English Registration Form - Alssaro Counseling Services, PLLC.

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PATIENT INFORMATION

Patient’s Last Name *

First Name *

Middle

Marital Status

Is this your legal name?

(Former Name)

Birth Date *

Age

Sex

Male
Female

Street Address *

Apt#

City *

State *

ZIP CODE *

Social Security

Home Phone No.

Cell Phone No.

P.O. Box

City

State

ZIP CODE

Occupation

Employer

Referred by:

Yes, please sign me up to receive e-mail and text messaging Confirmations. Until I tell you to stop, I authorized Alssaro Counseling Services to transmit patient information relating to my treatment by email or text.

Cell *

Email *

PLEASE LIST ANY HEALTH PROBLEMS AND CURRENT MEDICATIONS YOU ARE TAKING:

PARENT/ GUARDIAN INFORMATION

Parent/Guardian Name : *

Relationship to Patient *

Marital Status of Parents/Legal Guardians: *

If divorced: Joint Custody – Mother Sole Custody- Father Sole Custody Please provide legal custody documentation

INSURANCE INFORMATION

Please send a photo of both sides of your insurance card to billing@test.alssaro.com

Or Upload front side photo

Click or drag a file to this area to upload.

Allowed file formats: .jpg or .png

Upload back side photo

Click or drag a file to this area to upload.

Allowed file formats: .jpg or .png

Insured’s Name

Insured’s S.S. #

Birth Date

Patient’s Relationship to Insured

IN CASE OF EMERGENCY

Name of Local Friend or Relative *

(not living at same address)

Relationship to Patient *

Home or Cell Phone No. *

Alternative Phone No.

PLEASE READ THE FOLLOWING CAREFULLY

*What to Expect in Your Initial Session

During the first meeting, your therapist will ask you to complete some paperwork about your history. In order to determine the best way to help you, he or she will also ask you questions about your history and why you’re seeking treatment. The intake process is vital to the formation of any counseling relationship. Keep in mind that the initial appointment consists of both the written information and the verbal exchange.

1. NOTICE OF PATIENT RIGHTS-NOTICE OF PRIVACY PRACTICES Alssaro Counseling Services, PLLC shall collect acknowledgment of the provision of its Patient Rights -Notice of Privacy Practices to all patients. I acknowledge that I have been provided a copy of this Patient Rights -Notice of Privacy Practice.

2. I have read, understand, agree to and will abide by the Financial Policy. I understand that I am fully responsible and liable for the entire amount of any/all charges for the services rendered which have not been paid by any other source. I also agree that the failure of third-party payer make payments, for whatever reason, will in no way prevent Alssaro Counseling Services, PLLC from enforcing this agreement. I hereby authorize the release of necessary information for insurance reimbursement purposes as well.

3. I understand that I will be responsible for a missed appointment, cancellation session fee of $50.00 per appointment made if I decide to cancel, change or no show for my appointment without giving at least 24-hour.

I acknowledge that I have read, understand, and agree to the policies and procedures of Alssaro Counseling Services.

Initial *

4. Consent to treat a minor. I hereby give Alssaro Counseling Services, PLLC permission for the duration of therapy to examine and treat my son / daughter.

Initial *

5. Telemental Health:I hereby consent to engaging in telemental health video and/or phone sessions with Alsssaro Counseling Services . I understand that “telemental health” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of mental health data, and education using interactive audio, video, or data communications. I understand that telemental health also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located in New York or outside of New York. I understand that there are risks and consequences from telemental health, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical or mental health information could be disrupted or distorted by technical failures; the transmission of my medical or mental health information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons; and/or limited ability to respond to emergencies.

Initial:

YES *

NO *

6. PATIENT AUTHORIZATION: Behavioral Health/Medical Provider (PCP) Communication Consent.

Patient’s Medical Provider (PCP) Name

I, the undersigned, understand I may revoke this consent at any time except to the extent that the action has been taken in reliance upon it and that in any event, this consent shall expire 12 months from the date of signature unless another date is specified. I have read and understand the above information and give my authorization. To release any applicable medical information to my behavioral and/or medical health provider.

Initial: