TRI-S Counseling & Education, LLCsurrounding weight loss or issues that are totally unrelated to...

1 Bariatric TRI-S 2015

TRI-S Counseling & Education, LLC

Merrill Littleberry, LCSW, LCDC, CCM, CPT Lisa Badolato, RD, LD, CNSC

100 East 15th Street Suite 615 2100 North Highway 360 #1403 Fort Worth, Texas 76102 Grand Prairie, Texas 75050 Office: 817-920-9321 Office: 972-606-0812 Fax: 817-920-9336 Fax: 817-606-0813

Welcome to the Psychological, Behavioral,Nutritional and Fitnessportion of yourjourneytohealth &

weight loss through bariatric surgery. TRI-S Counseling & Education, LLC will complement your surgeon’s at

ASA with the transformationto a healthier you starting today.

Getting evaluated can be daunting and intimidating. Not everyone is at the same place when it comes

to understanding the dynamics of life after bariatric surgery. We are not searching for reasons that you should

not have surgery. If you are not quite ready, then it is our job to help you get ready! Bariatric surgery requires

a complex change not only to your body, but to your emotions and behaviors as well. We will explore, assess,

educate and help you apply realistic yet innovative strategies for your new lifelong lifestyle. In addition, to

your pre-surgical program we will be providing your ongoing education, support and assistance after

surgerywe will follow you post-surgeryat 4 weeks, 3 months, 6 months and 12 months post-surgery. We are

committed to your long term success. In addition, we provide therapeutic support groups and back on track

programs. We are available on a more frequent basis for those working through underlining issues

surrounding weight loss or issues that are totally unrelated to bariatric surgery. This is within any discipline

nutritional, emotional or fitness in which we can assist you in achieving your goals.

You should be ready tobe assessed, educated and start assignments to initiate your behavior

modification process. All subsequent individual visits will be based on the necessity.Your Psych-Evaluation is a

service typically covered by most major insurance providers. Payments are due at time of scheduling. The

services not reimbursable by insurance are the sessions pre and post-surgery with a dietitian, behavior

modification and fitness assessments. The pre-surgical requirements of your insurance along with the pre-

requisites of your surgeon will be completed with us to assure a smooth transition for surgery approval, not

only for your insurance but your surgeon as well.

Please make time to fill out everything in this packet prior to your first visit. Many things may appear

repetitious due to the combining of the packet for your convenience. Answer all questions even if they are a

repeat. Contact us as soon as possible to set up your appointments to avoid any delay in surgery. We look

forward to working with you on your new journey towards a healthier you.

Because of this partnership you are offered a significantly lower rate than market or if provided

individually. Payments are due in full at your first appointment.


$325 includes:

1. Initial consult with a dietitian one hour 1 on 1

Date: ___________

2. One hour behavior Modification Class

Date: ___________

3. One hour post-surgery Dietary Class

Date: ___________

4. Fitness Assessment

Date: ____________

5. Unlimited attendance to future classes

Your psych Evaluation is billed directly through your insurance. You are only responsible for co-pay, out-of

nextwork and deductible at time of service.

Date: _____________

Sessions Individually

1 Hour session with the dietitian $125.00

30 Minute sessions with the dietitian are $60.

1 hour Initial private pay Psychotherapy session $145

1 hour follow up private pay psychotherapy sessions are $100

Initial Fitness Assessments $75

Fitness Re-Assessment $50

A nonrefundable $25 confirmation fee will be due when scheduling your initial sessions with the dietitian and

with the psychotherapist. This will be applied toward your package after completing the originally scheduled sessions.


Lisa Badolato, RD, LDDietary Portion

Notice of Privacy Practices

Keeping our client’s personal health information secure is a top priority. While information is the cornerstone of

our ability to provide superior MNT services, our most important asset is our client’s trust. This notice tells you

how I collect, handle, and disclose personal health information about you. If you want to limit disclosing of this

information, please submit your wishes in writing.

Policies and Practices to Protect Your Personal Health Information

We protect personal health information we collect about you by maintaining physical, electronic, and procedural safeguards that meet or exceed applicable law.

Protected Health Information We Collect and May Disclose

The protected health information we collect about you comes from the following sources:

Information received from your physician or other healthcare provider.

Information we receive from you while providing MNT services and on enrollment forms, assessment surveys, or other forms.

Information we receive from other sources such as caregiver, insurer, employer and other third parties.

We may disclose any of your protected health information to the following entities as long as this information is directly related to health services or your individual care. These entities include doctors, hospitals, health care providers, pharmacies, insurance companies, family members or other persons involved directly in your individual care.

Protected health information will not be used for marketing, except if the communication is by me directly to you or to provide you with education or promotional material.

Your protected health information may be disclosed in the form of a “limited data set” for research, public health, and health care operations. A “limited data set” does not contain any direct identifiers of individuals (e.g. should not include name, address, phone number, social security number, medical number, etc.), but may contain any other demographic or health information needed for research public health or health care operations purposes. I understand and acknowledge receipt of the above Notice of Privacy Practices:

Signature Print name Date


New Patient Intake Form

Name: _______________________________________________________

Age: _____________ Date of Birth: ____________________________

Occupation: ___________________________________________________

Phone Number: ______________________Email: _____________________

Reason for consult: _____________________________________________

Referred by: ___________________________________________________

If referred for surgery:

Surgical Procedure: ____gastric bypass ____sleeve ____lap band _____Revision

Medical History:

Height: _____________ Weight: _____________

Weight 1 year ago: ______________ Desired Weight: ______________

Please indicate whether you have/had any of the following conditions:

Asthma Cancer Cardiovascular Disease Diabetes Drug Dependency Eating Disorder Food Allergies

Food Intolerances Kidney Disease Headaches Heart Attack

High Cholesterol Hypertension/High blood pressure Intestinal Problems

Menstrual Problems Mental Health Issues

Are you currently being treated for any medical conditions? __yes ___no

If yes, please specify: _________________________________________________________

Please list medications you are taking at this time: __________________________________

__________________________________________________________________________

Please list vitamin, mineral and food supplements that you are taking: __________________

__________________________________________________________________________

Have you ever been advised by a physician to follow a special diet? If yes, please

specify: ____________________________________________________________________


Are you following that diet now? ___yes ___ no

Do you drink alcohol? ___yes ___no Number of drinks per week: ________

Do you smoke cigarettes? ___yes ___no How long have you smoked? ____________

Diet History:

How many times have you tried to lose weight? __________________

Age of first attempt: _________________ Your weight at that time: ______

Diets attempted: Please circle all Weight Watchers Cabbage Soup Atkins South Beach HCG Grapefruit TOPS Low calorie Low Fat Diet pills

Other: ________________________________________________________

Do you experience periods of uncontrollable eating? ___________________

Binge eating? ___________ Nocturnal Eating? ________________________

Grazing? _______________Skipping meals? __________________________

Have you ever been diagnosed with an eating disorder? ___yes ___no

Please explain: ____________________________________________

Are you currently or have you ever received treatment? ___yes ___no

If yes, please explain: ____________________________________________

_____________________________________________________________

Exercise History:

Do you exercise? ___ yes ___ no

List type, frequently, duration and intensity of exercise activities: _________

_____________________________________________________________

Do you have any physical conditions that limityour ability to exercise? __yes ___ no

Eating Patterns:

How many days per week do you eat:

Breakfast: ______ Lunch: ________ Dinner: ______

Do you snack? ___yes ___no

When? ________________________________________________________


Do you drink carbonated beverages? __yes ___ no How many per day? _________________

Do you eat out? __ yes __ no How many meals do you eat out per week?________________

List restaurants/fast food that you usually choose: ____________________________________

Do you know how to cook? ___ yes ____no Who usually prepares the food? _____________

Who does the grocery shopping? _________________________

Do you read food labels? __yes ___no

What do you look at on the label? __________________________________

Do you eat standing up? ___ yes ___no

Do you eat in the car? ___ yes ___no

Do you eat while watching TV? ___yes ____no

Do eat while reading or while on the computer? ____yes ____no

Do you eat fast? ____yes ____no

Do you eat when bored? ____yes ____no

Do you eat when stressed? ____yes ____ no

Do you eat when lonely? ____yes ____no

Do you eat when not hungry? ____yes ____ no

Do you avoid certain foods? Please specify__________________________________________

What are your favorite foods? ____________________________________________________

Who will be your post-operative support person? _____________________________________________________________

Have you attended support groups? ____ yes ____ no

Do you plan to attend support groups? ____yes ____no



100 East 15th Street Suite 615 2100 North Highway 360 #1403

Fort Worth, Texas 76102 Grand Prairie, Texas 75050

Office: 817-920-9321 Office: 972-606-0812

Fax: 817-920-9336 Fax: 972-606-0813

IMPORTANT INFORMATION AND CLIENT CONSENT

Please read and sign all necessary pages.

THERAPUTIC RELATIONSHIP Your relationship with the therapist is a professional and therapeutic relationship. In order to preserve this

relationship, it is imperative that the therapist does not develop personal or business relationships which could

undermine the effectiveness of the therapeutic relationship. Gifts, bartering and trading services are not appropriate

and should not be shared between you and the therapist. Your therapist will not address you when outside of the office

doors unless you acknowledge the therapist first, this is done to protect your privacy.

SERVICES

By making your first appointment you have already made progress. Deciding to begin or to resume therapy

shows your courage and willingness to take risks in order to improve your life. We look forward to working with you and

hope that we can assist you in reaching your personal goals. EFFECTIVE PSYCHOTHERAPY is built from good working

relationships, rapport, and requires mutual understanding and commitment. THERAPY is the Greek word for change.

Often growth cannot occur until you experience and confront issues that induce feelings of sadness, anger, anxiety,

and/or pain. The success of working together depends on the quality of the joint efforts and the realization that

everyone is responsible for their lifestyle choices and changes that may take from therapy. You must practice and apply

the new strategies daily in order to gain long-term effectiveness.

APPOINTMENTS Appointments are scheduled as needed and will last approximately 50-55 minutes. Please arrive on time for

your scheduled appointment. If you arrive more than 10 minutes past your schedule time you will not be able to make

up that time in session. If you are more than 10 minutes late a cancelation fee is required before you can reschedule you

next appointment. Due to the nature of the services we render, it is sometimes necessary in a crisis situation for session

times to extend past 50 minutes. Therefore, it is possible your session start time will be slightly delayed. Your

understanding in these situations is greatly appreciated. If you need to reschedule or cancel an appointment, please call

the office at (817) 920-9321 or email us at [email protected] to let us know about your schedule change or

cancellation. It is important that changes be made 24 hours prior to your appointment.

PRIVATE PAY FEE SCHEDULE

Initial Evaluation-$145.00 Consultations-$40.00 Follow up session-$100.00

Weekend Sessions-$100.00 Phone intervention-$15.00 Return check fee $50.00

Written reports, evaluations, FMLA or Disability forms are Pro-rated at $50.00/hour.

Lower rate available for assignments to therapist under supervision.



100 East 15th Street Suite 615 2100 North Highway 360 #1403

Fort Worth, Texas 76102 Grand Prairie, Texas 75050

Office: 817-920-9321 Office: 972-606-0812

Fax: 817-920-9336 Fax: 972-606-0813

Release of Information/Release to Obtain Information

I hereby authorize TRI-S Counseling & Education, LLC to release and/or obtain information pertaining to the case of

_________________________________________________________________.

(Name of Client)

To/From: _____________________________________________________________________

PLEASE CHECK THE SECTIONS OF THE RECORDS NEEDED:

__ Discharge summary _X_ Psychological Evaluation _X_ Verbal Communication

__ Master Treatment Plan __ Therapy Notes

I understand any of the above requested/released information may include results of Human Immunodeficiency Virus

(HIV) or AIDS test, if one was performed.

Merrill L. Littleberry, LCSW, LCDC, CCM and associates are hereby released from legal responsibility of the

released/obtained records indicated and authorized herein. By signing this form I give the above entity to bill and

release information to my insurance provider.

I, the undersigned, understand that I may revoke this consent at any time expect to the extent that action has been

taken in reliance on it and that in any event this consent shall expire twelve (12) months from when it is signed unless

another date is specified below. Specification of the date, event or condition upon consent expires:

TO THE PARTY RECEIVING THIS INFORMATION: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from making further disclosure of it without the specific written consent of the person to whom it pertains, or as

otherwise permitted by such regulations A general authorization for the release of medical or other information is not sufficient for this purpose. FOR CLIENT

RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFR PART 2.

____________________________________ _____________________

Signature of the Client or Guardian Date

____________________________________ _____________________

Witness Date


Notice of Privacy Practices, Consent to Treat, Payment, Receipt & Acknowledgement of Notice

Client: ___________________________________________________________

Date of Birth: ______________________________________________________

Social Security #: __________________________________________________

I hereby acknowledge that I have received and have been provided the opportunity to read a copy of the TRI-S

Counseling & Education, LLC notice of privacy practices. I understand that if I have any questions regarding the notice or

my privacy rights, I can contact Merrill L. Littleberry, LCSW, LCDC, CCM. Required fees, co-pays, cancelations, and return

check fees are payable at the beginning of each session. We will honor contractual agreements made with managed

health care companies that stipulate specific reimbursement restrictions and claim filing requirements. If you are not

using a Managed Care/PPO/HMO plan and want to file your own claim, you will be expected to make the full payment.

In order to take full advantage of your session time, it is requested that payment be made prior to the session.

My signature is giving permission for the above name to bill my insurance companies for services rendered. I

understand that services not covered by my provider are my responsibility.

_____________________________________ ____________________

Signature of Client Date

__________________________________________________________________

Signature of Parent, Guardian or Personal Representative*

Client refuses to acknowledge receipt:

_____________________________________ ____________________

Signature of Staff Member Date

*If you are signing as a Personal Representative of an individual, please describe your legal authority to act for this

individual (Power of Attorney, Healthcare Surrogate, etc.) on the line above, beside your signature.


Emergencies: A mental health professional is on call and can be reached for crisis intervention on a 24- hour, 7 days per

week basis by calling 817-919-3814. In the case of life threatening immediate emergencies go to your nearest hospital

or call 911.

Therapist’s Incapacity or Death: I acknowledge that, in the event the undersigned therapist becomes incapacitated or

dies, it will become necessary for another therapist to take possession of my file and records. By signing this consent

form, I give my consent to allowing another licensed mental health professional selected by the undersigned therapist

to take possession of my file and records and provide me the copies upon request, or to deliver them to therapist of my

choice.

Limits of Confidentiality: Discussions between a therapist and client are confidential. No information will be released

without the client’s consent unless mandated by law. Possible expectations to confidentiality include, but are not but

not limited to the following situations: child abuse, abuse to the elderly or disabled, abuse to Clients in mental health

facilities, sexual exploitation, AIDS/HIV infections and possible transmission, criminal prosecutions, child custody cases

suits in which the mental health of a party is in issue; situations where the therapist has a duty to disclose, or when in

the therapist’s judgment, it is necessary to warn or disclose, fee disputes between the therapist and the client,

negligence brought by a client against a therapist or the filing of a complaint with the licensing and certifying board. If

you have any questions regarding confidentiality, you should bring them to attention of the therapist when you and the

therapist can discuss this matter further. By signing this consent form, you are giving consent to the undersigned

therapist to share confidential information with all persons mandated by law, with the agency that referred you, and the

insurance carrier responsible for providing you mental health care services and payments for those services. You are

also releasing and holding harmless the therapist from any departure from your right of confidentiality that might result.

I have read and understand the above limits to confidentiality. Furthermore, I grant the same permission and release to

the therapist who covers for my therapist when they are unavailable. I also grant permission for my therapist to share

my case in a case review, if they deem it necessary.

Emergency Contact & Duty to Warn: In the event that the undersigned therapist reasonably believes that I am or my

child is a danger physically or emotionally to myself or another person, I specifically consent for the therapist to contact

any person in a position to prevent harm to myself or any other person, including but not limited to the person in

danger, and to contact the following persons in addition to medical and law enforcement personnel:

Name ____________________________ Phone Number (___)________________ Relationship ____________

* Please note this is the name of the person you want us to contact

Consent to treatment: I voluntarily agree to receive a mental health assessment, care, treatment, or services as

considered necessary and advisable.

I understand and agree that I will participate in the planning of my care, treatment, or services that I receive through the

undersigned therapist at any time.By signing this client consent form, I, the undersigned client, acknowledge that I have

both read and understood all the terms and information contained herein. Ample opportunity has been offered me to

ask questions and seek clarification of anything unclear to me.

This signed copy will be kept in your file; if you want a copy for yourself, please ask and we will be happy to provide one.

____________________________________________ _____________________

Signature of adult Client or parent/guardian Date

___________________________________________ ______________________

Therapist Date


HIPAA 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 IT CAREFULLY.

This notice of privacy practices describes how we may use and disclose your protected health

information (PHI) to carry out treatment, payment or health care operations (TPO), and for other purposes that

are permitted or required by law. It also describes your rights to access and control your protected health

information. “Protected health information” is information about you, including demographic information that

may identify you and that relates to your past, present or future physical or mental health or condition and

related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Uses and Disclosures of Protected Health Information: Your protected health information may be used

and disclosed by your Therapist, our office staff, and others outside our office that are involved in your care

and treatment for the purpose of providing health care services to you, to pay your health care bills, to

support the operation of the Therapist’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health

care and any related services. This includes the coordination or management of your health with a third party. For

example, we would disclose your protected health information, as necessary, to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services.

For example, obtaining approval for a hospital stay may require that your relevant protected health information be

disclosed to the health plan to obtain approval for the hospital for the hospital admission.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the

business activities of your Therapist practice. These activities include, but are not limited to, quality assessment

activities, employee review activities, training students, licensing, and conducting or arranging other business activities.

For example we may disclose your protected health information to medical student that see Clients at our office. In

addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate

your therapist. We may also call you by name in the waiting room when your therapist is ready to see you. We may use

or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your

authorization. These situations include: as required by law, public health issues as required by law, communicate

disease, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law

enforcement,: coroners, funeral directors, and organ donation, research, criminal activity, military activity and national

security, workers’ compensation, inmates, and required uses and disclosures under the law. We must make disclosures

to you when required by the secretary of the Department of Health and Human Services to investigate or determine our

compliance with the requirements of section 164.500.

Other Permitted and Required Uses and DisclosuresWill Be Made Only With Your Consent Authorization or Opportunity

to Object unless required by law.

You may revoke this authorization, at any time, in writing, expect to the extent that your Therapist or the Therapist’s

practice has taken an action in reliance on the use or disclosure indicated in the authorization.


YOUR RIGHTS

The following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not

inspect or copy the following records: psychotherapy notes, and information for the purpose of treatment, payment, or

healthcare operations. You may also request that any part of your protected health information not be disclosed to

family members or friends who may be involved in your care or for notification purposes as describe in this notice of

privacy practices. Your request must state the specific restriction requested and to whom you want to restriction to

apply.

You have the right to request a restriction of your protected health information. You may ask us not to use or disclose

any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You

may also request that any part of your protected health information not be disclosed to family members or friends who

may be involved in your case or for notification purposes as described in this Notice of Privacy Practices. Your request

must state the specific restriction requested and to whom you want the restriction to apply.

Your Therapist is not required to agree to a restriction that you may request. If the Therapist believes it is in your

best interest to permit use and disclosure of your protected health information, your protected health information will

not be restricted. You then have the right to use another healthcare professional.

You have the right to request to receive confidential communication from us by alternative means or at an alternative

location, you have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to

accept this notice alternatively (i.e. electronically).

You may have the right to have your Therapist amend your protected health information. If we deny your request for

amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your

statement. You will be provided a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health

information.

We reserve the right to change the terms of the notice and will inform you by mail of any changes. You then

have the right to object or withdraw as provided in this notice.

Complaints

You may complain to us or to the secretary of the Department of Health and Human Services if you believe your privacy

rights have been violated by us. You may file a complaint with us by notifying our office in writing of your complaint. We

will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to

protected health information. If you have any objections to this form please ask to speak with our HIPAA compliance officer in person or by phone at

our main phone number.


PERSONAL INFORMATION

First Name ____________________________ M.I. ___ Last Name___________________________ Age____ Address ___________________________________ City, State, Zip_________________________________ Cell (____) ___________________ Home (____) ___________________ Work (____) ___________________ E-mail address ______________________________________ Primary contact # Cell WK HM May we leave a message for you at home? Yes No Work? Yes No Gender: Male Female Race: _______________________

SS# ___________________________ Birth Date______/_______/______

Primary Medical Doctor: ___________________________ Phone Number: __________________________

Other Treating Doctor: _____________________________ Phone Number: __________________________

INSURANCE INFORMATION

Are you are the primary insurance provider Yes No If yes, skip section II

Insurance Company Provider___________________________ Provider # (___) _______________________

Behavioral or Mental Health Provider _____________________ MH or BH # (___) _____________________

Employer’s Name ______________________________ Insured’s I.D. # _____________________

Section II Insurance Information Relationship to Insured Spouse Child Other

Insured’s I.D. # _____________________

Insured’s Name ___________________________ D.O.B___________ SS#___________________________

Insured’s address ____________________________________________________________________

(If different from Client)

Phone: Work (___)_______________ Cell (___)________________

Comments or Notes: _________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

_________________________________________________________________________________________________

We will need to copy your current insurance card and drivers license.


TREATMENT INFORMATION

Primary reason for your visit:_________________________________________________________________

Previous Treatment: Yes No Previous Therapist: _____________________________ Dates: from_____ to _____

Have you ever been hospitalized for mental health or a medically critical reason? Yes No

Hospital Name and Location Dates Reason

_______________________________ ___________ ____________________________

_______________________________ ___________ ____________________________

Have you use recreational drugs in the past? Yes No Do you currently use drugs? Yes No

Do you drink alcohol? Yes No Do you smoke cigarettes? No Yes # per day ____

Type of Drug How Much How OftenType of Liquor/Drink How Much How Often

__________________ __________ __________ __________________ __________ __________

__________________ __________ __________ __________________ __________ __________

Medications currently taking:

1) _______________ Dosage/Freq. __________Start Date __________ Purpose __________________



Prescribed by: _______________ Date of last medical evaluation _______ Date of next appt. _______

PERSONAL HISTORY

Marital: Married Divorced Widowed Partnered Single Cohabiting Separated

If married, how long have you been married? _____ Spouse’s Name: ____________________________

How many times have you been married? _____ Relationship satisfaction rating?:_________________

Please list your Children:

Name Age Natural/step Relationship Lives Where?

______________________________ ___ __________ __________ _______________

______________________________ ___ __________ __________ _______________

______________________________ ___ __________ __________ ________________

Others living in the home with you:

Name Age Relationship Grade/Occupation

________________________________ ___ __________ __________________________

________________________________ ___ __________ __________________________

Please list your Brothers and Sisters:

Name AgeNatural/Step Relationship Lives Where?

________________________ _____ __________ __________ __________________

________________________ _____ __________ __________ __________________


EDUCATION & EMPLOYMENT

Did you complete High School Yes No If Yes, When _______

College Name Dates Major of Study Graduate

________________________________ _________ ________________ ________

________________________________ _________ ________________ ________

Are you currently employed? Yes NoIf No, Why? __________________________________________

Are you seeking disability? Yes No

Name of most current employer Start DateDays/hours per week Salary___

_________________________________ _____________ _________________ _________

_________________________________ _____________ _________________ _________

Describe relationship with employer: ___________________________________________________________

Describe relationship with co-worker/peers: ______________________________________________________

FAMILY HISTORY

Your Biological Mother:Living Deceased Married Divorced Remarried: # of times ________

Describe relationship with mother while growing up: _______________________________________________

__________________________________________________________________________________________

Describe current relationship with mother: _______________________________________________________

__________________________________________________________________________________________

Your Biological Father: Living Deceased Married Divorced Remarried: # of times ________

Describe relationship with father while growing up: ________________________________________________

__________________________________________________________________________________________

Describe current relationship with father: ________________________________________________________

__________________________________________________________________________________________

Where do your parents currently live? Mother: _____________________ Father: ________________________

Do you have any close relatives (father, mother, sister, brother) who have experienced depression or other emotional

problems? Please list: _______________________________________________________________

Do you have any other health problems or important medical history about yourself or close family members, including

chronic ailments: ____________________________________________________________________

Who is your support system? __________________________________________________________________


Current Mental Status

Have you had any changes in sleeping habits? Yes NoDescribe: _________________________________________

Have you had any changes in eating habits? Yes NoDescribe: __________________________________________

Have you ever considered suicide in connection with your current problems? Yes No

Have you attempted suicide recently or in the past? Yes No

If so, please give a brief description with dates:

Description Date

_______________________________________________________ ___________

_______________________________________________________ ___________

Please check coping skills that you are currently using:exercise relaxation music reading hobby prayer

meditation organization/clubs/church volunteer other____________________________

Please describe any spiritual orientation or belief: (Christian, Catholic, None, etc.) ____________________

Physical Activity Level None Mild Moderate High Do you exercise regularly? Yes No

SELF-EVALUATIONS

Thoughts: (please check any of the following that apply to you)

__ I sometimes hear voices even though no one nearby is talking.

__ I sometimes feel that forces outside of me are controlling me.

__ I sometimes feel that other people control my thoughts.

__ I sometimes have the same thoughts over and over and cannot control it.

__ I sometimes feel someone is out to hurt me or do something against me.

__ I am sometimes unable to control my behavior. Please explain:_____________________________________

Please answer True or False for the following questions:

____ I rarely talk negatively about my body.

____ I do not weigh myself more than once a week.

____ If appearance did not matter in our society, I would still exercise the same amount that I do now.

____ I rarely compare my looks or body to others.

____ I can accept a compliment about my appearance.

____ I feel happy or content, for the most part, with my life at this time.

____ I wouldn’t panic if I gained a few pounds.

____ For the most part, I am satisfied with my current body shape and size.

____ If I had to do things that were unhealthy; (fasting, taking laxatives, or throwing up) in order to change my

weight, I would choose NOT to do them.


Adult Checklist of Concerns

Please mark all of the items below that apply. You may add a note or details in the space next to the concerns checked.

Abuse- physical, sexual, emotional, or neglect Judgment problems, risk taking

Aggression, violence Legal matters, charges, suits

Alcohol use Loneliness

Anger, hostility, arguing, irritability Marital conflict- infidelity/affairs, remarriage

Anxiety, nervousness Memory problems

Attention, concentration, distractibility Mental illness

Career concerns, goals, and choices Menstrual problems, PMS, menopause

Childhood issues (your own childhood) Mood swings

Children, child care, parenting Motivation, laziness

Codependence Nervousness, tension

Confusion Obsessions or compulsions

Compulsions Oversensitivity to rejection

Custody of children Panic or anxiety attacks

Decision making, indecision, mixed feelings Perfectionism

Delusions (false ideas) Pessimism

Dependence Procrastination, work inhibitions, laziness

Depression, low mood, sadness, crying Relationship problems

Divorce, separation Sadness

Drug use- prescription or street drugs School problems

Eating problems-overeating, not eating, vomiting Self-centeredness

Emptiness Self-esteem

Failure Self-neglect, poor self-care

Fatigue, tiredness, low energy Sexual issues-dysfunctions, desire differences

Frightened, Fears, phobias Shyness, oversensitivity to criticism

Financial-debt, impulsive spending, low income Sleep problems- too much, insomnia, nightmares

Friendships Smoking and tobacco use

Gambling Stress-stress disorders, tension

Grieving, mourning, deaths, losses, divorce Suspiciousness

Guilt Suicidal thoughts

Headaches, other kinds of pains Temper disorganization and confusion

Health, illness, physical problems Threats, violence

Inferiority feelings Weight and diet issues

Interpersonal conflicts Withdrawal, isolating

Impulsiveness, loss of control, outbursts Work problems, unemployment, overworking

Irresponsibility I have no problem or concern bringing me here

Any other concerns or issues:__________________________________________________________________

Please look back over the concerns you have marked off and choose the one that you feel is a priority of

concern to you. ____________________________________________________________________________


Please circle the one response to each item that best describes you for the past seven days.

1. Falling asleep:

0 I never take longer than 30 minutes to fall asleep.

1 I take at least 30 minutes to fall sleep, less than half the time.

2 I take least 30 minutes to fall asleep; more than half the time.

3 I take more than 60 minutes to fall asleep, more than half the time.

2. Sleep during the night:

0 I do not wake up at night.

1 I have a restless, light sleep with a few brief awakenings each night.

2 I wake up at least once a night, but I go back to sleep easily.

3 I awaken more than once a night a stay awake for 20 minutes or more, more than half the time.

3. Waking up too early:

0 Most of the time, I awaken no more than 30 minutes before I need to get up.

1 More than half the time, I awaken more than 30 minutes before I need to get up.

2 I almost always awaken at least one hour or so before I need to, but I go back to sleep eventually.

3 I awaken at least one hour before I need to, and can’t go back to sleep.

4. Sleeping too much:

0 I sleep no longer than7-8 hours/night, without napping during the day.

1 I sleep no longer than 10 hours in a 24-hour period including naps.

2 I sleep no longer than 12 hours in a 24-hour period including naps.

3 I sleep longer than 12 hours in a 24-hour period including naps.

5. Feeling sad:

0 I do not feel sad.

1 I feel sad less than half the time.

2 I feel sad more than half the time.

3 I feel sad nearly all of the time.

6. Decreased appetite:

0 There is no change in my usual appetite.

1 I eat somewhat less often or lesser amounts of food than usual.

2 I eat much less than usual and only with personal effort.

3 I rarely eat within a 24-hour period, and only with extreme personal effort or when others persuade me

to eat.

7. Increased appetite:

0 There is no change from my usual appetite.

1 I feel a need to eat more frequently than usual.

2 I regularly eat more often and/or greater amounts of food than usual.

3 I feel driven to overeat both at mealtime and between meals.

8. Decreased weight (within the last two weeks):

0 I have not had a change in my weight.

1 I feel as if I’ve had a slight weight loss.

2 I have lost 2 pounds or more.

3 I have lost 5 pounds or more.


9. Increased weight (within the last two weeks):

0 I have not had a change in my weight.

1 I feel as if I’ve had a slight weight gain.

2 I have gained 2 pounds or more.

3 I have gained 5 pounds or more.

10. Concentration/Decision making:

0 There is no change in my usual capacity to concentrate or make decisions.

1 I occasionally feel indecisive or find that my attention wanders.

2 Most of the time, I struggle to focus my attention or to make decisions.

3 I cannot concentrate well enough to read or cannot make even minor decisions.

11. View of myself:

0 I see myself as equally worthwhile and deserving as other people.

1 I am more self-blaming than usual.

2 I largely believe that I cause problems for others.

3 I think almost constantly about major and minor defects in myself.

12. Thoughts of death or suicide:

0 I do not think of suicide or death.

1 I feel that life is empty or wonder if it’s worth living.

2 I think of suicide or death several times a week for several minutes.

3 I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or

have actually tried to take my life.

13. General interest:

0 There is no change from usual in how interested I am in other people or activities.

1 I notice that I have less interested in people or activities.

2 I find I have interest in only one or two of my formerly pursued activities.

3 I have virtually no interest in formerly pursued activities.

14. Energy level:

0 There is no change in my usual level of energy.

1 I get tired more easily than usual.

2 I have to make a big effort to start or finish my usual daily activities (*for example, shopping, homework,

cooking or going to work).

3 I really cannot carry out most of my usual daily activities because I just don’t have the energy.

15. Feeling slowed down

0 I think, speak, and move at my usual rate of speed.

1 I find that my thinking is slowed down or my voice sounds dull or flat.

2 It takes me several seconds to respond to most questions and I’m sure my thinking is slowed.

3 I am often unable to respond to questions without extreme effort.

16. Feeling restless:

0 I do not feel restless.

1 I’m often fidgety, wringing my hands, or need to shift how I am sitting.

2 I have impulses to move about and am quite restless.

3 At times, I am unable to stay seated and need to pace around.


THE BURNS ANXIETY INVENTORY Place a check 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.

0

Not at all

1

Somewhat

2

Moderately

3

A Lot

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

0

Not at all

1

Somewhat

2

Moderately

3

A Lot

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 physical illnesses or heart attacks or dying

13. Fears of criticism or disapproval

14. Fears of being alone, isolated or abandoned

15. Fear of fainting or passing out

16. Fears that something terrible is about to happen

17. Concerns about looking foolish or inadequate

0

Not at all

1

Somewhat

2

Moderately

3

A Lot

18. Skipping, racing, or pounding of the heart

19. Pain, pressure, or tightness in the chest

Category I: Anxious Feelings

Category II: Anxious Thoughts

Category III: Physical Symptoms


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, lightheaded, 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

THE BURNS DEPRESSION CHECKLIST

Place a check 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.

0

Not at all

1

Somewhat

2

Moderately

3

A Lot

1. Sadness: Do you feel sad or down in the dumps?

2. Discouragement: Does the future look hopeless?

3. Low self-esteem: Do you feel worthless?

4. Inferiority: Do you feel inadequate or inferior to others?

5. Guilt: Do you get self-critical and blame yourself?

6. Indecisiveness: Is it hard to make decisions?

7. Irritability: Do you frequently feel angry or resentful?


8. Loss of interest in life: Have you lost interest in career, hobbies, family/friends?

9. Loss of motivation: Do you have to push yourself hard to do things?

10. Poor self-image: Do you feel old or unattractive?

11. Appetite change: Have you lost your appetite, overeat or binge compulsively

12. Sleep changes: Is it hard to get a good night’s sleep? Are you excessively tired and

sleeping too much?

13. Loss of sex drive: Have you lost your interest in sex?

14. Concerns about health: Do you worry excessively about your health?

15. Suicidal impulses: Do you have thoughts that life is not worth living or think you’d

be better off dead?

SERS

This is a questionnaire. There are no right or wrong answers. Please answer each item as carefully and as accurately as

you can by placing a number by each one as follows:

1= Never 2= Rarely 3= A little of the time 4= Some of the time 5= A good part of the time 6= Most of the time 7= Always

____1. I feel that people would NOT like me if they really knew me well.

____2. I feel that others do things much better than I do.

____3. I feel that I am an attractive person.

____4. I feel confident in my ability to deal with other people.

____5. I feel that I am likely to fail at things I do.

____6. I feel that people really like to talk with me.

____7. I feel that I am a very competent person.

____8. When I am with other people I feel that they are glad I am with them.

____9. I feel that I make a good impression on others.

____10. I feel confident that I can begin new relationships if I want to.

____11. I feel that I am ugly.

____12. I feel that I am a boring person.

____13. I feel very nervous when I am with strangers.

____14. I feel confident in my ability to learn new things.

____15. I feel good about myself.

____16. I feel ashamed about myself.

____17. I feel inferior to other people.

____18. I feel that my friends find me interesting.

____19. I feel that I have a good sense of humor.

____20. I get angry at myself over the way I am.

____21. I feel relaxed meeting new people.

____22. I feel that other people are smarter than I am.

____23. I do NOT like myself.

____24. I feel confident in my ability to cope with difficult situations.


____25. I feel that I am NOT very likable.

____26. My friends value me a lot.

____27. I am afraid I will appear stupid to others.

____28. I feel that I am an OK person.

____29. I feel that I can count on myself to manage things well.

____30. I wish I could just disappear when I am around other people.

____31. I feel embarrassed to let others hear my ideas.

____32. I feel that I am a nice person.

____33. I feel that if I could be more like other people then I would feel better about myself.

____34. I feel I get pushed around more than others.

____35. I feel that people like me.

____36. I feel that people have a good time when they are with me.

____37. I feel confident that I can do well in whatever I do.

____38. I trust the competence of others more than I trust my own.

____39. I feel that I mess things up.

____40. I wish that I were someone else.

The Three Factor Eating Questionnaire-Revised 18-Item

Definitely true (4) Mostly true (3) Mostly false (2) Definitely false (1)

1. When I smell a sizzling steak or juicy piece of meat, I find it very difficult to keep from eating, even if I have just

finished a meal. 4 3 2 1

2. I deliberately take small helpings as a means of controlling my weight. 4 3 2 1

3. When I feel anxious, I find myself eating. 4 3 2 1

4. Sometimes when I start eating, I just can’t seem to stop. 4 3 2 1

5. Being with someone who is eating often makes me hungry enough to eat also. 4 3 2 1

6. When I feel blue, I often overeat. 4 3 2 1

7. When I see a real delicacy, I often get so hungry that I have to eat right away. 4 3 2 1

8. I get so hungry that my stomach often seems like a bottomless pit. 4 3 2 1

9. I am always hungry so it is hard for me to stop eating before I finish the food on my plate. 4 3 2 1

10. When I feel lonely, I console myself by eating. 4 3 2 1

11. I consciously hold back at meals in order not to gain weight. 4 3 2 1

12. I do not eat some foods because they make me fat. 4 3 2 1

13. I am always hungry enough to eat at any time. 4 3 2 1

14. How often do you feel hungry? 4 3 2 1 Only at meal times (1) Sometimes between meals (2) Often between meals (3) Almost always (4)

15. How frequently do you avoid “stocking up” on tempting foods? Almost never (1) Seldom (2) Usually (3) Almost always (4)

16. How likely are you to consciously eat less than you want? Unlikely (1) Slightly likely (2) Moderately likely (3) Very likely (4)

17. Do you go on eating binges though you are not hungry? Never (1) Rarely (2) Sometimes (3) At least once a week (4)


Fitness Assessment Form

Please complete this form. It must be done prior to your Fitness Assessment.

Name: __________________________________ Age: _____________ Height: ____________

Weight: _______________ Sex: M or F Blood Pressure_________

Have you had your blood labs done recently? Circle One: Yes or No Last lab date: ___________________

*We greatly encourage getting copies of your most recent lab work and bringing it to your assessment.

Current Dietary Supplements: __________________________________________________________________

Have you had a personal trainer before? Yes or No

Are you currently experiencing pain or tension in your bones, muscles, or joints? Yes or No Explain:

___________________________________________________________________________________________

Do you have any illnesses or conditions that could interfere with exercising? Yes or No Explain:

___________________________________________________________________________________________

Are you currently involved in an exercise program? Yes or No

Time per workout: ___________ Average number of days per week: ___________

Explain your current workout: _________________________________________________________________

_________________________________________________________________________________________

Do you have friends that would be interested in working out with you? Yes or No Who: _____________________

How often do you eat out? ________________________

How much alcohol do you drink per day? ______ounces Type: ______________________________________

How much coffee do you drink per day? ______ounces Type: _______________________________________

How much soda do you drink per day? ______ounces Type: _________________________________________

How much sleep do you get per night? ______ hours

Do you have problems sleeping? Yes or No Are

you physically able to participate in a general exercise program? Yes or No

How much time do you spend sitting per day?______ hours

How much time do you spend standing or walking per day?_______ hours

Rate your physical health: Excellent____ Very Good _____ Good _____ Fair _____ Poor

Rate your psychological stress levels:____ High _____ Medium _____ Low

How well do you deal with psychological stress? ____ Very Good _____ Good _____ Fair _____ Poor

What psychological and physiological factors inhibit you from obtaining your health goals? _________________

__________________________________________________________________________________________

Name the three most important things to you in your life? ____________________________________________

__________________________________________________________________________________________

What are your three greatest psychological strength and opportunities? _________________________________

__________________________________________________________________________________________

What would you like to gain from your fitness assessment program? ___________________________________

__________________________________________________________________________________________

Do you have any exercise equipment? What: ______________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Any comments, questions or other relevant information you would like share? ___________________________

__________________________________________________________________________________________


PLEASE READ THIS IS VERY IMPORTANT!

Read the questions carefully and answer each one honestly.

Yes No PAR-Q

Has your doctor ever said that you have a heart condition and that you should only do

physical activity recommended by a doctor?

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you have a bone or joint problem that could be made worse by a change in your

physical activity?

Is your doctor currently prescribing drugs (for example, water pills) for your blood

pressure or heart condition?

Do you know of any other reason why you should not do physical activity?

If you answered YES If you answered "yes" to one or more questions, you must talk with your doctor

before you start becoming much more active or before you have a fitness test. Tell your doctor about the PAR-

Q and which questions you answered "yes". You will need your PCP to complete the form below prior to your

fitness assessment appointment.

If you answered NO If you answered "no" honestly to all of the questions, you can be reasonably sure

that you can start becoming much more physically active or take part in a physical fitness appraisal – begin

slowly and build up gradually. This is the safest and easiest way to go. No additional forms are needed before

your fitness assessment appointment.

I attest that the above information is correct to the best of my knowledge.

_______________________________________ ______________

Client Signature Date


Medical Clearance Request Form a Personal Fitness Trainer

Your patient ___________________________ has applied to participate in an exercise Assessment and training

program,which would include:

• A fitness assessment to measure muscle strength and endurance, cardiovascular fitness

level, posture and flexibility

• An exercise program that ranges from low to moderate levels

Does your patient require a diagnostic test prior to beginning a program?___ Yes ___ No

Is this patient able to participate in a fitness assessment. ____Yes _____No

These are restrictions or exercise limitations that should be followed:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Is this patient taking medications that will affect heart rate or other parameters during exercise?

Type of Medication Effect

1) RX _______________ Effect __________________

2) RX _______________ Effect __________________

3) RX _______________ Effect __________________

4) RX _______________ Effect __________________

5) RX _______________ Effect __________________

Physician’s Signature: _________________________________________________ Date: _______________________

Please forward this form to:


100 East 15th Street Suite 615

Fort Worth, Texas 76102

Phone: 817-920-9321

or

FAX: 817-920-9336

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