Welcome!

This questionnaire is designed to get to know you better. Because I work from a whole-person perspective, the more information I know about you – including information that may not appear to be specifically related to the reason you are here – will help me design a plan to help you.

If your information does not fit in the space reserved for your response, please use additional paper. You may also wish to explain additional details to me when we meet.

It may be that you are not yet ready to talk about a certain area of your life and would like to get to know me better before you share such information. If so, please let me know.

Please leave any sections blank that do not apply to you or you do not understand, and we can discuss your concerns or additional information in more detail.

Please note the Informed Consent and Disclosure section. When signed, I receive permission to talk with a current or previous helping professional, attorney or other person who may be helpful with your care.

All information shared in this form is confidential according to federal law.

I look forward to working with you.

Karen Carnabucci, LCSW, TEP

(717) 466-0788

Name
Name you like to be called
Street address
City, state and ZIP
Home phone	Work phone
Mobile phone	Email address
OK to send Karen’s confidential e-mail newsletter with events, health information, helpful links?
Referred by

Personal information

Date of birth	Age

Emergency contact

Name
Relationship
Day phone	Evening phone

Insurance information (This info is for file purposes only. I do not accept health insurance but will provide you with a receipt that you may submit to your insurance company, HSA or other health account.)

Insurance company name
Insurance company phone
Identification number of policy
Group number of policy
Precertification needed?
How many sessions	Deductible
Policy holder’s name
Relationship to insured	Date of birth
Policy holder’s address

Identifying information (check when appropriate)

Male Female

White Black Hispanic Asian Native American Biracial Multiracial

Single Married Partnered Separated Divorced Living together Widowed

Adopted as a child Parent Children at home with you Others at home with you

Are you taking any medications, prescribed by a physician, over the counter or given to you?

Medication	Dosage	Prescribed by	For what reason

Do you drink alcohol?

Yes No

I am concerned about my use of alcohol.

I am concerned about my use of prescribed medications.

I am concerned about my overuse of medications, recreational drugs or other compulsive activities.

(Use additional paper if necessary)

Previous treatment or counseling	When (approximate dates)	For what reason

What events, behaviors, problems, concerns or needs have led to this appointment?

What would you like to achieve or focus upon during this process of counseling with me?

PERSON'S BILL OF RIGHTS

Karen Carnabucci, MSS, LCSW, TEP, affirms the value of the individual rights of all persons seeking help.

The right to respectful care without regard to race, creed, gender, ethnicity, marital status, color, national origin, sexual orientation, handicap or religion.

The right to confidentiality. This means that any and all information given to the psychotherapist during any session cannot be divulged by the therapist to anyone outside of the therapy session without the client's written consent. This right may be waived is there is a clear and present danger of physical harm to the client or another becomes apparent and the therapist is ethically require to inform those who have a direct need to know.

The right to obtain from the therapist or staff complete and current information about diagnosis, treatment, goals and prognosis in easy-to-understand terms.

CONSENT TO TREATMENT AND POLICIES

I understand that I am consenting to psychotherapeutic treatment for myself with Karen Carnabucci, MSS, LCSW, TEP, in Lancaster, Pa. I may inform Karen that I want to stop treatment at any time. It is also understood that Karen may discuss referral to another professional if it is believed that more appropriate treatment may be offered by another therapist.

I understand that payment of fees is expected at time of service unless other arrangements have been made.

I understand that I am responsible for paying charges that are not covered by my insurance, including co-pays, no-show fees and/or bank charges for insufficient funds.

I understand that bills that remain unpaid after 90 days will be referred to a collection agency which will involve interest charges, a collection agency fee and my credit record.

I give permission for Karen Carnabucci to contact my insurance company for payment according to the terms of my insurance policy.

I also understand that I may make payment by cash or check and send my receipts to my insurance policy at my convenience if I am unsure if I wish to use my insurance coverage.

I understand that notice of 24 hours notice is required for cancellation of appointments (unless there is an emergency situation). Parents or guardians, if the client is a minor, are personally responsible for payment for broken appointments.

I give permission for Karen Carnabucci to contact the person I list for "emergency contact" in the case of emergencies.

By signing below, I _________________________________________________affirm my understanding of my rights, consent to treatment and policies.

X____________________________________________________________________________

Client

______________________________________________________________________________

Witness and date

INFORMED CONSENT AND DISCLOSURE

I, __________________________________________________________________authorize

Karen Carnabucci, MSS, LCSW, TEP, to disclose/receive from:

_____________________________________________________________________________

(person, organization, agency)

I understand that the following information will be disclosed:

Presence in treatment

Summary of contacts

Evaluation

I understand that the information will be used for the purpose of:

Providing continuity of care with other helping professionals

For legal representation

To receive medical records or other health records

For insurance contact

To meet probation/parole requirements

Other (specify)

This information has been disclosed to the above person, organization or agency for records, for which confidentially is protected by law. Federal law prohibits the above person, organization or agency from making further disclosure of this information without my written consent.

I understand that I have no obligation to disclose information from my record and that I may revoke this consent at any time by notifying Karen Carnabucci.

X____________________________________________________________________________

Client

______________________________________________________________________________

Witness

______________________________________________________________________________

Date

Client received did not receive a copy of this consent and disclosure form.

Karen Carnabucci, MSS, LCSW, TEP

Lancaster, Pa.

(262) 466-0788

INFORMED CONSENT AND DISCLOSURE

I, __________________________________________________________________authorize

Karen Carnabucci, MSS, LCSW, TEP, to disclose/receive from:

_____________________________________________________________________________

(person, organization, agency)

I understand that the following information will be disclosed:

Presence in treatment

Summary of contacts

Evaluation

I understand that the information will be used for the purpose of:

Providing continuity of care with other helping professionals

For legal representation

To receive medical records or other health records

For insurance contact

To meet probation/parole requirements

Other (specify)

This information has been disclosed to the above person, organization or agency for records, for which confidentially is protected by law. Federal and/or state law prohibits the above person, organization or agency from making further disclosure of this information without my written consent.

I understand that I have no obligation to disclose information from my record and that I may revoke this consent at any time by notifying Karen Carnabucci.

X____________________________________________________________________________

Client

______________________________________________________________________________

Witness

______________________________________________________________________________

Date

Client received did not receive a copy of this consent and disclosure form.

Karen Carnabucci, MSS, LCSW, TEP

Lancaster, Pa.

(262) 466-0788