Client Contact Information. Name Date of Birth Soc Sec # Address City Zip. Home Phone Cell Phone Work Phone

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Phillip Byrd
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1 Client Contact Information Name Date of Birth Soc Sec # Address City Zip Home Phone Cell Phone Work Phone May I leave messages on your home phone? Yes No work phone? Yes No cell phone? Yes No May I text appointment reminders to you? Yes No Address May I send invoices, appointment reminders, and/or other information to you by ? Yes No How did you hear about me? (internet search, doctor s referral, friend) Marital Status Occupation Highest level of education Please list individuals living in the home, their ages, and their relationship to you Insurance Information I do not wish to use my insurance for mental health treatment I would like to use my insurance for mental health treatment. I understand that certain information about my condition (such as diagnosis, progress, etc) may be required by my insurance company in order to reimburse Micah Perkins, M.S., L.P.C. for services. Primary Insurance Policy Holder Name Relationship to Client Policy Holder s Date of Birth Policy Holder s Soc Sec # Policy Holder s Address City State Zip Insurance Provider Policy # Group # Secondary Insurance Policy Holder Name Relationship to Client Policy Holder s Date of Birth Policy Holder s Soc Sec # Policy Holder s Address City State Zip Insurance Provider Policy # Group #

2 Release of Treatment Information I authorize the following people to be informed of my treatment (this authorization may be revoked at any time) Name: Relationship: Address: Phone Number: This person may be informed of all information concerning my treatment This person may only be contacted in case of emergency (illness/injury while at Mr. Perkins office, psychiatric hospitalization, ect.) Signature: Date: Office Use Only Name: Relationship: Address: Phone Number: This person may be informed of all information concerning my treatment This person may only be contacted in case of emergency (illness/injury while at Mr. Perkins office, psychiatric hospitalization, ect.) Signature: Date: Office Use Only Name: Relationship: Address: Phone Number: This person may be informed of all information concerning my treatment This person may only be contacted in case of emergency (illness/injury while at Mr. Perkins office, psychiatric hospitalization, ect.) Signature: Date: Office Use Only

3 Physician Release of Information Would you like for Mr. Perkins or his staff to have contact with your primary care physician, psychiatrist, or other healthcare professional? (Such contact would include initial diagnosis and assessment information, changes in diagnosis, and treatment progress) Yes No If so, please complete Physician s Name: Address: Clinic Name: Phone Number: Fax Number: Signature: Date: Office Use Only Physician s Name: Address: Clinic Name: Phone Number: Fax Number: Signature: Date: Office Use Only

4 Medical History Date of last physical exam Do you currently or have you ever suffered from the following: An under or overly active thyroid Parkinson's disease Lyme disease Cohn s Disease A sexually transmitted disease (type) Head Trauma (One incident such as a car accident or repeated incidents such as in sports- football, martial arts, etc.) If yes, please briefly explain Cancer Diabetes High Blood Pressure Heart Disease Arthritis (type) Lupus Alzheimer's Disease Chronic Pain If yes, please briefly describe Other: Current Medication Dosage Prescribing Physician Please briefly list any past psychiatric treatment you have received in the past (outpatient counseling, inpatient hospitalization, ect) Name of Provider Focus of Counseling (Depression, Anxiety, ect) Start Date End Date

5 Current Symptoms Please check all that you have experienced in the past three months. Office Use Frequent Feelings of Sadness Feelings of Hopelessness Suicidal Thoughts Difficulty Sleeping Increased Sleeping The use of medication or over the counter sleep aids Poor Appetite Increased Appetite Feelings of Euphoria Increased Irritation Strong Feelings of Anger or Rage Anger Outbursts (yelling at others, destroying property, aggression toward others, ect) Self Harmful Behaviors Frequently checking to make sure tasks were completed Difficulty concentrating Forgetting to complete task or missing appointments Feelings of Anxiety Panic Attacks (heart palpitations and/or difficulty breathing when under stress) Excessive Thoughts Auditory or Visual Hallucinations (noises or sights experienced by you but that others don t report experiencing)

6 Beginning or increasing alcohol use Beginning or increasing illegal drug use Avoiding certain people, places or conditions (family members, work, the mall, stores, ect) Recent life change (loss of job or starting a new job, married, divorce, birth of a new baby, death in the family) Any other symptoms or conditions you are experiencing that you would like to be a focus during counseling: Office Use

7 Family History Biological Father- Biological Mother- Stepfather- Stepmother- Other significant adults in your life prior to age 18 Siblings- (please circle) Biological, Step, Half, Adopted Biological, Step, Half, Adopted Biological, Step, Half, Adopted Biological, Step, Half, Adopted Biological, Step, Half, Adopted Indicate Current Relationship Status Spouse (s) Current spouse: Married (month, year) Past spouse: Divorced Widowed When: Past spouse: Divorced Widowed When: Past spouse: Divorced Widowed When: Office Use

8 Prior to your 18th birthday: 1. Did a parent or other adult in the household often or very often Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? No Yes 2. Did a parent or other adult in the household often or very often Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? No Yes 3. Did an adult or person at least 5 years older than you ever Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you? No Yes 4. Did you often or very often feel that No one in your family loved you or thought you were important or special? or Your family didn t look out for each other, feel close to each other, or support each other? No Yes 5. Did you often or very often feel that You didn t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? No Yes 6. Were your parents ever separated or divorced? No Yes 7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or repeatedly hit for at least a few minutes or threatened with a gun or knife? No Yes 8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? No Yes 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? No Yes 10. Did a household member go to prison? No Yes Other events you believe significantly impacted your family (for example death of close family members which heavily impacted the family, frequent moves, accidents, ect) Office Use

10 PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential, so please be honest. For each question in the chart below, place an X in one box that best describes your answer. NOTE: In the U.S., a single drink serving contains about 14 grams of ethanol or pure alcohol. Although the drinks below are different sizes, each one contains the same amount of pure alcohol and counts as a single drink:

11 The Drug Abuse Screening Test (DAST) Directions: The following questions concern information about your involvement with drugs. Drug abuse refers to (1) the use of prescribed or over-the-counter drugs in excess of the directions, and (2) any non-medical use of drugs. Consider the past year (12 months) and carefully read each statement. Then decide whether your answer is YES or NO and check the appropriate space. Please be sure to answer every question. 1. Have you used drugs other than those required for medical reasons? 2. Have you abused prescription drugs? 3. Do you abuse more than one drug at a time? 4. Can you get through the week without using drugs (other than those required for medical reasons)? 5. Are you always able to stop using drugs when you want to? 6. Do you abuse drugs on a continuous basis? 7. Do you try to limit your drug use to certain situations? 8. Have you had blackouts or flashbacks as a result of drug use? 9. Do you ever feel bad about your drug abuse? 10. Does your spouse (or parents) ever complain about your involvement with drugs? Do your friends or relatives know or suspect you abuse drugs? Has drug abuse ever created problems between you and your spouse? 13. Has any family member ever sought help for problems related to your drug use? 14. Have you ever lost friends because of your use of drugs? 15. Have you ever neglected your family or missed work because of your use of drugs? Have you ever been in trouble at work because of drug abuse? Have you ever lost a job because of drug abuse? 18. Have you gotten into fights when under the influence of drugs? 19. Have you ever been arrested because of unusual behavior while under the influence of drugs? Have you ever been arrested for driving while under the influence of Have you engaged in illegal activities in order to obtain drug? 22. Have you ever been arrested for possession of illegal drugs? 23. Have you ever experienced withdrawal symptoms as a result of heavy drug intake? 24. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding, etc.)? 25. Have you ever gone to anyone for help for a drug problem? 26. Have you ever been in a hospital for medical problems related to your drug use? 27. Have you ever been involved in a treatment program specifically related to drug use? 28. Have you been treated as an outpatient for problems related to drug abuse? YES NO

12 Standard Rates for Services Session Fees (Individuals, Couples, or Family Therapy) CPT Code minutes- $180 (Initial Intake Meeting) CPT Code minutes- $150 (53-60 min session with client and/or family member) CPT Code minutes- $130 (38-52 min session with client and/or family member) CPT Code minutes- $80 (16-30 min session with client and/or family member) CPT Code minutes- $150 (53-60 min session with family members without client present) CPT Code minutes- $150 (53-60 min session with family members with client present) CPT Code Group psychotherapy- $60 CPT Code Psychotherapy for Crisis- $180 Used to address a potentially life threatening situation which requires immediate attention. May involve psychotherapy, a risk assessment, and/or utilization of outside resources to defuse the crisis. (60 min) Other Fees No Show/ Late Cancellation (less than 24 hour notice)- $150 Change of a scheduled session due to inclement weather will not be considered a late cancelation Three no show/ late cancelations fees (per yearstarting from our initial session) will be waived and not charged to the client. After three no show/ late cancelations the client will be charged $150 for each no show/ late cancelation thereafter (sorry, no exceptions). Excessive no shows/ late cancelations/ or rescheduling (as defined by six or more per year) may result in termination of services and a referral to another provider. Report Fee- $50 per hour (one hour minimum) (Court Reports, SSI Forms, etc) Court appearances- $800/ day (one day minimum) Each additional 30 min (CPT Code 90840)- $90 I understand that session fees may be paid in full or in part by my insurance company. However, I am aware that I am ultimately responsible for the fees incurred during my treatment. I am aware that if I am unable to pay for counseling sessions I am responsible for asking that an alternative rate be considered or in asking my clinician to assist me in finding an alternate provider. I have read and understand my financial responsibility to Micah Perkins. Signature of person responsible for session fees Date

13 Documents for review This Notice of Privacy Practices presents the information that federal law requires us to give our patients regarding our privacy practices. We must provide this notice to each patient beginning no later than the date of our first service delivery to the patient, including service delivered electronically, after April 14, We must make a good-faith attempt to obtain written acknowledgment of receipt of the notice from the patient. We must also have the notice available at the office for patients to request to take with them. We must post the notice in our office in a clear and prominent location where it is reasonable to expect any patients seeking service from us to be able to read the notice. Whenever the notice is revised, we must make the revised notice available upon request on or after the effective date of the revision in a manner consistent with the above instructions. Thereafter, we must distribute the notice to each new patient at the time of service delivery and to any person requesting a notice. We must also post the revised notice in our office as discussed above. I, hereby acknowledge that I have received a copy of the above and foregoing Notice of Privacy Practices currently in effect for the management, use and disclosure of health information created or received by Micah Perkins, M.S., L.P.C., L.A.D.C. Signature Date

14 Informed Consent, Description of Services and Confidentiality I understand that my physician/patient relationship is limited to, and is exclusively between myself and Micah Perkins, M.S., L.P.C., L.A.D.C.,. Although other psychologists maintain an office at this location, Micah Perkins is not responsible for any of the actions or activities of any such psychologists. Description of Services: Psychotherapy involves discussing in detail my concerns, giving background information and talking about areas that may cause me emotional pain, all for the purpose of trying to develop new and more effective methods of coping with problem areas in my or my child s life. I understand I am free to withdraw from therapy at any time if I so desire and will only be responsible to pay for the completed sessions. If I withdraw from group therapy before the group sessions end, I will be responsible for paying all group fees for the remaining sessions. Confidentiality: All services rendered and all information obtained is kept confidential and cannot be released without your written permission. You need to know, however, that there are special situations under which confidential information could be revealed such as: 1. A duty to warn ethic allows a clinician to break confidentiality when danger exists to the patient and/or others. 2. Allegations of neglect and/or physical, emotional, or sexual abuse of a child or vulnerable adult must be reported, by law, to the Department of Human Services for investigation. 3. Under special circumstances the court may subpoena a patient s records and may order a clinician to give testimony during a court hearing. 4. Third party payors, such as insurance companies, have a right to review a patient s records. 5. Delinquent accounts (accounts with balances longer than 90 days) may be turned over to a collection agency. 6. Based on clinical judgment, consultation with another professional in regards to your treatment. Your signature indicated that you have read and understood the above information concerning confidentiality and that you have read and understood the description of possible services, and consent is given to provide services to you and/or your child (children),, who is/are not of legal age. Signature Date

15 Oklahoma Licensed Professional Counselor & Oklahoma Licensed Alcohol and Drug Counselor STATEMENT OF PROFESSIONAL DISCLOSURE I am required by law to inform you about my professional training, orientation /techniques, expertise and credentials. Education and Experience Licensed Professional Counselor, Oklahoma Department of Health, # 2498 Licensed Alcohol and Drug Counselor, Oklahoma Board of Alcohol and Drug Counselors # 1174 Master's Degree in Behavioral Sciences Bachelor's Degree in Psychology Present Private Practice, Edmond, Oklahoma. Specializing in the treatment of children, teens and adults Psychotherapist for a psychiatric hospital treating children, adolescents, and their families Psychotherapist for a community mental health center. Treated adults with issues such as: depression, anxiety, trauma from past abuse, drug abuse, and marital problems Head of Training for a psychiatric hospital Psychotherapist for a therapeutic foster care agency Served as a Mental Health Technician and later as a psychotherapist for children and adolescents in partial hospitalization program. Advanced Training Training in Parent- Child Interaction Therapy, Oklahoma University Health Science Center Certified Reality Therapist, William Glasser Institute Advanced Training in Rational Emotive Behavior Therapy, Albert Ellis Institute In addition, I am required to complete continuing education yearly in order to maintain my license. Associations American Counseling Association Association for Counselor Education and Supervision International Association of Marriage and Family Counselors Theoretical Orientation I primarily use Cognitive Behaviors Therapies including: Rational Emotive Behavior Therapy, Reality Therapy, and Cognitive Therapy. I also use Feedback Informed Treatment to assess progress and to adjust counseling as needed. Licensing Boards Contact Information State Board of Behavioral Health Licensure 3815 N. Santa Fe, Suite 110 Oklahoma City, OK Phone: (405) The licensing website for Oklahoma Licensed Professional Counselors is: Oklahoma State Board of Licensed Alcohol and Drug Counselors 101 NE 51st St :: Post Office Box :: Oklahoma City, OK Tel: (405) On both sites you can access the law and regulations which govern my licenses. I will furnish you with printed materials about the requirements of my licensure if you so desire. The above-designated licensee has satisfactorily supplied me with information regarding his practice, license and professional development. Client name Date

ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.

ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time. ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email: