The Cottage Clinic
(858) 259-0146
CLIENT IDENTIFICATION RECORD
DATE: _______________
NAME: ___________________________________________________________
STREET ADDRESS: ________________________________________________
CITY, STATE, ZIP: _________________________________________________
TELEPHONE: DAY: ______________________ EVENING: _______________
CELL: _____________________
DATE OF BIRTH: ________________________ SSN: ____________________
OCCUPATION: _____________________________________________________
EMPLOYER: _______________________________________________________
ADDRESS: _______________________________________________________
WHO REFERRED YOU HERE: ________________________________________
PREVIOUS EXPERIENCE WITH THERAPY: ____________________________________________________________________
CURRENT MEDICATIONS: ____________________________________________________________________
PHYSICIAN: _________________________________________________________
MARITAL STATUS: ____________________________________________________
REASON FOR SEEKING TREATMENT: ____________________________________________________________________
____________________________________________________________________
METHOD OF PAYMENT: ________SELF ________ INSURANCE
___________________ OTHER
Name of insurance company: ____________________________________
Address: ___________________________________________________________
I.D. Number: _______________________ Group Number: ________________
IN CASE OF EMERGENCY NOTIFY:
Name: ___________________________________ Phone: _______________________
Address: ________________________________________________________________
Relationship: ____________________________________________________________
PO. Box 3101 Rancho Santa Fe, California, 92067 858-259-0146
_________________________________________________________________________
Diana Weiss-Wisdom, Ph.D. psy#12476
Licensed Psychologist
Confidentiality
In general, law protects the confidentiality of all communications between a client and a psychologist, and I can only release information about our work to others with your written permission. However, there are a few exceptions. In most judicial proceedings, you have the right to prevent me from providing any information about your treatment. However, in some circumstances such as child custody proceedings and proceedings in which your emotional condition is an important element, a judge may require my testimony if he/she determines that resolution of the issues before him/her demands it.
1. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a client threatens to harm himself/herself, I may be required to seek hospitalization for the client, or to contact family members or others who can help provide protection.
2. If I believe that a child, an elderly person, or a disabled person is being abused, I must file a report with the appropriate state agency.
3. If I assess the patient to be a danger to self, or unable to take care of himself/herself, I may notify the appropriate authorities.
4. In the event of failure to pay a bill in reasonable time, the name of the patient may be given to a collection agency to collect payment or may be recorded in small claims court.
5. Some legal actions initiated by the patient or the patient’s estate may result in the court ordering the release of records.
6. Records and information regarding your diagnosis and treatment must be submitted to your insurance carrier for determination of benefits and authorization for continued treatment.
Patient Name: ____________________________________________
Patient Signature: _______________________Date: _____________
Witness: _____________________________ Date: _____________
_________________________________________________________________________
Diana Weiss-Wisdom, Ph.D. psy#12476
Licensed Psychologist
FEE CONTRACT
CLIENT: __________________________________________________________
Payment is expected following each session. Under some conditions, clients may be billed monthly. If this is the case, payment is due ten (10) days after receipt of your statement. Failure to keep your account up to date may result in the discontinuation of services.
Initial: _________
Cancellations must be made 24 hours before you r scheduled appointment. Late cancellations or missed appointments will be your responsibility, as the insurance company will not pay for non-rendered services.
Initial ________
Should your account become delinquent by a three month period, and you do not comply with a mutually agreed upon schedule of payment, your account may be turned over to a collections agency.
Initial ________
I have read and understand this financial agreement, and agree to its terms.
SIGNED: ___________________________________________
DATE: ___________________________________________