):

While technology is incredibly advanced today, nothing is perfect, and no technology can truly

guarantee that only the intended person of a communication will get it and not an unauthorized person.

You can watch the news at any time and see how a major bank or credit card company had data

compromised. While I take all the standard precautions (passwords, anti-virus/hacking software, etc.) if

data can be compromised within a major credit card company or bank, it can happen to me or any other

mental health provider. I generally use texts and e-mails to schedule/change appointments. Please let

me know if you would like me to NOT do this with you. Also please let me know any other

communication preferences you may have.

AGREEMENT:

I have read the above material and agree to everything, and I fully understand my rights and obligations

as a patient. I freely agree to psychotherapy. I understand that I am responsible for charges that are not

covered under my insurance policy and/or charges that are incurred due to failure to inquire about or

obtain pre-authorization, if applicable.

_____________________________________________________________________________________

Name of Patient Date

_____________________________________________________________________________________

Signature Date

(Client or parent/legal guardian)

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Acknowledgement of Notice of Privacy Practices (Attached at Bottom):

The Notice of Privacy Practices tells you how we may use and share your health records. Please read it.

We will use and share your health records to treat you and to bill for the services we provide.

We will use and share your health records to run our business.

We will use and share your health records as required by law.

All the ways we may use and share your health records are explained in more detail in the Notice of

Privacy Practices. You have the following rights with respect to your health records:

1. You have the right to look at and receive a copy of your health records. 2. You have the right to receive a list of those to whom we have given your health records. 3. You have the right to ask for us to correct a mistake in your health records. 4. You have the right to ask that we not use or share your health records. 5. You have the right to ask us to change the way we contact you.

All of these rights are explained in more detail in the Notice of Privacy Practices.

I have had the opportunity to receive a copy of the Notice of Privacy Practices.

Signature: ________________________________________________(of patient or legal representative)

Date: ______________________

Capacity of Legal Representative (if applicable)*:____________________________________________

Consent

I give Vaitkus Psychological Services LLC my consent to use or disclose my protected health information

to carry out my treatment, to obtain payment from insurance companies, and for health care operations

like quality reviews.

I have been informed that I may review Notice of Privacy Practices (for a more complete description of

uses and disclosures) before signing this consent.

I understand that Vaitkus Psychological Services LLC has the right to change privacy practices and that I

may obtain any revised notices at the practice.

I understand that I have the right to request a restriction of how my protected health information is

used. However, I also understand that the practice is not required to agree to the request. If the practice

agrees to my requested restriction, they must follow the restriction(s).

I also understand that I may revoke this consent at any time, by making a request in writing, except for

information already used or disclosed.

Signature: _______________________________________________________________

Date: __________________________________________________________________

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No-show and Late Cancellation Fees for Melody Vaitkus, Ph.D.

No-shows are defined as a failure to show for therapy by the agreed appointment time start. Late

cancellation is defined as any cancellation with less than 24-hours notice. The no-show/late cancellation

fee for my therapy sessions is $100.00 and will be collected at the next attended session. Insurance will

not pay for this fee. It is the patient's responsibility.

I will provide a business card with your next appt. date and time at the end of each session. If you

believe I have charged you one of these fees in error, please show me the business card at our next

session for clarification. Thanks for your understanding in this matter. Because clients are waiting for

appointment openings, my availability is critical.

_____________________________ _________

Client Date