INTAKE FORM                                                                                     TODAY’S DATE:____________               

Ocean Breeze Counseling, LLC

202 4th Ave

Indialantic, Fl. 32903

Ph 321-373-2281    Fax 321-373-2294

 

GENERAL INFORMATION

 

Referred By:_____________________________________   Therapist Name_____________

Name:_____________________________________  Sex: M F (circle one)

Preferred Name:_____________________________ DOB:_________   Age:_____________

Employer and/or School:______________________________________________________

Occupation:_________________________________   Grade Level:____________________

Circle one: Married  Divorced Single Child  Separated Widowed

Spouses Name:______________________________________________________________

 

CONTACT INFORMATION

Home Address:________________________________________________________________

City:____________________ State:_____  Zip:______ May we send mail to this address:   Y N

If no, list other address here: _____________________________________________________

Home Phone:_________________ May we leave a message here:    Y N

Cell Phone:___________________ May we leave a message here:    Y N Text: Y N

Work Phone:_________________  May we leave a message here:  Y N

Email:_______________________ May we send a message here:     Y N

Emergency Contact  Name:_______________________________________________________

Relationship:_______________________  Phone:_____________________________________

 

INSURANCE INFORMATION

Will you be using Insurance: Y  N If Yes, fill out information below:

Name of Primary Insurance:_______________________ Member ID:______________________

Group Number:____________________  Authorization #:_______________________________

Name of Secondary Insurance, if any:_______________________ Member ID:______________

Group Number:____________________  Authorization #:_______________________________

Person Financially Responsible:____________________ Relationship to client:______________

Permission to contact:  Y N If Yes, Contact Number:____________________________________

Is Address same as above:  Y N If No, List Address:____________________________________

 

AGREEMENT FOR SERVICES

As the client, you have the right to read our Notice Privacy Practices before you decide to sign this consent.

 

Insurance Authorization: I hereby give permission to Ocean Breeze Counseling, for myself and/or my dependents, to use benefits for services rendered.  I authorize Ocean Breeze Counseling to release all information necessary, to submit a claim to my insurance carrier, and to process this and related claims. I understand that all co-payments and deductibles (if any) are my responsibility, and that my debt may be sent to collections, if payment or payment arrangements have not been made. I acknowledge that payment and/or fees are due at time of service. You have the right to revoke this consent at any time, and can do so by, giving us written notice. Keep in mind, we will still have the right, to complete prior claims for billing purposes. We also have the right to decline treatment/services if you refuse to sign this agreement.

 

Client Signature: ____________________________________  Date:___________________

 

Guardian/Parent Signature :___________________________________ Date:___________

(If client is a minor)

 

Health Information Release Form

I authorize the persons below to have access to any and all my health information.  By signing this form, Ocean Breeze Counseling can share any medical information with the persons that are listed below.

 

I hereby request and authorize:

Ocean Breeze Counseling, LLC                  ____ to release to ____ to obtain from

 

Persons/Medical Providers/School or Work personnel (Full name, Phone, Relationship).

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

 

You may notify me or the parties listed above with appointment reminders and other information regarding my health information.  

Print Name:_____________________________________

Signature: ______________________________________    Date: _________________________

Witness: _______________________________________    Date: _________________________

 

PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected. Any further redisclosure is strictly prohibited unless the person provides specific written consent for the subsequent disclosure of this information. Florida law requires that any person, agency, or entity receiving information shall maintain such information as confidential and exempt from the provisions of the public records law.

 

 

CONSENT TO TREAT

 

I hereby give consent for treatment to Ocean Breeze Counseling, LLC and _________________ (Therapist Name). In a very small number of situations, counselors are legally required to disregard confidentiality. For example, if you reveal information that indicates a clear danger of injury to yourself or others (ex. potential suicide or homicide) the counselor will need to contact appropriate authorities or family members. Also, all helping professionals are required by law to report any knowledge of the abuse or neglect of a child or an incompetent or disabled person. Your counselor will be happy to discuss any concerns you have about the protection of the information you provide.

 

READ & INITIAL BELOW

 

_____I have been informed that if I have advance directives that include psychiatric designations it is my responsibility to supply that to this office.

_____I am aware that if I miss a scheduled appointment or cancel less than 24 hours in advance, I may be charged a $50 late cancelation/missed appointment fee.

_____I am aware that Ocean Breeze Counseling, LLC  has the HIPPA Privacy Practice and financial policies for my viewing in hard copies, which are available to me upon request. In the event I participate in phone or internet sessions I understand that HIPPA compliance is not guaranteed.

_____If you try to contact your therapist, and for any unforeseen reason, you do not hear from her, or she is unable to reach you, and you feel you cannot wait for a return call or feel unable to keep yourself safe, contact; Circles of Care, go to your local Hospital Emergency Room, or call 911.

 

APPOINTMENT REMINDERS

You can receive an appointment reminder to your email address, your cell phone (via a text message), or your home phone (via a computer generated voice message) the day before your scheduled appointment.

 

How would you like to receive appointment reminders- Initial One

____ text message  ___ email ____automated telephone message  _____ None I’ll remember

(Text message rates may apply)

 

Being this is a 3rd party service, it is still your responsibility to keep any appointments you have made, as we can not guarantee you will successfully receive a reminder every time.

Appointment information is “Protected Health Information” under HIPPA.

By signature, I am waiving my right to keep this information completely private and am requesting that it be handled as I have noted above.

 

SIGNATURE_______________________________________________        DATE___________________

 

Witness:_________________________________________________         DATE___________________