Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
INTAKE PACKET
Referral Date: _________ Referral Source: ________________ Referral Telephone #____________
Assessment Date: _________________ Admission Date: _________ Discharge Date: _______________
Last Name:
First Name:
Middle Int.:
Maiden
Social Security Number:
Date of Birth/Age:
Gender:
County of Residency:
Record Number:
Address:
City:
State:
Zip Code:
Telephone Number:
Cell Phone:
Marital Status:
Race/Ethnicity:
Occupation:
Insurance Id number:
Funding Source:
Verified:
Yes__ No__
Religious Affiliation:
Legal Guardian:
Home telephone #
Address:
Work telephone #
Emergency Contact:
Cellular telephone #
Address:
Home telephone #
Work telephone #
Cellular telephone #
Emergency Physician/Hospital
Address
Telephone:
FAMILY INFORMATION
Father’s name:
Address:
Home telephone #
Occupation/Work telephone #
Mother’s name:
Address:
Home telephone #
Occupation/Work telephone #
Step’s Father’s name:
Address:
Home telephone #
Occupation/Work telephone #
Step’s Mother’s name:
Address:
Home telephone #
Occupation/Work telephone #
© P & G Clinical Services / Copyright 2014
Cellular telephone #
Cellular telephone #
Cellular telephone #
Cellular telephone #
Intake Packet – Revised 05/2014
1
Client:
Insurance ID#:
Medical Record#:
SIBLINGS/CHILDREN
Name of brother(s)/sister(s):
Ages:
How Related? Full/Half/Step
Relationship? Good/Fair/Discord
Name of son(s) and/or daughter(s)
Ages:
How Related? Full/Half/Step
Relationship? Good/Fair/Discord
SIGNIFICANT OTHER
Significant Others:
Address:
Home telephone #
Work telephone #
Cellular telephone #
MEDICATIONS
MEDICATIONS (Past & Present)
DOSAGE
PURPOSE
ADMIN. INSTRUCTION
Allergies: ____________________________________________________________________________________________________
Currently Receiving Services ___________ Yes (Agency Name________________________________________________) / ____ No
Prior Treatment History: (MH/SA/DD, hospitalizations, other Relevant: _________History of hospitalizations at Behavioral Health
Current Family situation:
Living arrangements/Homelessness: (Check only one):
____ Private residence ____ Rooming House____ Homeless ____ Correctional facility ____ Institution
____ Residential facility, excluding nursing homes ____ Foster family or alternative family
____ Adult care home – 7 or more beds ____ Adult care home – 6 or less beds (family care home) ____ Other
Who currently resides in the home? ______________________________________________________________________________________
Marital history of the biological parents:
Married
Separated Deceased
Divorced
Never Married
Current Concerns:_________________________________________________________________________________________________________
Why are you seeking counseling?_________________________________________________________________________________
How long have these problems occurred?______________________________________________________________________________________
Problems perceived to be (Please circle):
© P & G Clinical Services / Copyright 2014
Very serious
Serious Not serious
Intake Packet – Revised 05/2014
2
Client:
Insurance ID#:
Medical Record#:
What happened that makes you seek help at this time?___________________________________________________________________________
What changes would you like to see in you?____________________________________________________________________________________
Have you ever seen a therapist/psychologist/counselor before? Please explain:____________________________________________________
Social History: _________________________________________________________________________________________________
Family History: (Relationships, interactions affecting client, etc.):_________________________________________________________
Appearance: ___________________________________________________________________________________________________
Behavioral Evaluation: __________________________________________________________________________________________
Employment Status: ____________________________________________________________________________________________
Economic/Financial Issues: _______________________________________________________________________________________
Functional Evaluation:__________________________________________________________________________________________
Developmental Evaluation: _____________________________________________________________________________________
Psychological Evaluation: ______________________________________________________________________________________
Legal History: Criminal Record
Yes
No
Pending charges
Yes
No
Probation
Yes
No
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Substance Abuse / Use History: (type of substances, onset, frequency/duration, family history)
n/a for this client.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Signs and/or Symptoms of Addiction (Check all that apply):
None
Tolerance
Loss of Control
Blackouts
Preoccupation
Withdrawal
Money Problems
Medical Advice
Morning Drinking
Drinking alone
Attempts to
stop
Use Despite Consequences
Excessive time Spent Using
Reduction in Activities due to Use
Other
Signs and/or Symptoms of Withdrawal PRESENT DURING Assessment (Check all that apply):
None
Muscle Cramps
Abdominal Cramps
Vomiting
Nausea
Chills
Pale Color
Itching
Runny Nose
Panic/Anxiety
Chest Pain
Disoriented
Alcohol Order
Other _____________________________________________
ASAM Level: ___________________ Comments: ___________________________________________________________________________
_____________________________________________________________________________________________________________________
Diagnosis: Axis I: ______________________________________________________________________
Axis II: _____________________________________________________________________
Axis III: _____________________________________________________________________
Axis IV: _____________________________________________________________________
Axis V: ______________________________________________________________________
COMMENTS: ____________________________________________________________________________________________________________
STEPS TAKEN: [
[
] Referred for Eligibility Screening
[
] Referred for Comprehensive Clinical Assessment - Date:_____________
] Referred to Another Provider: Name of Provider / Date: ___________________________________________________________________
Therapist’s signature: _______________________________________________________ / Date:________________________________________
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
3
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
FINANCIAL AGREEMENT
Client: ________________________________________________
Address: _______________________________________________
_______________________________________________________
County:________________________
SSN: _______________________________
Telephone #:________________________
DOB: ________________________
I have the following insurance (please attach a copy of the insurance card):
[ ]
Medicaid / Medicaid #:
[ ]
NC Health choice / Health choice # : ____________________________________
[ ]
Other / Number: ____________________________________________________
[ ]
No insurance / Self Pay
____I understand that I will be required to pay the co-pay or agreed upon fee for each session prior to the time it is held, unless we agree
otherwise.
____I am paying for counseling services out of pocket. I am responsible for the full amount of $ ___________ at each session with
cash, personal check, money order, cashiers check or credit card.
____I understand that for credit cards, debit cards and HSA cards, I will be charged the 2.7% service fee.
____I understand that the return check fee is $25 per deposit. I will be responsible for all overdraft fees assessed to P & G Clinical
Services as a result of a returned check. And my checks will not be accepted again.
____I authorize P & G Clinical Services to file the necessary documents and provide the appropriate information to my insurance
company.
____I agree to notify P & G Clinical Services within 24 hours of discovering a change with my insurance.
____I agree to notify P & G Clinical Services at least 24 hours in advance if I am unable to make a scheduled appointment. I am also
aware that I am responsible for any missed appointments and again I must give 24 hours notice of cancellation. Otherwise, I am
responsible for and will be charged $70.00 fee for a missed appointment at the first no show or late cancellation. After the second no
show or late cancellation, you are responsible for the entire fee of $110 and to continue scheduling, you will have to pre-pay the third
session at $110. When you schedule a time, you prevent P & G Clinical Services from scheduling another needed client. Please be
respectful of our time and services as we are of yours. I am aware that I can ask for clarification of any policy.
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
4
Client:
Insurance ID#:
Medical Record#:
____Failure to pay the charge timely will result in a 5% late fee per month. If I require additional time to pay the charge, I must make
those arrangements with the office as soon as possible.
____I understand that in the case of an emergency. I will call and discuss the emergency with the office as soon as possible.
____I understand that my therapist will have the right to waive the cancellation fee for this event as long as it is not a pattern.
____I understand that any outstanding Debt: Including any session not paid for at the time of your discharge. I agree to allow P & G
Clinical Services to charge any outstanding copayments, deductibles or coinsurance to bring my account balance to zero to the credit
card provided.
____I understand that if I do not agree to provide a credit card on file, I fully understand that after 60 days delinquency, my account will
be turned over to a collection agency and reported to all three major credit bureaus. I also understand that additional legal action may be
taken against me including civil court action to recoup any fees not paid in full as promised in this agreement, as well as attorney and
court costs.
Credit Card Type: _______________________________
Name as it appears on the credit card:___________________________________________________________
Credit card number: ____________________________________________________
Expiration Date: ___________________________________________
Billing Zip Code: _____________________
CVC: Credit Verification Code (3 digit code on back of your credit card): ____________________
I have read and fully understand the insurance policies of this practice as well as those of my own and my own insurance company. I
agree to be fully financially responsible for any therapeutic service provided to me. I have received a copy of this agreement.
This signature means I am agreeing to this FINANCIAL AGREEMENT, which includes cancellation, no show & outstanding debt
details as, described above and give my consent for my credit card to be charged in the event of violation of this policy.
My signature on this form is valid for any charge made in adherence to this policy. In the event I am not present to sign, this form gives
permission for my signature to be provided electronically. I will be notified via phone or email when I have been charged.
_________________________________________
Client and/or Legal Guardian Signature / Date
© P & G Clinical Services / Copyright 2014
___________________________________
Therapist’s Signature / Date
Intake Packet – Revised 05/2014
5
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Cancellation Policy
We look forward to working with you. Our appointment sessions are approximately forty-five (45-60) minutes long. It is
our strict policy to stay on time for all scheduled appointments. Therefore, if at all necessary, your wait time is kept to a
minimum. Due to the length of time provided for each appointment, it is critical that you arrive on time for your
appointments. If you are more than 15 minutes late, we will have no choice but to reschedule your appointment and you will
be responsible for the fees of a no show. In order to avoid paying no show fees, we require at least twenty-four (24) hours
notice for all cancellations, unless your appointment is on Monday, at which we cancellation needs to be before 3pm on the
prior THURSDAY.
Insurance companies will not pay for “No Shows or Late Cancellations,” therefore you will be responsible for the $70 fee
for a missed appointment at the first no show or late cancellation. After the second no show or late cancellation, you are
responsible for the entire fee of $110 and to continue scheduling, you will have to pre-pay the third session at $110.
After 3 cancellations or no shows, you will not be able to schedule another appointment and will be referred to another
provider. If you have arranged with your therapist to have standing appointments, then after the first no show, all
appointments will be removed from the schedule and will have to arrange appointments weekly.
I have read and understand the cancelation policy.
________________________________________________________
_____________________________
Client and/or Legal Guardian Signature
Date
_________________________________________________________
_____________________________
Witness Signature
Date
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
6
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Person Served Choice of Providers
P & G Clinical Services has not been pressured me to choose this provider and I am aware that I can change at
any time for any reason.
I agree to accept the following checked services from P & G Clinical Services:
Check all that apply:
____Diagnostic Assessment
___ Outpatient Therapy
____Family
____Parenting
____Couples/Marital
I understand that P & G Clinical Services has not influenced my decision in any way.
________________________________________________________
_____________________________
Client and/or Legal Guardian Signature
Date
_________________________________________________________
_____________________________
Witness Signature
Date
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
7
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Consent Form
ACKNOWLEDGEMENT STATEMENTS
____I have received the Client Confidentiality handout, which has been explained to me, and I understand the contents to be released, the need for
information and that there are statutes and regulations protecting the confidentiality of information.
____I further acknowledge that I have received the HIPPA Notice of Privacy statement and understand information contained in the document and this
agency’s methods for protecting the privacy of my health information that is used in providing health care services to me.
____I have received the Person Served Handbook which explains to me and I understand the contents contained in the document.
____I have received the Client Rights Handout which explains my rights as a Person Served and I understand the contents.
____I have received the Client grievance Policy, which explains my right to file a grievance, and I understand the contents.
ELECTRONIC COMMUNICATION
I have been informed of the potential risks to my confidentiality and HIPPA rights in using email or any type of electronic communication with P & G
Clinical Services. I ___ consent/ ___ do not consent to using electronic communication.
REQUIRED REPORTING
____P & G Clinical Services, is required by state and federal regulations to report non-identifying client information for the purpose of evaluation and
funding purposes. It will also be necessary for P & G Clinical Services, to use and disclose certain information about myself in order to carry out
treatment, payment and health care operations.
REPORTING OF SUSPECTED ABUSE/NEGLECT
____P & G Clinical Services, LLC, professionals are required by state laws to report suspected abuse or neglect to the appropriate authorities. If you
have any questions about this, please feel free to ask for a better understanding before you sign this document. Your signature below acknowledges
receipt of this information.
EMERGENCY TREATMENT / EMERGENCY INFORMATION / EMERGENCY RESTRICTIVE INTERVENTION
In case of sudden illness/accident/emergency, I hereby give permission to P & G Clinical Services, to seek emergency treatment on behalf of the below
named client should the need arise. It is understood that this treatment will be provided by a qualified medical professional, physician, and/or hospital
emergency room personnel. In addition, a copy of current medications and known medical conditions and allergies may be released. Efforts will be
made to contact the identified emergency contact person prior to treatment, should this be possible. I also will hold harmless P & G Clinical Services,
LLC, against any liability caused by their taking of any emergency procedures and/or contacts.
____I agree to the emergency procedures as outlined above.
____I will assume the full responsibility of all incurred emergency treatment expenses.
____Emergency restrictive interventions will only be utilized when a Person Served presents an imminent danger to him/herself or others or when
substantial property damage is occurring. Whenever possible, less restrictive interventions will be used prior to the use of restrictive intervention.
CONSENT FOR SERVICES I agree to participate in the treatment, services and support that are provided by P & G Clinical Services, LLC, as
outlined in the client’s service plan. I have been informed of the services in terms that I can understand. I have also been informed of the alleged
benefits, potential risks and possible alternative methods of treatment. I understand that I am free to discontinue services at any time.
I agree to accept the following checked services from P & G Clinical Services:
____
Diagnostic Assessment
___ Outpatient Therapy
___Family
____Parenting
___Couples/Marital
The above consents have been read by me or to me and explained to me by an employee of P & G Clinical Services, LLC in simple non-technical
language, that all questions have been answered to my satisfaction and that I understand my rights.
___________________________________________________
Client and/or Legal Guardian Signature
_____________________________
Date
______________________________________________________________
Witness Signature
___________________________________
Date
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
8
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
5500 Executive Center Drive
Suite 228
Charlotte, NC 28212
Date:
Client:
DOB:
Dear:
You have been identified as the primary care physician for the client mentioned above. I am writing to inform
you that the above client is receiving Outpatient Therapy from P & G Clinical Services. It is essential that we
coordinate treatment to better serve _______________. It is our hope that you and/or your clinic will provide
clinical documentation regarding client’s medical records.
A copy of consent for us to exchange health care information is enclosed with this correspondence. If you have
any questions, please do not hesitate to contact me at your earliest convenience.
Thanking you in advance and sincerely yours,
Loredana Pampinella, M.Ed, LPC
P & G Clinical Services
5500 Executive Center Drive
Suite 228
Charlotte, NC 28212
(704) 408-8489
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
9
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Physician Collaboration
Date of Contact / Disclosure:
Current Consent Date:
Method of contact: [
] telephone
[ ] facsimile
[
] face-to-face
Current Psychotropic Medication:
___________________________________________________________________________________________
___________________________________________________________________________________________
Current Health & Wellness Medications (Over-the-counter & Prescribed by Primary Care Physician:
___________________________________________________________________________________________
___________________________________________________________________________________________
Name of Primary Care Physician:_______________________________________________________
Address:_____________________________________________________________________________
Telephone Number:_________________________ / Fax:________________________________
Illness (es) Being Treated:______________________________________________________________
_____________________________________________________________________________________
Outline issues discussed below, or list documents disclosed.



Follow-up Items:
_____________________________________________________________________________________
_____________________________________________________________________________________
____________________________________
Therapist’s Name / Printed
© P & G Clinical Services / Copyright 2014
____________________________________
Therapist’s Signature / Date
Intake Packet – Revised 05/2014
10
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Authorization for Use and Disclosure of Protected Health Information
I, ______________________________, authorize ________________________________________________
Person Served or Person Served legal representative
Agency or person authorized to use/disclose the information
_____________________________________________________________________________________________________________________
to use or disclose to: P & G Clinical Services, 5500 Executive Center Drive, Suite 228, Charlotte, N.C 28212
Agency or Person to whom the requested use or disclosure will be made
_____________________________________________________________________________________________________________________
the following protected information: _________________________________________________________________
Provide specific meaningful description of the information to be used/disclosed
______________________________________________________________________________________________
______________________________________________________________________________________________
The purpose of this disclosure is Continuity of
care__________________________________________
Describe purpose of the requested use or disclosure
______________________________________________________________________________________________
I understand information regarding my treatment may include information pertaining to psychiatric or psychological treatment, drug
abuse and/or alcohol abuse, or Acquired Immunodeficiency Syndrome (AIDS or Human Immunodeficiency Virus (HIV).
REDISCLOSURE: Once information is disclosed pursuant to this signed authorization, I understand that the Federal Health Privacy Law (45CFR
Part 164) protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit re-disclosure. When this agency disclosed mental health and developmental disabilities
information protected by state law (NCGS 122C) or substance abuse treatment information protected by federal law (42CFR Part 2), we must
inform the recipient of the information that re-disclosure is prohibited except as permitted or required by these two laws. Our Notice of Privacy
Practices describes the circumstances where disclosure is permitted or required by these laws.
REVOCATION AND EXPIRATION: I understand that, with certain exceptions, I have the right to revoke this authorization at any time. If I
revoke this authorization, I must do so in writing. The procedure for how I may revoke this authorization, as well as the exceptions to my right to
revoke, are explained in P & G Clinical Services’ Notice of Privacy Practices, a copy of which has been provided to me.
If not revoked earlier, this authorization expires upon: ____________________________________
(Not to exceed one year from date of signature)
NOTICE OF VOLUNTARY AUTHORIZATION: I understand that I may refuse to sign this authorization form. If I choose
not to sign this form, I understand that P & G Clinical Services cannot deny or refuse to provide treatment, payment, enrollment in a
health plan, or eligibility for benefits on my refusal to sign unless the provision of health care is solely for the purpose of creating
protected health information for disclosure to a third party on provision of an authorization for the disclosure of the protected health
information to such third party.
_________________________________________________
Signature of Person Served
_______________________________________
Date
_______________________________________________________________
Please Print Name
_______________________________________________________________
Signature of Legal person responsible / personal representative if required.
_________________________________________________
Date
Please explain representative’s authority to act on behalf of Person Served: ______________________________________________________________
___________________________________________________
_________________________________________
Witness Signature
Date
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
11
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Authorization for Use and Disclosure of Protected Health Information
I, ______________________________, authorize ________________________________________________
Person Served or Person Served legal representative
Agency or person authorized to use/disclose the information
_____________________________________________________________________________________________________________________
to use or disclose to: P & G Clinical Services, 5500 Executive Center Drive, Suite 228, Charlotte, N.C 28212
Agency or Person to whom the requested use or disclosure will be made
_____________________________________________________________________________________________________________________
the following protected information: _________________________________________________________________
Provide specific meaningful description of the information to be used/disclosed
______________________________________________________________________________________________
______________________________________________________________________________________________
The purpose of this disclosure is Continuity of
care__________________________________________
Describe purpose of the requested use or disclosure
______________________________________________________________________________________________
I understand information regarding my treatment may include information pertaining to psychiatric or psychological treatment, drug
abuse and/or alcohol abuse, or Acquired Immunodeficiency Syndrome (AIDS or Human Immunodeficiency Virus (HIV).
REDISCLOSURE: Once information is disclosed pursuant to this signed authorization, I understand that the Federal Health Privacy Law (45CFR
Part 164) protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit re-disclosure. When this agency disclosed mental health and developmental disabilities
information protected by state law (NCGS 122C) or substance abuse treatment information protected by federal law (42CFR Part 2), we must
inform the recipient of the information that re-disclosure is prohibited except as permitted or required by these two laws. Our Notice of Privacy
Practices describes the circumstances where disclosure is permitted or required by these laws.
REVOCATION AND EXPIRATION: I understand that, with certain exceptions, I have the right to revoke this authorization at any time. If I
revoke this authorization, I must do so in writing. The procedure for how I may revoke this authorization, as well as the exceptions to my right to
revoke, are explained in P & G Clinical Services’ Notice of Privacy Practices, a copy of which has been provided to me.
If not revoked earlier, this authorization expires upon: ____________________________________
(Not to exceed one year from date of signature)
NOTICE OF VOLUNTARY AUTHORIZATION: I understand that I may refuse to sign this authorization form. If I choose
not to sign this form, I understand that P & G Clinical Services cannot deny or refuse to provide treatment, payment, enrollment in a
health plan, or eligibility for benefits on my refusal to sign unless the provision of health care is solely for the purpose of creating
protected health information for disclosure to a third party on provision of an authorization for the disclosure of the protected health
information to such third party.
_________________________________________________
Signature of Person Served
_______________________________________
Date
_______________________________________________________________
Please Print Name
_______________________________________________________________
Signature of Legal person responsible / personal representative if required.
_________________________________________________
Date
Please explain representative’s authority to act on behalf of Person Served: ______________________________________________________________
___________________________________________________
_________________________________________
Witness Signature
Date
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
12
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Authorization for Use and Disclosure of Protected Health Information
I, ______________________________, authorize ________________________________________________
Person Served or Person Served legal representative
Agency or person authorized to use/disclose the information
_____________________________________________________________________________________________________________________
to use or disclose to: P & G Clinical Services, 5500 Executive Center Drive, Suite 228, Charlotte, N.C 28212
Agency or Person to whom the requested use or disclosure will be made
_____________________________________________________________________________________________________________________
the following protected information: _________________________________________________________________
Provide specific meaningful description of the information to be used/disclosed
______________________________________________________________________________________________
______________________________________________________________________________________________
The purpose of this disclosure is Continuity of
care__________________________________________
Describe purpose of the requested use or disclosure
______________________________________________________________________________________________
I understand information regarding my treatment may include information pertaining to psychiatric or psychological treatment, drug
abuse and/or alcohol abuse, or Acquired Immunodeficiency Syndrome (AIDS or Human Immunodeficiency Virus (HIV).
REDISCLOSURE: Once information is disclosed pursuant to this signed authorization, I understand that the Federal Health Privacy Law (45CFR
Part 164) protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from redisclosing it. Other laws, however, may prohibit re-disclosure. When this agency disclosed mental health and developmental disabilities
information protected by state law (NCGS 122C) or substance abuse treatment information protected by federal law (42CFR Part 2), we must
inform the recipient of the information that re-disclosure is prohibited except as permitted or required by these two laws. Our Notice of Privacy
Practices describes the circumstances where disclosure is permitted or required by these laws.
REVOCATION AND EXPIRATION: I understand that, with certain exceptions, I have the right to revoke this authorization at any time. If I
revoke this authorization, I must do so in writing. The procedure for how I may revoke this authorization, as well as the exceptions to my right to
revoke, are explained in P & G Clinical Services’ Notice of Privacy Practices, a copy of which has been provided to me.
If not revoked earlier, this authorization expires upon: ____________________________________
(Not to exceed one year from date of signature)
NOTICE OF VOLUNTARY AUTHORIZATION: I understand that I may refuse to sign this authorization form. If I choose
not to sign this form, I understand that P & G Clinical Services cannot deny or refuse to provide treatment, payment, enrollment in a
health plan, or eligibility for benefits on my refusal to sign unless the provision of health care is solely for the purpose of creating
protected health information for disclosure to a third party on provision of an authorization for the disclosure of the protected health
information to such third party.
_________________________________________________
Signature of Person Served
_______________________________________
Date
_______________________________________________________________
Please Print Name
_______________________________________________________________
Signature of Legal person responsible / personal representative if required.
_________________________________________________
Date
Please explain representative’s authority to act on behalf of Person Served: ______________________________________________________________
___________________________________________________
_________________________________________
Witness Signature
Date
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
13
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Person Served Handbook Acknowledgement Receipt
Client and/or Legal Guardian: ________________________________
This signature page states that I have received and read the information in the P & G Clinical Services Person Served
Handbook.
A person served handbook has been given and explained to me. I have been given the opportunity to ask questions about
any information I did not understand.
By signing this page, I am stating that I fully understand the information explained in the handbook. I understand that it is
my responsibility to follow all the rules and regulations set forth in the handbook as long as I am a client of P & G Clinical
Services.
ANNUAL UPDATE REQUIRED
Signature (Client and/or Legal Guardian)
Date
Witness (P & G Clinical Services Representative)
Date
Signature (Client and/or Legal Guardian)
Date
Witness (P & G Clinical Services Representative)
Date
Signature (Client and/or Legal Guardian)
Date
Witness (P & G Clinical Services Representative)
Date
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
14
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Transition Planning
Anticipated Discharge Date: ______________________
Client’s Name: ________________________________Admission Date:__________
Legal Guardian’s Name/Telephone Number: __________________________________
Case Manager’s Name / Telephone Number:____________________________________
Services Received:________________________________________________________
ANTICIPATED BARRIERS TO DISCHARGE
BARRIERS
IDENTIFIED
PLAN TO REMEDIATE
BARRIER
TIME
FRAME
PERSON
RESPONSIBLE
STATUS
1.
2.
3.
4.
5.
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
15
Client:
Insurance ID#:
Medical Record#:
Participants involved in the development of plan: (Include name and relation to client)
_____________________________
__________________________________
_____________________________
__________________________________
_____________________________
__________________________________
Current Medications:
Medication Name
1.
2.
3.
4.
5.
6.
Dosage
Frequency
Additional referrals recommended:
Contact Name:
Phone Number:
Location: ________________________________________________________________________
Days and Hours of Operation:
Expected Discharge Date: _______________ / Actual Discharge Date:____________________
Planned Discharge Level of Care:____________________________________________________
Actual Discharge Level of Care:______________________________________________________
Planned Discharge Residence: _______________________________________________________
Actual Discharge Residence: ________________________________________________________
Client and/or Legal Guardian information for follow up in the event of transition or discharge
from program:
Name: _________________________________________
Phone: ______________________
Relationship: ___________ Address:_______________________________________________
I confirm and agree with my involvement in the development of this Transition/Discharge Plan.
Client and/or Legal Guardian Signature:________________________ Date: _______________
Participants Signature: _________________________
Date: ______________________
Therapist’s Signature:_______________________________
Date:_______________________
P & G Clinical Services
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
16
Client:
Insurance ID#:
Medical Record#:
Anticipated Aftercare Resources Needed
RESOURCES
IDENTIFIED
POSSIBLE AGENCIES TO
PROVIDE RESOURCES
TIME
FRAME
PERSON
RESPONSIBLE
STATUS
1.
2.
3.
4.
5.
6.
Client and/or Legal Guardian Signature:____________________________________ Date: _______________
Participants Signature: __________________________________________________ Date:________________
Therapist’s Signature:________________________________________________ Date:________________
Therapist’s Name / Credentials
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
17
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Discharge Summary
Actual Date of Discharge:________________________________________________
Discharging Service: ____________________________________________________
Type of Discharge: [ ] Planned, [
] Behavioral,
[ ] other ___________________
Reason For Discharge:____________________________________________________
Residence Upon Discharge:________________________________________________
_______________________________________________________________________
Telephone Number:_______________________________________________________
Treatment Summary
Goals Outlined In Treatment Plan
Progress Towards Goal / Gains Achieved
1.
2.
3.
4.
Medications Upon Discharge / Dosage
Effectiveness
1.
2.
3.
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
18
Client:
Insurance ID#:
Medical Record#:
P & G Clinical Services
Discharge Summary cont.
PERSON CENTERED FOCUS
Strengths:____________________________________________________________________
Needs:_______________________________________________________________________
Abilities:_____________________________________________________________________
Preferences:__________________________________________________________________
FINAL DIAGNOSIS
Axis I:_______________________________________________________________________
Axis II: ______________________________________________________________________
Axis III:______________________________________________________________________
Axis IV:______________________________________________________________________
Axis V: GAF on Admission: _________________ Current:____________________________
LOCUS or CALOCUS Score on Admission: ______________ [ ] LOCUS
[ ] CALOCUS
LOCUS or CALOCUS Score on Discharge: ______________ [ ] LOCUS
[ ] CALOCUS
Appointments Scheduled / Recommendations:________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Client’s Signature / Date:_____________________________________________________
Legal Guardian’s Signature / Date:__________________________________________
Therapist’s Signature / Date:____________________________________________________
(A copy of the Transition Plan and Discharge Summary Shall Be provided to client and/or Legal Guardian)
© P & G Clinical Services / Copyright 2014
Intake Packet – Revised 05/2014
19