Department to Contact:

Select Records Dr Norma Ann Faraone-Ledgard

First Name:

Middle Initial:

Last Name:

E-Mail Address:

E-Mail Address again:

Please enter your E-mail Address a second time.

Date:

Social Security Number:

Street Address:

City:

State:

Zip Code:

Date of Birth:

Age:

Sex:

Male Female

Telephone Numbers

Home Phone number:

Work Phone number:

Pager:

Cell Phone:

Person(s) to contact in case of emergency:

Telephone Number(s):

Relationship:

Insurance Information

Medical Insurance Provider:

Policy Number:

Policy Telephone Number:

Insurance Address:

Name of person holding insurance:

Relationship to card holder:

Card Holder's Date of Birth:

If you have two insurance companies please complete the next section

Second Insurance Provider:

Policy Number:

Policy Telephone Number:

Insurance Address:

Name of person holding insurance:

Relationship to card holder:

Date of Birth of card holder:

Employment Information

Place of Business:

Address:

Current Occupation:

Education Information

Highest Grade Completed:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+

Elementary School/Jr. High School:

High School:

Associate's Degree:

Associate's Degree Major:

Bachelor's Degree:

Bachelor's Degree Major:

Master's Degree:

Master's Degree Major:

Post Grad:

Post Grad Major:

Certificate Program:

Certificate Program Major:

Family Information

Marital Status:

Single Married Divorced Widowed

Spouse/Significant Other's Name:

Spouse/Significant Other's SSN:

Spouse/Significant Other's DOB:

Spouse/Significant Other's Age:

Years together with Spouse/Significant Other:

Number of Children:

Children's Name and Ages:

Other Household Members: Names, Ages, Relationships

Religious Background:

From whom did you hear about Rhode Island Counseling and Hypnotherapy Center?

Chief Complaint

Briefly describe the problem(s) for which you are seeking treatment, including the severity and how long you have had this (these) problem(s).

Whom have you consulted for this problem? (e.g. MD or friend) Please provide name and information.

Give a brief description of how you think RICHC can help you and what type of treatment you are:

Have you ever been in therapy before?

Yes No

Name of person:

Address:

Telephone Number:

How long were you with this person?

What diagnosis were you given?

HIPPA Compliance: I give RICHC, Inc. permission to contact all providers necessary to provide continuity of care.

Consent to outreach for prior treatment information?

Yes No

Medical Professional Taking Care of You

Name of current medical doctor PCP:

Address:

Telephone Number:

Name, address, and telephone number of any other providers you are seeking for treatment and for what?

Are you currently taking any medication (Rx or OTC)? Please list name, dosage and frequency?

What medications have you taken in the last two years and are no longer taking?

Have you ever stopped taking a medication that was prescribed to you without your doctor knowing? If yes what was the medication?

Agreement of Consent for Treatment - Digital Signature

Patient’s name or responsible person and date:

Agreement of Consent for Hypnotherapy Treatment - Digital Signature

Patient’s name or responsible person and date:

Agreement of Consent to contact other necessary providers who have or are currently treating you - Digital Signature

Patient’s name or responsible person and date:

COURT CASES

RICHC, Inc.’s philosophy is that since it is a solo practice so on a case by case basis it will only be considered. You will be responsible for ALL cost associated to your case. - Digital Signature

Patient’s name or responsible person and date:

NOTE TAKING

RICHC, Inc.’s philosophy due to confidentiality issues will write what is necessary to provide care. Should you need a written summary of any kind this will only be permissible upon your written consent with at least a two-week advanced notification. RICHC, Inc. reserves the right to what is felt necessary to provide care and information to other providers. - Digital Signature

Patient’s name or responsible person and date:

MISSED APPOINTMENTS/BILLED SERVICES

Unless cancelled at least 24 hours in advance RICHC, Inc.’s policy is to charge for missed appointments at the rate of a standard office visit. Keeping your appointment is considered part of your treatment plan. If using insurance, they will not pay this fee and you are responsible for the payment of the missed appointment. RICHC, Inc. understands that unforeseen circumstances may arise. Billed services: I understand that I will be billed for a missed appointment and for other outstanding balances, and if payment is not received within one month’s time; late charges will be added to my account. If I still fail to make restitution to RICHC, Inc. after three attempts, I understand that my account will be sent to Rossi’s Law Office. I also understand that if my insurance company fails to pay for whatever reason I am responsible for the total billed. - Digital Signature

Patient’s name or responsible person and date:

EMERGENCY SITUATIONS

The office is reachable by telephone at all times, 24 hours a day, seven days a week. You can leave a message on the voice mail anytime and expect a return call within 24 hours. In cases of an emergency, simply state that it is an emergency in the message and a return call will be made as soon as possible. However, IF YOU CAN NOT WAIT please seek attention by calling 911, your PCP, or by going to your nearest emergency treatment facility. Should RICHC, Inc. be closed (ex. Vacation) a covering mental health professional will be available to assist your needs. - Digital Signature

Patient’s name or responsible person and date:

LEGAL SITUATIONS

I understand the my records are protected under the state law governing health care information that relates to mental health services and they cannot be disclosed without my written consent unless otherwise provided for in state or federal regulations. I understand that by choosing to use my health insurance I am authorizing the provider to supply information to the insurance company or its representative for the purposes of managing care. The information will be in the form of treatment plans or whatever documentation is in compliance with their guidelines. I also understand that I may revoke this consent at any time except to the extent that action has been taken place in reliance to it. I understand that you are legally responsible to report any findings of child or elderly abuse, homicidal or suicidal actions caused by the patient to the appropriate authorities. - Digital Signature

Patient’s name or responsible person and date:

Workman’s Compensation Cases

I understand that all workmen’s compensation cases are billable at the regular rate of the appropriate service charge. I understand that I am financial responsible for any discrepancies in payment. - Digital Signature

Patient’s name or responsible person and date:

** Digital Signature - I acknowledge that I am signing my name digitally in the required areas. I understand that I am certifying my agreement to the questions/statements asked. **
Do you agree?

Yes

Treatment Goals

What do you want out of treatment from RICHC, Inc.? List 3 Goals:

Hobbies

List 3 hobbies you enjoy:

Strengths and Weakness

List three strengths you feel you possess as well as three weakness:

Opportunity to provide any other information you want RICHC, Inc. to know:

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