Print Name: _______________________________________ DOB: _______________

Angelus Therapeutic Services, Inc At Signature Hill

Adult Registration Form

Last Name: ______________________ First __________________ M ____

Address: ____________________________ City _______________ State_____ ZIP _________

Home Phone: ____________________________ Alt Phone: ____________________________

Can we call you at home? _____/ Alt #?_____ Can we leave a message? ______/ Alt #?_______

Email: ____________________________ Would you like emailed appointment reminders?____

SSN: ______________________ DOB: _____________ Marital Status: ___________________

Person Responsible for Payment

Last Name: ______________________ First __________________ M ____

Address: ____________________________ City _______________ State_____ ZIP _________

Home Phone: ____________________________ Alt Phone: ____________________________

SSN: ______________________ DOB: _____________ Relationship to Client: _____________

Insurance Information:

Primary Insurance__________________

Insured __________________________

ID # _____________________________

Group # __________________________

Effective Date _____________________

Phone # __________________________

Policy Holder Name ________________

PH DOB __________ Copay _________

Secondary Insurance________________

Insured __________________________

ID # _____________________________

Group # __________________________

Effective Date _____________________

Phone # __________________________

Policy Holder Name ________________

PH DOB ___________ Copay ________

Primary Care Physician ___________________________________________________

PCP Phone/ Address_______________________________________________________

Consent To Treat

I hereby request psychological treatment as deemed necessary by both my therapist and I.

Signature ___________________________________________ Date ________________

Consent to Bill

This signature authorizes Angelus Therapeutic Services to bill my insurance for services.

In the event that my insurance doesn’t cover these services, I understand that I am

responsible for payment: Co-payments are due at time of service. A 24-hour notice is

required to cancel an appointment or else a $25 cancellation/ fail fee will be charged.

Signature ___________________________________________ Date ________________

Print Name: _______________________________________ DOB: _______________

A N G E L U S T H E R A P E U T I C S E R V I C E S , I N C S I G N A T U R E H I L L

Adult Intake Packet

Family Information Please list all household and immediate family members

Name Relationship Age DOB

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Emergency Contact

Name: ______________________Relationship: _______________ Phone: ___________

May we leave a message with this person if we are unable to contact you? ____________

Referral & Medical Information

How were you referred to us? _______________________________________________

Briefly describe your reason for seeking services ________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Who is your family Physician? ______________________________________________

May we have a release of information (ROI) for your family doctor? ____ Yes ____ No

What is the date of your last exam? ___________________________________________

Please list any medical health problems _______________________________________

Current Medicatoins_______________________________________________________

________________________________________________________________________

Allegies_________________________________________________________________

Print Name: _______________________________________ DOB: _______________

Psychological/ Psychiatric Information

Have you previously received any psychological or psychiatric services? ____Y ____ N

If yes please complete the following.

Dates Facility Reason Results ROI

Y N

Y N

Y N

Y N

Are you currently involved in any other MH or D&A treatment? If yes, where?

________________________________________________________________________

May we have a release of information? ______ Yes ______ No

Do any of your family members struggle with mental health or D&A issues? _________

If yes, please explain ______________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Please complete the following table on general use/ abuse of caffeine, cigarettes, drugs

and alcohol. This information is important to establish the most effective treatment

options available for your needs. As with all information discussed here, this information

remains confidential.

Drug (Alcohol, cocaine, etc)

Caffeine Use Cigarettes

Frequency of use (ex: daily, weekly)

Age of first use Age when it

became a problem

Last used

Print Name: _______________________________________ DOB: _______________

Legal History

Dates Charges Results Status

Are your services here in compliance with a legal or court mandate? _______________

Probation Officer _______________________ Phone___________________________

Address________________________________________________ ROI complete: Y/N

Lawyer ________________________________ Phone___________________________

Address________________________________________________ ROI complete: Y/N

Please expand on and current or recent charges _________________________________

________________________________________________________________________

________________________________________________________________________

Education:

High School Graduate? _____ GED? _______ Year Obtained: ______ College: _____________

Community Involvement

Do you actively participate in any groups/ activities on a regular basis? ______________

________________________________________________________________________

Do you attend a church or have any religious involvement/ beliefs? _________________

________________________________________________________________________

What are your favorite activities? ____________________________________________

What do you see as your strengths? ___________________________________________

What do you see as your best supports or resources? _____________________________

________________________________________________________________________

Print Name: _______________________________________ DOB: _______________

ANGELUS THERAPEUTIC SERVICES, INC

724-654-9555

Name: ___________________________ DOB: ___________ Date: ______________

Burns Depression Checklist

Instructions: Place a check mark in the box to the right of each of the 15 symptoms to indicate

how much this type of feeling has been bothering you in the past several days.

0-Not at All 1-Somewhat 2-Moderatly 3-A lot 4- Extremely

0 1 2 3 4

Thoughts and Feelings

1 Feeling sad or down in the dumps

2 Feeling unhappy or blue

3 Crying spells or tearfulness

4 Feeling discouraged

5 Feeling hopeless

6 Low self-esteem

7 Feeling worthless or inadequate

8 Guilt or Shame

9 Criticizing yourself or blaming yourself

10 Difficulty in making decisions

Activities and Personal Relationships

11 Loss of interest in family, friends or colleagues

12 Loneliness

13 Spending less time with family or friends

14 Loss of motivation

15 Loss of interest in work or other activities

16 Avoiding work or other activities

17 Loss of pleasure or satisfaction in life

Physical Symptoms

18 Feeling tired

19 Difficulty sleeping or sleeping too much

20 Decreased or increased appetite

21 Loss of interest in sex

22 Worrying about your health

Suicidal Urges***

23 Do you have any suicidal thoughts?

24 Would you like to end your life?

25 Do you have a plan for harming yourself?

Total Score on Items #1-#25:

*Copyright 1894 David Burns, M.D. (Revised 1996)

***Anyone with suicidal urges should seek help from a mental health professional

Print Name: _______________________________________ DOB: _______________

The Burns Anxiety Inventory

Instructions: The following is a list of symptoms that people sometimes have. Put a check in the space to the right that best describes how much that symptom or problem has bothered you during the past week. If you would like a weekly record of your progress, record your answers on the separate “Answer Sheet” instead of filling in the spaces on the right.

0 = Not At All 2 = Moderately

1 = Somewhat 3 = A Lot

Symptom List 0 1 2 3

Category I: Anxious Feelings

1 Anxiety, nervousness, worry, or fear.

2 Feeling that things around you are strange, unreal or foggy.

3 Feeling detached from all or part of your body.

4 Sudden unexpected panic spells.

5 Apprehension or a sense of impending doom.

6 Feeling tense, stressed, “uptight”, or on edge

Category II: Anxious Thoughts

7 Difficulty concentrating.

8 Racing thoughts or having your mind jump from one thing to the next.

9 Frightening fantasies or daydreams.

10 Feeling that you're on the verge of losing control.

11 Fears of cracking up or going crazy.

12 Fears of fainting or passing out.

13 Fears of physical illnesses or heart attacks or dying.

14 Concerns about looking foolish or inadequate in front of others

15 Fears of being alone, isolated, or abandoned.

16 Fears of criticism or disapproval.

17 Fears that something terrible is about to happen.

Category III: Physical Symptoms

18 Skipping or racing or pounding of the heart (sometimes called “palpitations”)

19 Pain, pressure, or tightness in the chest.

20 Tingling or numbness in the toes or fingers.

21 Butterflies or discomfort in the stomach.

22 Constipation or diarrhea.

23 Restlessness or jumpiness.

24 Tight, tense muscles.

25 Sweating not brought on by heat.

26 A lump in the throat.

27 Trembling or shaking.

28 Rubbery or “jelly” legs.

29. Feeling dizzy, light-headed, or off balance.

30. Choking or smothering sensations or difficulty breathing.

31. Headaches or pains in the neck or back.

32 Hot flashes or cold chills.

33 Feeling tired, weak, or easily exhausted

Total of Each Column

TOTAL ________

Print Name: _______________________________________ DOB: _______________

ANGELUS THERAPEUTIC SERVICES, INC Informed Consent

Risks and Benefits of Treatment: Although psychotherapy and psycho diagnostic services have been

demonstrated to be safe and effective procedures, clients may experience transient discomfort or heightened

symptoms, in the course of psychotherapy or diagnostic testing associated with working through difficult

emotions, events, or historical material. A small number of clients may not improve as a result of therapy or

may terminate before it is clinically indicated. It is important to keep your clinicians advised of any difficulty

you may encounter in the course of your treatment or of any concerns that you may have about your treatment

plan and/ or progress

Confidentiality: Under Federal and Pennsylvania Law, clients are assured of confidentiality, in that staff at

Angelus Therapeutic Services can and will not release any information pertaining to treatment without prior

expressed written permission. In couples or family therapy, confidentiality applies to the couple or family unit.

In couple's counseling there is no guarantee of confidentiality between partners due to the nature of couple's

work. There are specific instances where exceptions to confidentiality are legally or ethically mandated. The

law requires that relevant others, including legal authorities, be notified in cases of individuals who intend to

harm others or themselves and in cases of neglect, abuse, or molestation of a child or older adult. In legal cases,

clinical records may be subpoenaed. If you are requesting services as the guardian or parent of a child, or the

guardian of a dependant adult, the same general rules will apply. Parents/ guardians have the right and

responsibility to question and understand the nature of therapy, and we must use clinical discretion as to what is

appropriate to disclose while allowing the client to feel secure and safe in treatment.

Completing or Leaving Treatment: Termination of psychotherapy may occur any time and may be initiated by

either the client or the therapist. Termination can be a constructive, useful process and is in fact the ultimate

goal of treatment. If any referral is warranted, it can be made at that time. We recommend a “termination

session” to review progress and recommendations. The client always maintains the right to stop services at any

time or to transfer or seek services with any other provider without penalty. In addition, Angelus Therapeutic

Services retains the right to decline referrals, services or treatment to any individual/ family unit if it is deemed

to be a conflict of interest or outside of the providers realm of experience/ expertise.

Grievance Procedure: If at any point you do not feel that you are treated professionally or adequately at

Angelus Therapeutic Services you retain the right to file a grievance with Angelus, your insurance carrier

and/or any applicable licensing body.

Litigation Limitations: In initiating services at Angelus Therapeutic Services it is agreed that neither the

client(s) nor their attorneys nor anyone acting on their behalf will request or require any clinician from this

agency to testify in court. This is in order to protect the therapeutic relationship developed in treatment and due

to the fact that in a court situation the clinician might have to make full disclosure regarding matters that may be

of a confidential nature and significantly jeopardize the treatment process.

CONSENT TO PARTICIPATE IN PSYCHOTHERAPY OR DIAGNOSTIC SERVICES:

My signature below indicates that I have read the above related information regarding Angelus Therapeutic

Services, Inc and have discussed and understand the possible risks and benefits of psychological therapy and

diagnostic procedures. I am affirming that I am voluntarily requesting these services. I have the right to

develop and review my own treatment goals with my therapist. In addition, I may discontinue services at any

time.

CLIENT COPY TO KEEP

Print Name: _______________________________________ DOB: _______________

ANGELUS THERAPEUTIC SERVICES, INC

About Our Services

Appointments: the lengths of appointments vary based on need, but one clinical hour is 45-50 minutes. Please

cancel any appointments at least 24 hours in advance so that the time can be allotted to another client. If you do

not cancel your appointments 24 hours prior to your scheduled time, you will be responsible for the co-pay

amount or a no-show fee of $25.00. If you fail to attend or cancel two or more scheduled appointments you may

be declined from scheduling future appointments.

Fee Structure:

o Diagnostic Interview (Intake) $125

o Individual Psychotherapy (20-30min) $65

o Individual Psychotherapy (30-50min) $85

o Individual Psychotherapy (50-60min) $125

o Couple's Counseling (45-60min) $160

o Family Therapy (45-60min) $160

*These charges are based on the usual, customary, and reasonable profiles for this area.

Insurance Coverage/ Payments: If you have health insurance plan, your insurance company may cover your

visits. Many insurers require that the client make a co-payment. We suggest that you check with your insurer to

verify that Angelus is covered in your plan and the amount of your financial responsibility for services. If your

services are declined from your managed care company you will be responsible for the full payment.

Payments/ Co-payments will be due prior to your session. If they are not paid the day of service a $5 service

fee will be added and both must be paid prior to attending your next session. If you have no insurance full

payment must be made at the time of service.

o In the event that a check is returned unpaid from the bank for any reason, your account will be charged

a $30 return check fee and you will not be able be seen until your account is made whole.

o If a Managed Care Organization manages your benefits, you may need to obtain a referral and prior

approval for services from them before scheduling your first appointment. Most insurance companies

require diagnosis and treatment information. In order to provide treatment we will need to release that

information. Signing this paper grants Angelus Therapeutic Services, Inc the ability to release

treatment information to your insurance provider.

Telephone Calls: Although a secretary is not consistently in the office to answer your calls, messages are

checked several times a day. Please leave a detailed message including your name, contact number and area of

inquiry. All calls received prior to 3:00p on a business day will be returned that day, barring unforeseen

circumstances. Calls received after that time will be returned the next business day.

Emergencies: For emergency situations where it may be detrimental to wait for a next day call back please call

724-740-9555 for Angelus Staff, 724-652-9000 for the Lawrence County/ HSC Crisis Line, present to your

nearest emergency room, or contact 911 for severe emergencies.

CLIENT COPY TO KEEP

Print Name: _______________________________________ DOB: _______________

ANGELUS THERAPEUTIC SERVICES, INC

CANCELLATION AND NO SHOW POLICY

We understand that situations arise in which you must cancel your appointment. It is therefore

requested that if you must cancel your appointment you provide more than 24 hours notice. This

will enable another client who is waiting for an appointment to be scheduled in that appointment

slot. With cancellations made less than 24 hours notice, we are unable to offer that slot to other

people.

Office appointments which are cancelled with less than 24 hours notification will be subject to a

$25 cancellation fee.

Patients who do not show up for their appointment without a call to cancel an appointment will

be considered as a NO SHOW.

Patients who No-Show two (2) or more times in a six (6) month period, may be dismissed

from the practice thus they will be denied any future appointments and will be unable to be

reopened for a six (6) month period from the date of their last failed appointment.

Repetitive less than 24 hour appointment cancellations may be an indication of a patient not

being ready for or vested to the treatment process and creates a barrier in scheduling for clients

who are in greater need of services. Two (2) less than 24 hour cancellations will be considered

a failed session and fall under our No Show policy, consequently four (4) less than 24 hour

cancellations in a six (6) month period will necessitate being dismissed from ATS for a

minimum of a 6 month period.

The Cancellation and No Show fees are the sole responsibility of the patient and must be paid in

full before the patient's next appointment.

We understand that Special unavoidable circumstances may cause you to cancel within 24 hours.

Fees in this instance may be waived, but only with management approval and only for one (1)

instance per six (6) month period.

Our practice firmly believes that a good clinician/ patient relationship is based upon

understanding and good communication. Questions about cancellation and no show fees should

be directed to the Clinical Director at 724-654-9555.

Please sign that you have read, understand, and agree to this Cancellation and No Show Policy

CLIENT COPY TO KEEP

Print Name: _______________________________________ DOB: _______________

ANGELUS THERAPEUTIC SERVICES, INC

Acknowledgement of Receipt of Privacy Practice Notice

The Health Insurance Portability and Accountability Act of 1996 is a set of federal laws designed

to safeguard your health information. These privacy laws serve several purposes. For example,

they establish how your health information can be used by us- your health care provider. They

also identify instances when your permission is required to disclose your health information to

other persons. Additionally, they identify your rights, and our rights, when it comes to the

handling of your health information.

These privacy laws allow us- as your health care provider- to use your health information in

several ways. For example, in order to provide health care services to you, we are required to

maintain certain records about the treatment that we provide to you. These privacy laws allow us

to use your health information to maintain these records. We are also allowed to use your health

information to seek payment for the services that we provide to you. Additionally, we are

allowed to use your health information in the course of certain of our day-to-day operations.

These privacy laws allow you to ask us to restrict how your health information is used in certain

circumstances. For example, if you do not want us to call you at a certain phone number, you

may request that we use an alternate number if we need to contact you. We will work with you if

you have any reasonable requests on how you would like to your health information to be used,

but we would like to make you aware that these privacy laws do not require us to agree to your

requests in all situations. If you have any reasonable requests on the use of your health

information, please ask to speak to our director.

These privacy laws also allow us to seek your written consent for us to use and disclose your

health information in order to: 1) provide treatment to you, 1) seek payment for services that we

provide to you, and 3) for certain day-to-day operations of our organization. We are not required

to obtain your consent- we are voluntarily seeking your consent to use and disclose your health

information for the purposes of treatment, payment, and our health care operations because we

want you to know about your rights and our rights- regarding the handling of your health

information. If you have any questions about how we may use or disclose your health

information, or about the records that we must maintain about you, please ask to speak with our

director.

In order to better protect your records and your privacy Angelus Therapeutic Services utilizes a

secured Electronic Medical Record System, Practice Fusion. This allows us to safeguard your

information and prevent any non-authorized parties from accessing your information.

I have read and understand the information contained within the HIPPA Consent. I also

acknowledge that I have received a copy of Angelus Therapeutic Services Notice of Privacy

Practices.

CLIENT COPY TO KEEP

Print Name: _______________________________________ DOB: _______________

ANGELUS THERAPEUTIC SERVICES, INC

Notice 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 this notice carefully*

This Notice of Privacy Practices serves several purposes. It describes 1) Your rights regarding your control of, and

access to, your protected health information, 2) How we may use and disclose your protected health information,

and 3) Our organization’s legal duties regarding our use and disclosure of protected health information, and our

practices related to protecting the privacy of all protected health information.

We are committed to protecting the privacy of your protected health information. In providing health care

services, we will create and maintain records regarding you and the treatment and services that we provide to you.

We are required by law to maintain the confidentiality of protected health information that identifies you. We are

also required by law to provide you with this Notice, and to abide by all terms of this Notice. This Notice will be

posted at all of your physical service delivery sites. We reserve the right to update this Notice as appropriate, and to

make the provisions of the updated Notice effective for all protected health information that we maintain.

Privacy Rights Pertaining to Protected Health Information

Although your health record remains the physical property of our organization, the information contained in our

records belongs to you. You have numerous rights regarding your protected health information.

Written Authorization for Disclosure of Protected Health Information: When required by regulation, law or

internal privacy practices, we will obtain your written permission prior to disclosing your protected health

information to person/ entities outside of our organization. This permission will be obtained using an Authorization

to Disclose Protected Health Information form. You have the right to refuse to sign any Authorization, and the right

to revoke a previously signed Authorization. Please make sure that you carefully read the Authorization form prior

to signing it.

Confidential Communications: You have the right to request that we contact you at a certain location, or in a

certain manner. As an example, you may request that we use and alternate address or phone number to contact you.

We will attempt to accommodate reasonable requests, but we are not required to do so.

Requesting Restrictions to Our Uses and Disclosures: You may request that we use or disclose your protected

health information in a certain way related to our treatment, payment, and health care operations activities. As an

example, you may request that we not disclose your protected health information to a particular person. Please be

aware that we are not required to a requested restriction, but if we do agree to a request we are bound by our

agreement except in emergency circumstances and certain other situations.

Access to Your Health Records, and Obtaining Copies: You may request to review and obtain a copy of certain

of your health records. We may deny your request under limited circumstances; however, you may request a review

of certain denials. If you request and are granted a copy of your health records, we may charge you a reasonable

cost-based fee.

Amendment of Your Health Records: You may request an amendment to certain of your protected health

information if you believe it is incorrect or incomplete. We may deny your request under certain circumstances.

Disclosure Accounting: You may request an accounting of certain disclosures that we have made regarding your

protected health information. The first accounting requested within a 12 month period will be provided at no charge.

We may charge a reasonable cost-based fee for all additional requests received within the same 12-month period.

Receiving a Copy of this Notice: You are entitled to receive a copy of this Notice at any time. To obtain a copy,

please inquire with any of our staff.

Filing a complaint: You may file a complaint with us, or with the Federal Government, if you believe that your

privacy rights have been violated. Review the section at the end of this document regarding the filing of complaints

in order to determine how to file a complaint.

Print Name: _______________________________________ DOB: _______________

How We May Use and Disclose Protected Health Information

The following information describes how we may use and disclose your protected health information. It contains some examples,

but this should not be considered and exhaustive list, and some examples may not apply to your situation.

Treatment: We will use your protected health information to provide treatment and services to you. The protected

health information obtained about you by our staff will be recorded in your health record and will be used to determine the best

course of treatment for you. Also, any staff involved in your care can share information about you with your signed consent.

Payment: We will use and disclose your protected health information to prepare, submit and/or process bulls to you or

your insurer. We may contact your insurer to determine your benefits for services, and we may provide your insurer with

information regarding your treatment and the services that we provide to you for purpose of payment. The information we use on

a bill may include information that identifies you, as well as your diagnosis and services rendered.

Health Care Operations: We will use and disclose your protected health information in the course of our day-to-day

operations. Certain members of our staff may use your protected health information to assess the quality of the services that we

provide to your and to conduct normal business planning activities.

Contacting You: We may use your protected health information to contact you in order to 1) Remind you of a

scheduled appointment, 2) Reschedule an existing appointment, 3) Talk to you about a missed appointment, 4) Inform you about

potential treatment alternatives or other health related information, 5) Talk to you about an outstanding balance owed to us, and

6) For other issues related to the services that we provide to you and related to seeking payment for those services.

Business Associates: In some instances, we may utilize external contractors- referred to as “business associates” – who

will provide services to us in support of our operations. Protected health information may be provided to these “business

associates” so that they can perform the tasks for which they have been contracted. Please be aware that we require our “business

associates” to appropriately safeguard all protected health information which has been disclosed to them.

Notification in Case of Emergency: Our staff, using its best judgment, may use or disclose protected hath information

about you to notify pr assist in notifying a family member, personal representative, or another person/ entity/ health care provider

in the case of an emergency. If required by regulation or law, we will obtain your written authorization prior to making these

disclosures.

Court Orders and Subpoenas: We may disclose your protected health information pursuant to a court order or

subpoena pertaining to any purpose defined by statute, and as ordered by a court of competent jurisdiction.

Suspected Abuse, Neglect, or Domestic Violence: We may disclose your protected health information, as required or

allowed by law, if we suspect neglect, abuse, or domestic violence, but only to entities authorized to receive such reports.

Licensing and Accreditation Organizations: We may disclose your protected health information pursuant to

licensing and accreditation activities to maintain the health, safety and welfare of the people we serve and/ or promote quality

outcomes.

Correctional Institutions: Should you become an inmate of a correctional institution or be placed under supervision of

the juvenile or adult criminal court, we may disclose to the institution or agents thereof, probation or parole officer or their

designees, protected health information necessary to preserve or maintain your health and the health and safety of other

individuals.

Health Oversight and Public Health Activities: We may disclose your protected health information to appropriate

health oversight agencies, and for the purposes of preventing or controlling disease, injury, or disability, as required or allowed

by law.

To Avery a Serious Thereat to Health and Safety: We may disclose your protected health information, with certain

exceptions, in order to avert a serious threat to the health or safety of your or others.

Disclosures Required by Law: We may disclose your protected health information in other circumstances, as required

by regulation or law.

Our Duties and Responsibilities

We will not use or disclose your protected health information without your consent and/ or authorization, except as allowed by

law and as described in this Notice. We are required by law to maintain the privacy of your protected health information, and to

provide you with a Notice as to our legal duties, and our privacy practices, with respect to the information we collect and

maintain about you. We are required to abide by the terms of this Notice, to notify you in writing if we are unable to agree to a

requested restriction on the use of your protected health information, and to accommodate reasonable requests made by you to

communicate protected health information b alternative means or to alternative locations. We reserve the right to change our

privacy practices at any time, and to make the new provisions effective for all protected health information that we maintain.

Requesting Assistance, Asking Questions, or Filing Complaints

If you have questions, would like additional information about our privacy practices, experience a problem, or believe your

privacy rights have been violated, you may contact our Director, Nessa Wilson, MSW LCSW at 724-654-9555 or you may

contact the Secretary of Health and Human Services, U.S. Department of Health and Human Services or the United States Office

of Civil Rights. There will never be any type of retaliation for making an inquiry or filing a complaint, and you will never be

asked to waive your right to make a complaint or report a problem as a condition of receiving services from us.

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