NEW PATIENT INTAKE FORM

PATIENT INFORMATION (ADULT)

First
MI
Last
Address *
Address
City
State/Province
Zip/Postal

PATIENT INFORMATION (CHILD)

PLEASE FILL IF PATIENT IS A CHILD:

PARENT / LEGAL GUARDIAN

Parent | Legal Guardian First Name/Middle Name
Parent | Legal Guardian Last Name
Relation to Client

REFERRING SOURCE

Full Name

INSURANCE *** MUST BE FILL ***

YOUR HEALTH CARE PROVIDER, INSURER, OR PLAN MAY REQUIRE A PHYSICIAN REFERRAL OR PRIOR AUTHORIZATION AND YOU MAY BE OBLIGATED FOR PARTIAL OR FULL PAYMENT FOR SERVICES PROVIDED.

INSURED OR AUTHORIZED PERSON’S SIGNATURE:

AUTHORIZATION TO RELEASE/OBTAIN CONFIDENTIAL INFORMATION

I hereby authorize the release of any necessary information to process insurance claims, including medical and billing information, as well as to discuss the child’s case information with other Therapists working within the building structure of Carrousel Health Care Corporation to/from, from/to the referring physician, Therapist Co-workers and insurance company.
Name
Name
First
Last

PATIENT CONSENT OF SERVICE AGREEMENT

I consent that treatment will be rendered at the following locations.
SIGNATURE: PARENT/LEGAL GUARDIAN

New Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations

( the term “I” refers to the Parent/Legal Guardian of child) understand that as part of my healthcare, “Carrousel Health Care Corporation,” originates and maintains paper and/or electronic records describing “my” (the term “my” refers to parent and/or child) health history, symptoms, examinations and test results, diagnoses, treatment, and any plans for future care of treatment. I understand that this information serves as: -A basis for planning my care and treatment, -A means of communication among the many health professionals who contributes to my care, -A source of information for applying my diagnosis and surgical information to my bill, -A means by which a third-party payer can verify that services billed were actually provided, and -A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcareprofessionals. I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: -The right to review the notice prior to signing this consent, -The right to object to the use of my health information for directory purposes, and -The right to request restrictions as to how my health information may be used or disclosed to carry out treatment,payment, or healthcare operations. I understand that “Therapy,” is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. I further understand that “Therapy,” reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should “Therapy,” change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or if I agree e-mail).
I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via text, fax and/or e-mail.
Parent/legal Guardian’s Signature

Credit Card Agreement

All parents and guardians are responsible for paying their child’s co pay and deductibles, set by their Insurance Company. These fees are nonnegotiable. Unless otherwise specified, we will collect these fees every session. We have made this process easier by accepting Visa card, Master card, American Express card, and Discover card. By signing below it is agreed that your credit card number will remain on file and “Carrousel Health Care Corporation” will charge that credit card only in the event that your child attends his or her therapy session. A receipt will be provided to you for all charges applied. We hope this makes everything easier for you to keep track of your fees. Thank you,

HIPPA Release Form

I,
give permission to “CARROUSEL HEALTH CARE CORPORATION.” and all employees to discuss and/or receive medical information including medical records concerning any and all aspects of patient’s previous healthcare by a doctor, physical, occupational or speech therapist, or other medical professional. This release is required to obtain medical information according to the privacy rule detailed in HIPPA (The Health Insurance Portability and Accountability Act of 1996).

COVID-19 PATIENT SCREENING FORM

1. Do you have fever or have you felt hot or feverish recently?
2. Do you have a dry cough?
3. Have you experienced shortness of breath or other difficulties breathing?
4. Do you have a runny nose?
5. Do you have any recent onset of headache or sore thoat?
6. Do you have muscle pain?
7. Do you have flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
8. Have you recently lost or had a reduction in your sense of taste or smell?
9. Have you been in contact with someone that have tested positive for COVID-19?
10. Have you tested positive for COVID-19?
11. Are you over the age of 65?
12. Do you have heart disease, lung disease, kidney disease diabetes or any auto-immune disorders?

Hamilton Anxiety Rating Scale (HAM-A)

Patient Name
Patient Name
First
Last

Bellow is a list of phrases that describe certain feeling that people have. Please select one of the five responses for each of the 14 questions.

0 = Not Present 1 = Mild 2 = Moderate 3 = Severe 4 = Very Severe
Worries, anticipation, of the words, fearful anticipation, irritability.
Feeling of tension, fatiguability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax.
Of dark, of strangers, of being alone, of animals, of trafic, of crowds.
Difficulty in falling to asleep, broken sleep, unsatisfying sleep, and fatigue on walking, dreams, nightmares, night terrors.
Difficulty in concentration, poor memory
Loss of interest, lack of pleasure in hobbies, depression, early walking, diurnal swing.
Pains and aches, twitching, stiffness, myoclonic jerks, grinding of teeth, unsteady voice, increased muscular tone.
Tinnitus, blurring of vision, hot and cold flashes, feeling of weakness, pricking sensation.
Tachycardia, palpitations pain in chest, throbbing of vessels, fainting feelings, missing beats.
Pressure or constriction in chest, choking feeling, sighing, dyspnea.
Difficulty in swallowing, wind abdominal pain, burning sensations, abdominal fullness, nausea, vomiting, borborygmi, looseness of bowels, loss of weight, constipation.
Frequency of micturition, urgency of micturition, amenorrhea, menorrhagia, development of frigidity, premature ejaculation, loss of libido, impotence.
Dry mouth, flushing, pallor, tendency to sweat, giddiness, tension, headache, raising of hair.
Fidgeting, restlessness or pacing, tremor of hands, furrowed brow, strained face, sighing or rapid respiration, facial pallor, swallowing, etc.

0 = Not Present 1 = Mild 2 = Moderate 3 = Severe 4 = Very Severe

Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where <17 indicates mild severity, 18–24 mild to moderate severity and 25–30 moderate to severe.
time

Patient Depression Questionnaire (PHQ-9)

Patient Name
Patient Name
First
Last

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Scare: 0-4 Minimal or non Monitor; may not require treatment 5-9 Mild 10-14 Moderate (Use clinical judgment {symptom duration, functional impairment} to determine necessity of treatment) 15-19 Moderate severe 20-27 Severe (Warrants active treatment with psychotherapy, medications, or combination)

CRITICAL ACTIONS: Perform suicide risk assessment in patients who respond positively to item 9 “Thoughts that you would be better off dead or of hurting yourself in some way.” Rule out bipolar disorder, normal bereavement, and medical disorders causing depression.
Time

Download for your records the Consumer Handbook in English or Spanish.