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Payment Information
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I hereby authorize Christian Counseling Professionals, LLC to use the above credit card information to cover
any copays, coinsurance or self-pay amounts or amounts not
covered by my insurance for payment.
Please type your full name to indicate your electronic
signature:
Type Full Name:
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INSURANCE INFORMATION
Have you contacted your insurance company about this
appointment?
Primary Insurance Co.
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Is this an Employee Assistance Program Visit (EAP) ?
Auth #:
# of visits:
If you will be using your commercial insurance once your
EAP visits have been exhausted, please fill out insurance information above.
How did you hear about us?
Reason for seeking care?
Medical History
Do you have any drug allergies:
What medicines are you allergic to?
What type of reaction do you have?
What medications, including dosages, are you currently
taking?
Past hospitalizations?
Are you sexually active?
Are you pregnant or trying to get pregnant?
Do you currently smoke?
How much do you smoke?
Have you quit smoking?
When did you stop smoking?
ACKNOWLEDGEMENT OF RECEIPT
OF PRIVACY NOTICE
I have been presented with a
copy of Christian Counseling Professionals's Notice of Privacy
Policies, detailing how my
information may be used and
disclosed as permitted by federal and state law. I understand the contents of
the Notice, and I request
the following restriction(s)
concerning the use of my personal medical information:
Restrictions:
Please type your full name here to acknowledge receipt of
Privacy notice:
CONSENT TO TREATMENT
I hereby consent to treatment by the staff of Christian
Counseling Professionals (CCP). I understand that CCP uses an
interdisciplinary approach to treatment and that the staffing about my case my
include physicians, nurse practitioners, therapists, psychologists, and social
workers who may confer and consult regarding the best method of treatment. I
understand that my treatment will by confidential except in cases of suspected
harm to others, suspected physical or sexual abuse of minors or elders, or
ordered by a court of law, or for insurance purposes I understand my clinician
is required by law to report the above abuses.
I will have the opportunity to discuss with my clinician
the nature of my problem, results of the initial evaluation, the treatment
plan, alternative treatment, and reasonable foreseeable risks of my treatment.
I understand that Christian Counseling Professionals's staff are licensed professionals that practice from a Christian
belief system.
I understand that my care is payable at the time of service
and that I am responsible for the bill unless otherwise specified. I will be
provided documentation to file my insurance. A fee is due for any scheduled
appointment unless the appointment is canceled twenty-four (24) hours in
advance.
Please check here to accept the terms of the CCP Consent to Treatment
Please type your full name here to indicate your electronic
signature:
For: (Child's name):
Credit Card Requirement for New Patient Psychiatrist
Appointments
Due to the prohibitive costs of new patient missed
appointments, we require a credit card on file to schedule a new patient
appointment with our psychiatrists, Dr. Baca and Dr. Sievert.
There is a tremendous shortage of psychiatrists in the
Albuquerque area and when people do not show for scheduled appointments it
negatively impacts a number of patients in need who could have used that
appointment time.
If a new patient fails to attend their scheduled
appointment, the credit card will be charged $100.00 + tax. This amount is not
covered by insurance. If the appointment is kept as scheduled or canceled with
at least 24 hours notice, no charge will be made to your card.
You will be responsible for any applicable co-pays,
co-insurance, deductibles, or self-pay amounts. Our regular no-show fee of
$50.00 will remain in effect for all other appointment types.
Please check here to accept the terms of the CCP Credit Card Requirement for
New Patient Psychiatrist Appointments.
CCP Policies and
Procedures
The following information is important and should be read
carefully. Your understanding of our services and policies will help us reach
your goals more effectively and prevent the use of your valuable session time
for business matters.
CONFIDENTIALITY
Your records are confidential and will not be released or
disclosed except by a HIPAA compliant release form which you have signed, or
by court order from a judge.
APPOINTMENT TIMES
Appointments are scheduled on the hour for therapists and
in 15, 30, 45 and 60 minute increments for physicians and nurse practitioners.
Appointments with the therapists are schedule for 45-50 minutes with the
remaining minutes of the hour reserved for writing case notes and to complete
necessary paperwork.
PUNCTUALITY
Punctuality is important to get the full use of your
session time. While sometimes the therapists and doctors may experience
emergencies or delays which may result in them running late, we recognize that
your time is valuable and will make every effort to avoid unnecessary delays.
MISSED APPOINTMENTS
As a courtesy to our staff and other patients, we require
at least 24 hours advance notification when you need to cancel or reschedule
appointments. You will be charged $50.00 for each appointment missed without
24 hours notice, which must be paid prior to rescheduling. We have and
answering service available after hours and on weekends where you may leave a
message. If at all possible, Monday appointments should be canceled by 5:00 pm
on the previous Friday.
INITIAL MEDICAL APPOINTMENT NO-SHOWS
As a courtesy to our other patients and due to the extreme
shortage of availability with our medical providers, we require a credit card
to secure a new patient appointment. In the event that patients do not appear
for initial appointments, their credit card will be charged $100.00. If the
appointment is canceled with less than 24 hours notice, the credit card will
be charged $50.00.
INFORMED CONSENT
Under certain circumstances, it may become necessary for us
to contact you outside of appointment times. It is our policy to leave a
simple message stating the name of the provider and our return phone number.
GRIEVANCE PROCEDURES
At CCP, we strive to provide the highest standard of
mental health care and quality customer service. We welcome your comments and
concerns, and appreciate your input. Should you have any concerns that you
feel require our immediate attention, you may feel free to call 856-0300 or
(888) 711-1231 to speak with our administrator. Your concern will be addressed
with our management committee.
FEES
A fee schedule is available from the receptionist. Lengthy
telephone consultations are subject to the standard fee-per-hour. (Most
insurance plans do not provide coverage for phone consultations.) If clinic
staff are required to meet with school or government officials, employers, or
if any related reports are required, an appropriate charge will be made.
Payment is due at the time of service. For your convenience, we accept
MasterCard, Visa, American Express and Discover. We also accept personal
checks and cash.
DISABILITY PAPERWORK
As our practice has grown, we are experiencing an increased
amount of paperwork surrounding short and long term disability claims for our
patients. We charge $25.00 per page for disability paperwork, which must be
paid in full before the paperwork will be released. Any professional letters
or narrative reports will be charged at the full hourly rate of the provider.
BURNS DEPRESSION CHECKLIST
Read each statement and place the appropriate number next to it:
Over the last 2 weeks, how often have you been bothered by any of the following problems?
0 - Not at all
1 - Somewhat
2 - Moderately
3 - A lot
(Fill all fields then click Submit at bottom)
The Burns Anxiety Inventory
Please select which number applies to you in the box to the right of each category to indicate how much this type of feeling has bothered
you in the past several days. None = 0 Somewhat = 1 Moderate = 2 A lot = 3
|
Category I: Anxious Feelings |
| 1. Anxiety, nervousness, worry or fear |
|
| 2. Feeling that things around you are strange or unreal |
|
| 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 |
|
| 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 illness or heart attacks or dying |
|
| 14. Concerns about looking foolish or inadequate |
|
| 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 Symtoms |
| 18. Skipping, pounding, or racing heart |
|
| 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 about 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, smothering sensations/difficulty breathing |
|
| 31. Headaches or pain in the back of the neck |
|
| 32. Hot flashes or cold chills |
|
| 33. Feeling weak, tired , or easily exhausted |
|
|
Reference: Ten Days to Self-Esteem, David D. Burns |
TOTAL SCORE FOR ITEMS 1-33
|
|
The Mood Disorder Questionnaire- Please answer "yes" or "no"
Has there ever been a time when you were not your usual self and ...
| A.... you felt so good or so hyper that other people thought you were not your normal self or you were so
hyper that you got into trouble? |
|
| B...you were so irritable that you shouted at people or started fights or arguments? |
|
| C...you felt more self-confident than usual? |
|
| D...you got much less sleep than usual and found you didn't really miss it? |
|
| E...you were much more talkative or spoke much faster than usual? |
|
| F...thoughts raced through your head or you couldn't slow your mind down? |
|
| G...you were easily distracted by things around you that you had trouble concentrating or staying on track? |
|
| H...you had much more energy than usual? |
|
| I...you were much more active or did many more things than usual? |
|
| J...you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? |
|
| K...you were much more interested in sex than usual? |
|
| L...you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? |
|
| M...spending money that got you or your family into trouble? |
|
| N. If you selected "YES" to more than one of the above, have several of these ever happened during the same period of time? |
|
| O.How much of a problem did any of these cause you- like being unable to work, having family, money, or
legal troubles; getting into arguments or fights? Please select one response only: no problem, minor
problem, moderate problem, severe problem |
|
TOTAL OF "Yes" RESPONSES |
|