Step 1 of 520%NameThis field is for validation purposes and should be left unchanged.Provider Name:(Required)Select ProviderAbiseid, Cira, LCSWBailey, Kristy, LPE-IBallinger, Thalia, LCSWBassarear, Amy, LCSWBoehm, Diane, LPC, RPTBurns, Jessica, LPCCamargo, Laura, LCSWCavell, Timothy, Ph.DCordell, Carol, LPCCouncil, Julie, LCSWCrouch, Robert, LPEGheen, Sarah, LPCGoodrum, Courtney, LCSWGray, Kelly, LCSWHill, Nicole, LPCHussey, Jonna, LCSWJarchow, Rachel, LCSWJordan, Kathy, LCSWKnight, Carley, LCSWMalbica, Kathryn, LCSWMedford, Haley, LMSWMeeker, Leslie, LPCMeeks, Kamie, LCSWMendenhall, Anna, LCSWMitchell, Ashley, LPCNaples, Steffanie, LCSWRaggio, Alyssa, Psy.DReed, Carrie, LPCRosa, Ananda, LCSWSawyer, Caroline, LCSWShackelford, Susan, Ph.DShields, Chuck, LPCSnyder, Melia, Ph.D., LPCWalton, Lee, LPCWill, Danell, LPCPatient's Legal Name(Required) First Last Preferred NameIs the patient a minor?(Required) Yes NoWho is completing this form?(Required) The patient A parent / legal guardianName of person completing this form(Required) First Last Parent / Legal Guardian InformationPlease list parent / legal guardian information below. To list more than one, click the "+" icon to add a new row.First NameLast NameRelationship to Patient Add RemoveAre there any court ordered custody agreements or custody issues we should be aware of? Yes NoPlease explainIf there is any decree of divorce or court order in place which contains provisions regarding parents' or guardians' rights to consent to psychological treatment of your child, you will need to provide a copy of that decree of divorce or court order before starting your child's treatment.Patient Phone Number (Parent/Guardian number if patient is a minor):(Required)Email Address(Required) Patient Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Patient Date of Birth(Required) Month Day Year Patient Gender Male Female Non-Binary Trans-Male Trans-Female OtherPlease SpecifySexual Orientation (Optional): Straight / Heterosexual Gay or Lesbian Bisexual Pansexual Asexual Queer Questioning / Unsure Another identity Prefer not to sayAnother Identity:Highest Level of Education Completed: Some high school High school diploma / GED Some college Associate’s degree Bachelor’s degree Graduate / Professional degree Other - Please SpecifyCurrent employment or primary daily activity: Full-time work Part-time work Student Unemployed Stay-at-home parent Retired On disabilityJob title / field (if applicable):Current School or Program:Grade / Level:Does the patient have: IEP (Individualized Education Program) 504 Plan Informal support/learning plan None of the above UnsureAre you experiencing any of the following symptoms? Please select all that apply.(Required) Feeling down or depressed Unable to enjoy activities Loss of interest in activities Problems with sleep Concentration difficulties Forgetfulness Changes in appetite Fatigue Racing thoughts Impulsivity Increased risky behavior Increased libido Decreased libido Excessive energy Suspiciousness Increased irritability Crying spells Excessive guilt Excessive worry Anxiety attacks Hallucinations Avoidance Thoughts of self-harm OtherIf you would like to provide additional details about any symptoms, you can do so here:How long have these symptoms been present?Suicide Risk AssessmentIf you are currently in danger, call 988 (Suicide & Crisis Lifeline), 911, or go to the nearest ER. If you are completing this for a child/teen and aren't sure, choose "Not known to me (parent/guardian)".Have you ever had feelings or thoughts that you didn't want to live? Yes No Not known to me (parent/guardian) Prefer not to answerDo you currently feel that you don't want to live? Yes No Not known to me (parent/guardian) Prefer not to answerHow often do you have these thoughts?Have you ever tried to kill or harm yourself before? Yes No Not known to me (parent/guardian) Prefer not to answerIn the past week, have you been having thoughts about killing yourself? Yes No Not known to me (parent/guardian) Prefer not to answerTrauma History (optional)Have you experienced events you consider traumatic?Some people find it helpful for their provider to know whether they have gone through difficult or traumatic experiences (such as abuse, neglect, serious accidents, sudden loss, violence, or other events that felt overwhelming or life-threatening). I prefer not to answer on this form I have not had experiences like this I have had difficult or traumatic experiences and would prefer to discuss them in person I have had difficult or traumatic experiences and would like to provide a brief description Not known to me (parent/guardian)Brief DescriptionSubstance UseDo you drink alcohol?(Required) Yes NoHow many days per week do you drink any alcohol?(Required)Please enter a number from 0 to 7.How many drinks containing alcohol do you have on a typical day when you are drinking?(Required) 1 or 2 3 or 4 5 or 6 7 to 9 10 or moreDo you have any concerns about your alcohol use?(Required) Yes NoIs there any other substance use related information you would like to add?Have you had mental health treatment in the past? (Therapy, Medication Management, or Testing) Yes NoPlease list where and whenCurrent MedicationsCurrent MedicationsPlease list all of the medications that you are currently taking (including over the counter). Please add each medication as a separate line. You can use the "plus" icon to add a new line.MedicationDosage Add RemoveMedical HistoryPrimary Care Provider / Pediatrician:Have you ever been diagnosed with any of the following? (Check all that apply.) High blood pressure Heart disease or irregular heartbeat High cholesterol Diabetes Thyroid problems Seizures / epilepsy History of concussion or serious head injury Stroke or TIA Kidney disease Liver disease / hepatitis Sleep apnea Asthma or chronic lung disease Chronic pain condition Neurologic conditions (e.g., Parkinson’s, multiple sclerosis) Autoimmune diseasePlease list any major surgeries you have had Add RemoveDo you exercise regularly? Yes NoHow many days a week do you get exercise?Please enter a number from 0 to 7.What kind of exercise do you do?Family HistoryHave any close family members (parents, siblings, children, grandparents, aunts/uncles) had the following?Please check that all that apply. Depression Anxiety Bipolar disorder Schizophrenia or other psychotic disorder ADHD Autism spectrum disorder Substance use problems (alcohol or drugs) Suicide attempt Death by suicide None of the above / None knownIf you wish, list relatives and conditions: (e.g., "sibling - depression"):ConsentsClient Name(Required)Client Date of Birth(Required) Month Day Year Provider Name:(Required)Select ProviderAbiseid, Cira, LCSWBailey, Kristy, LPE-IBallinger, Thalia, LCSWBassarear, Amy, LCSWBoehm, Diane, LPC, RPTBurns, Jessica, LPCCamargo, Laura, LCSWCavell, Timothy, Ph.DCordell, Carol, LPCCouncil, Julie, LCSWCrouch, Robert, LPEGheen, Sarah, LPCGoodrum, Courtney, LCSWGray, Kelly, LCSWHill, Nicole, LPCHussey, Jonna, LCSWJarchow, Rachel, LCSWJordan, Kathy, LCSWKnight, Carley, LCSWMalbica, Kathryn, LCSWMedford, Haley, LMSWMeeker, Leslie, LPCMeeks, Kamie, LCSWMendenhall, Anna, LCSWMitchell, Ashley, LPCNaples, Steffanie, LCSWRaggio, Alyssa, Psy.DReed, Carrie, LPCRosa, Ananda, LCSWSawyer, Caroline, LCSWShackelford, Susan, Ph.DShields, Chuck, LPCSnyder, Melia, Ph.D., LPCWalton, Lee, LPCWill, Danell, LPCConsent to Care and Scope of Services(Required)Independently Practicing Providers I understand the provider practices with an association of independently practicing professionals which shares certain expenses and administrative functions under the name PCA Resources, Inc. While they share office space, this provider is a completely independent professional rendering clinical services and is fully responsible for those services. Clinical records are separately maintained, and other professionals cannot have access to them without your permission. Nature and Purposes of Services Behavioral health services are intended to assess, support, and treat emotional, psychological, behavioral, and relational concerns that may affect a patient's functioning and well-being. Services may include diagnostic evaluation, psychotherapy, treatment planning, psychoeducation, supportive counseling, skills training, other clinically appropriate interventions, and psychological testing. The purposes of these services are to promote emotional wellness, reduce symptoms, improve coping and daily functioning, strengthen insight and self-understanding, and assist patients in working toward identified treatment goals. Treatment may address present concerns, past experiences, interpersonal patterns, stressors, and other factors relevant to the patient's mental health. Risks and Benefits Potential benefits of therapy and psychological testing include improved insight, diagnostic clarification, treatment planning, enhanced coping, and support in addressing emotional, behavioral, or interpersonal concerns. However, no specific outcome can be promised. Potential risks include emotional discomfort, stress, or upset related to discussing personal experiences or receiving testing findings and recommendations. Alternatives Alternatives include self-help resources, support groups, therapy, community programs, and referrals to other clinicians. Patient Responsibilities & Safety Patients are responsible for providing accurate and complete information, participating in treatment and/or testing as appropriate, and asking questions when they do not understand recommendations, procedures, or policies. Patients are also responsible for informing their provider of significant changes in symptoms, safety concerns, or other important clinical information. Emergencies, After-Hours, and Termination We do not provide 24/7 coverage. For urgent concerns, call 988 or 911 or go to the nearest emergency department. For non-urgent matters, call us at 479-443-5575. If a higher level of care is recommended, we will discuss referrals. We may transition or conclude services, with reasonable notice and subject to applicable law, when ongoing treatment is no longer clinically indicated or beneficial; when appointments are repeatedly missed or fees remain unpaid despite notice; or when conflicts of interest or boundary concerns arise. When clinically appropriate, we will provide information about alternative providers and community resources, though we cannot guarantee availability or acceptance. By checking this, I understand and consent to receive services from the above-named provider.Authorization for Insurance Payment(Required)By checking the box below, I indicate that I agree to authorize payment of insurance benefits to the service provider, authorize the release of any information necessary to process insurance claims, and accept payment responsibility of the portion of the bill which insurance does not cover. I agreeConfidentiality Policy(Required)Confidentiality and Limits: Although I am bound by ethical principles to keep information about you confidential, there are certain exceptions to these principles that you should understand prior to entering into the therapeutic relationship. 1. In a case of suspected child abuse, I am required to report this to the appropriate authorities even when this requires breaking confidentiality. 2. If, at some point, I believe that your child's life or someone else’s life is endangered, I may break confidentiality to warn or prevent harm to your child or another person. 3. If you are using a third-party payer (private insurance, managed health care, or Medicare), I may be required to submit reports or information, such as diagnoses, to obtain reimbursement from your insurer. If there are irresolvable difficulties in payment of fees, it may be necessary to turn account names over to an attorney or a collection agency. 4. Under some circumstances, such as custody and divorce litigation, records may be subpoenaed by a judge. 5. If you sign a release of information in order that I may speak or correspond with professionals with whom you have had previous contact, information about you or your child will be divulged with your consent. 6. If you are a legal minor (under age 18) or a person under the age of 21 (who is under the supervision of your parents), and you engage in behaviors that are seriously threatening your health and well-being, this information may be divulged. I will try to inform you of this decision before I do so. Records, Access, and Retention: We maintain a confidential clinical record (treatment notes, testing reports, communications, and administrative information) in an electronic health record (EHR). You may request access to your record as permitted by law and may request amendments. We maintain client records according to state record retention guidelines. Administrative fees may apply for copies, summaries, or disclosures. Clinician psychotherapy notes: If a clinician keeps separate psychotherapy notes (kept apart from the EHR), these receive special protection under HIPAA and are generally not released without specific authorization. By checking this box, I acknowledge that I have reviewed the Confidentiality Policy.Notice of HIPAA Privacy Practices(Required)You can review the Notice of HIPAA Privacy Practices at https://pca-nwa.com/hipaa By checking this box, I acknowledge that I have reviewed the Notice of Privacy Practices. The notice describes how my health information may be used or disclosed. I understand that I should read it carefully. I am aware that the notice may be changed at any time and that I may obtain a revised copy of the notice at the clinic location where I receive healthcare services.Fees, Insurance, and Financial Policies(Required)Professional fees: A current fee schedule is available upon request and may vary by clinician. Time spent outside sessions at your request (e.g., letters/forms, extended calls, portal messages, coordination with schools/providers and/or records preparation) that takes more than 15 minutes will be billed in 15 minutes increments at your clinician’s regular hourly rate. Legal matters (e.g., depositions, testimony, record reviews, travel) are billed at higher rates with minimum retainers. Payment: Payment (or known copay/coinsurance/deductible) is due at the time of service. Unpaid balances may lead to suspension of non-urgent services and may be referred to collections after notice. Insurance: If we are in network, we will bill your plan, and you are responsible for amounts your plan assigns to you. If we are out of network or you elect self-pay, you are responsible for full charges. Your plan may require diagnoses and clinical information to approve payment; denied claims become your responsibility. Upon request, we can provide a superbill to seek out of network reimbursement. Good Faith Estimates (self-pay): If you are not using insurance, you are entitled to a Good Faith Estimate of expected charges. This is an estimate, not a contract, and your actual needs may change. Ask us if you have questions or want a written estimate. Scheduling, late arrivals, cancellations/no shows: Please arrive on time. If you are late for an appointment, we may need to reschedule, and the full fee may apply. Appointments canceled with less than 24-hour notice or missed without notice may be charged a no-show fee of up to $150 (not billable to insurance). Repeated late cancels/no shows may result in termination of services with referrals offered. I have reviewed the fees, cancellation/no show policy, insurance information, and Good Faith Estimate. I agree to pay any amounts my plan does not cover.Digital Communication and Telehealth(Required)Digital Communication: You may receive non-clinical messages (e.g., scheduling reminders, rescheduling requests) by text/email. Email and text (if used) are for logistics only and are not appropriate for clinical content or emergencies. Our patient portal is the preferred option for sending non-urgent messages and is a HIPAA secure method of communication. We generally reply within 1-2 business days and do not monitor messages after hours. Telehealth: Telehealth uses secure audio/video technologies to deliver care when in person visits are not feasible. By participating in telehealth, you acknowledge: (a) the need for a private location and reliable connection; (b) we must both be physically located in states where the clinician is permitted to practice; (c) rare technology failures and reduced nonverbal cues may affect care; (d) if the connection fails, we may switch to phone or reschedule; (e) no recording of sessions by either party without written consent. I consent to receive non-clinical messages (e.g., scheduling reminders) by text/email with awareness of privacy risks. I also agree to receive services via telehealth and understand technology requirements, privacy considerations, risks/benefits, and emergency procedures.
