Intake Form

Thanks for joining us. We value you as a client and are committed to helping you achieve your goals.

Issues: Please underline any of the following that apply: anxiety; depression; family/marriage/relationship problems; child-adolescent behavior; substance abuse_______ ; work problems; family/marriage; kids; smoking; weight loss; anger management; stress reduction; chronic illness; auto-work accident/injury; pain; other_____________________

I would benefit from: (please underline) telephone counseling; in-office counseling-psychotherapy; family counseling; marriage counseling; relaxation training; hypnosis to___________________;
pain management; adjustment to injury or illness; disability assessment/counseling; substance abuse treatment; relationship counseling; anger management; depression management; anxiety management; ADD evaluation; personality testing; stress reduction; other_____________

Patient Name_________________________________ Please underline: Marital

Status: Single Married Other; Employment: Employed Full Time Student Part-Time

Student; Pt. Email Address_____________________________; May we send

updates and information there? Y N Pt. Birthday:_______________; SS#________________________Address_______________________________

Pt relationship to insured: self spouse child other_______; Phone Numbers:____________________________________

Is there a phone # on your card listed specifically for mental health services?
If so, please include it:______________________________

If your condition has been caused
by a work injury or auto accident, please include the adjuster’s contact info here:
_________________________________________________________________

Insured’s SS #_____________________Insured’s Name____________________
Insured’s Address_____________________________________
Insured’s Phone#______________________________________
Insured’s Policy-Group-FECA#______________________
Insured’s Birthday______________
Employer-School Name____________________________________________
Insurance Plan Name__________________________
Insurance Benefits Verification Phone Number_______________________________

Is There Another Health Benefit Plan? Yes___________________________No___

Other Insured’s Name____________________________
Other Insured’s Policy or Group #__________________________
Other Insured’s Birthday:____________________
Employer/School Name________________________
Insurance Plan_______________________________
Insurance Verification Number_____________________
Address to Send Claims___________________________________________________

I acknowledge that my co-pay is payable at each visit with you billing my insurance company for the balance. If I cancel an appointment in less than 24 hrs in advance, I agree to pay ½ of the regular fee to compensate for my therapist and the office space not being available to others.
I recognize that I will be afforded absolute confidentiality within the parameters prescribed by law.

I also authorize you to release any information necessary to process my insurance claims and I request that the resulting benefits be assigned directly to, you, Dr. Michael E Shery as payment for the services rendered.

Signature:______________________________Date:_______________

Please email this form by clicking here now:  drmike@carypsychology.com

______________________________________________________________
For office use only:

Verify: Deductible__________Satisfied? Y N; Co-Pay__________Session Limits______________

Claims Address________________________________________________

90801-90806 Pre-Auth Required? Phone #:________________________Y N O; #__ of______;

#__of______; Case #_______________; Auth #________________

Good ‘til_______________96100 Auth Required? Phone #:_____________Y N O; #__ of______;

Y; Deductible______________Co-Pay____________

Tests: 16-PF A16+ 30; ABEL Screen (sx int) AAdol+ 180; CPI A 13+ 30; Dementia Rating Scale A65-81 60; Hare Psychopathy Checklist-R (PCL-R) A18+ 150; MAPI (pers inv) A13-18 60; MACI A13-19 60; Millon Beh Hlth (med coping) A18+ 45; MMPI-2 A18+ 60; MMPI-A A14-18 60; NEO Personality-R A3-12 120; Omni Person Inv A18-76 60; Omni 4 Personality Disorder Inv A18-76 60; PAI A18+ 60; Personality Research Form A11+ 60; Psychiatric Diagnostic Interview, revised (PDI-R) A18+ 45; Rotter Incomplete Sentence Test Achild+ 60; Structured Interview of Reported Sxs (malingering) A18+ 45; Trauma Sx Inv A18+ 30; Validity Indicator Profile (malingering) A18-69 60; Wechsler Ab Scale of Intelligence (IQ) 60

Verify: Blank/Completed Forms; Stamps; Clarifiers: Envelopes

Please email this form by clicking:  drmike@carypsychology.com