Intake FormThe Atlanta Network for Individual and Family Therapy

Please print or write legibly

Date Docter _

Patient Name _If the patient is a minor there will be an additional intake sheet to fill out to include parent intormatlon.,

Age Date of Birth M, ale Female Marital Status _

Address _Street

City State Zip

Home Phone Work Phcne _

Cell Phone email

Employer Occupation _

Name of Spouse Age DOB _

Spouse Employer Occupation _

Spouse Work Phone Cell Phone _

Ch'ld 'N s DOB A Ch'ld 'N s DOB AI ren s ames ex \ge I ren s ames ex ~ge

.

Next of Kin Not living with you Phone _

Referred By Phone _

If referred by a doctor may we contact that doctor? Yes __ No__ .

Signature of Patient Date _

(2)

BRlEFL Y. WHAT DIFFICULTIES OR PROBLEMS BRING YOU HERE AT TIllS TIME?

When did these problems begin? _

Are drugs and alcohol involved? Which ones? --'- _

_ If you have received counseling in the past, when, with whom and nature of concern.:

Any current medical problems? (explain), _

Name, address and phone number of physician _

Which medications are you currently taking? _

Have you ever been hospitalized for emotional reasons? (explain)

Doyoupre~tlyf~l~cidru? _

Commen~: ~~-·~ _

Information Necessary for Insurance Verification

Please print or write legibly

Patient Name ~ Oate _

Name of Insured _

DOB of Insured SSN ---------

Relationship to client _

Name of Insurance Carrier _

Address of carrier -:- _

Phone number of Carrier _

Policy Number Group Number _

Deductable Co Pay_

-I authorize the release of any information to obtain assignment of health care benefits for service.

Signature of responsible party Date _

Print name here.\

I authorize payment of benefits to my Doctor for services rendered.

Signature of responsible party Date _

Print name here

Please note. Information that is not up to date, incomplete or inaccurate resulting in non payment by the insurance companywiff result in the responsible party being responsible for full payment for services. Please remember that you are responsiblefor payment for services. We will provide your insurance carrier with the information they request, however they will onlypay for what your plan allows. It is your responsibility to pay for what your insurance plan does not affow. I have read andagree to the proceeding statements.Signature Oate _

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Atlanta Network For Individual and Family Therapy

Psychologist-Patient AgreementSignature Pagefor

Doctor _

By signing below you are agreeing to the stipulations in the attached Psychologist-PatientServices Contract.

There is a pink copy for you to take and read at your leisure.

Name:-------------------------------------Please Print

Signature: Date: _

Atlanta Network For Individual and Family Therapy

Date: _ Doctor: _

Because of the new HIP AA regulations, you are required to sign a formindicating that you are familiar with the requirements and regulationsconcerning the disclosure of your private health information (PHI).

Please review and sign this form indicating you are familiar with and havebeen provided a copy of the attached document which is the Georgia NoticeForm describing how psychological and medical information about youmaybe used and disclosed and how you can get access to tills information.

Name: -----------------------------Print name here

Name: ~ Date: __ -- __Please sign here.

No,. _

ATLANTA NEiWORK.FOR lNDIV\DUALAND

FAMilY THERAPY

1864 INDEPENDENCESQUAREDUNWOODY GEORGIA 30338

TELEPHONE# 770-6680350

Pleasebe aware that we are not responsible to know if your insurance carrier haschanged. If it has and we are not made aware by you, you are responsible for allpayments not covered by your insurance.

Have you provided us your up to date insurance? Yes, _

No _

Do you need Authorization? Yes, _

Sign. ~----- Date--------------------

24 HOUR CANCELLATION POLICY

Atlanta Network For Individual and ~amlly Therapy1864 Independence Square Suite A

Dunwoody, Georgia 30338 .

If you need to ,change or cancel an appointment, please call the office orAnswering service at least 24 hour ahead of your scheduled appointed time.

Failure to do so will result in a Full Charge (not just the copayment).This charge cannot be billed to your insurance and therefore, will be your soleResponsibility. '

The reason for this Office Policy is that an Hour is set aside for you, out of theDoctor's schedule. If you cancel 24 hours prior to your appointment, it is morelikely that another client in need of services can be accommodated.

This policy may be reconsidered on a case by case basis at the discretion ofYour Doctor if an emergency or sickness occurs. .

Thank you for being considerate of all our clients.

I have read and understand the above.