Christopher Carter, licsw 8 Faneuil Hall Marketplace, 3



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Christopher Carter, LICSW

8 Faneuil Hall Marketplace, 3rd floor, Boston MA 02109

Psychotherapist
617-444-9391

chriscarterpsychotherapy@gmail.com

www.chriscarterpsychotherapy.org

Intake Information




Demographic Information

Full Name:

DOB:

Age:

Address:

Phone #:

Email:

Emergency Contact:

Contact #:

Who referred you or how did you find this service? :

If Student, list school:

If Employed, list employer:

Guardian or Personal Representative, if applicable:




Payment Information

 Private Pay  Reduced Rate  Insurance

Insurance & policy #:

Insurance phone #:

Policy Holder:

Policy Holder DOB:

Policy Holder employer:

Policy Holder phone #:

Secondary Insurance (if applicable):


Completed By:




Date:






Christopher Carter, LICSW

8 Fanieul Hall Marketplace, 3rd floor, Boston MA 02109

Psychotherapist


617-444-9391

chriscarterpsychotherapy@gmail.com

www.chriscarterpsychotherapy.org

Practices and Policies



Privacy and Limits of Confidentiality
In compliance with HIPPA law and NASW ethics, I will not divulge your personal information to individuals, agencies or other health care providers without your written consent. Information you share in session will be considered strictly confidential except in situations where you are a danger to yourself or others or if I am subpoenaed by an officer of the court for legal proceedings. In addition, I am required by law to report to local protection agencies any suspected or actual incidences of abuse or neglect of a child/dependent, elderly, or disabled person.
Billing
It is your responsibility to pay entire session fee at the beginning or end of each scheduled appointment. I accept payment by cash or check. I do not accept credit cards as a form of payment. Many people find it helpful to prepare check or cash payment prior to their appointment in order to maximize time devoted to therapy.
Fees
Insurance Accepted: Blue Cross/Blue Shield plans. I can often accept out-of-network payments if you have a PPO plan from another insurance company. You will need to contact your insurance company to determine this benefit.
Private Pay rates, to be paid by check or cash only:


  • Individual Psychotherapy: $120 per clinical hour

  • First Session: $150 per clinical hour for individuals and couples

  • Couples Therapy: $150 per clinical hour

  • Consultation: $150 per clinical hour

Payment is due upon the date services are rendered. If you are using insurance, this means that only your copay is due. If you have a deductible, we can work out a payment plan if necessary.

Additional services not listed can be discussed on a case-by-case basis.
Cancellations and Missed Appointments
Please remember to call at least 24 hours before scheduled appointment time if you need to cancel. If you do not provide 24 hours notice of cancellation or miss a session, you will be responsible for paying half the private pay rate out-of-pocket for the missed appointment prior to or at the start of our next meeting in order for treatment to continue. This means that even I you use your insurance, if you miss an appointment or cancel past deadline, you would owe $60. This policy is to honor the treatment agreement, respect professional boundaries and understand that the time that is unused could be going to someone else who needs it.
This policy applies to those using their insurance in addition to those in private pay arrangements.
Contact and Mental Health Emergencies
I have 24 hour voicemail service and you may leave a message for me anytime. During regular business hours of 9am to 8pm, I will make every attempt to get back to you, usually within 24 business hours. If you are experiencing an emergency and cannot reach me, please leave me a message and go to your the nearest hospital emergency room. The closest emergency room to my office is at Massachusetts General Hospital at 55 Fruit Street Boston. In addition, Samaritans of Boston operate a 24-hour crisis number at 617-247-0220.

By signing, I certify that I have received and understand these aforementioned Practice and Policies. I have been informed of my rights under the HIPPA act and consent to treatment with this provider under these guidelines.

x

Client Signature Date
___________________________________________________________

Printed Name

x

Therapist Signature Date
Christopher Carter LICSW_____________________________

Printed Name
Christopher Carter, LICSW

8 Faneuil Hall Marketplace, 3rd floor, Boston MA 02109

Psychotherapist
617-444-9391

chriscarterpsychotherapy@gmail.com

www.chriscarterpsychotherapy.org

Consent To Treat

I acknowledge that I have fully discussed with Christopher Carter, LICSW (henceforth “psychotherapist”) the various aspects of psychotherapy. The nature of the treatment has been described, including the extent, its possible side effects, and possible alternative forms of treatment. I understand I may withdraw from treatment at any time but if I decide to do this I will discuss my plan with my psychotherapist before acting on it.
My psychotherapist has further discussed with me scheduling policies, fees to be charged, payment procedures, policies regarding missed or canceled appointments, emergency procedures, holidays and vacations, matters relating to insurance, and, if applicable, preauthorization and utilization review issues.
I have read the documents provided and fully understand procedures and policies, the nature of treatment, the alternatives to this treatment, the limits of confidentiality and the circumstances in which confidential communications may need to be breached.
I have been given the opportunity to ask questions regarding my psychotherapist's education and training, areas of special interest or training, and types of psychotherapy utilized by the psychotherapist.
I understand that I may request copies of any policies or administrative documents.
I agree and consent to psychotherapy with the above-mentioned psychotherapist.
Private Pay option only: The agreed upon fee is currently $___________ per session to be paid at the time of each appointment. I understand that this may be negotiated in the future.

_________________________________ _____________________________________

Client Signature Date

Christopher Carter, LICSW

8 Faneuil Hall Marketplace, 3rd fl Boston, MA 02109

617-444-9391

Authorization for Use or Disclosure of Protected Health Information

1.

I hereby authorize to use and/or disclose the

[Name of Health Care Provider]

protected health information described below to .



[Name of Individual]

2.

Authorization for Release of Information.

to



Covering the period of health care from

□ all past, present and future periods:

OR

a. □ I hereby authorize the release of my complete health record (including records relating

to mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse).



OR

b. □ I hereby authorize the release of my complete health record with the exception of the following information:











Mental health records

Communicable diseases (including HIV and AIDS) Alcohol/drug abuse treatment

Other (please specify):

3.

This medical information may be used by the person I authorize to receive this information for

medical treatment or consultation, billing or claims payment, or other purposes as I may direct.



4.

This authorization shall be in force and effect until , at which time this

[Date or Event]

authorization expires.

5.

I understand that I have the right to revoke this authorization, in writing, at any time. I

understand that a revocation is not effective to the extent that any person or entity

has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

6.

I understand that my treatment, payment, enrollment or eligibility for benefits will not be

conditioned on whether I sign this authorization.



7.

I understand that information used or disclosed pursuant to this authorization may be disclosed

by the recipient and may no longer be protected by federal or state law.



Signature of Patient or Personal Representative

Date

Print Name of Patient or Personal Representative

Relationship to Patient

New Patient Self-Report Questionnaire

To the best of your ability, answer the following questions as fully as possible.

PERSONAL DEMOGRAPHICS (you may write “Skip”)

Where born/Where raised:

Culture/ethnicity/sex orientation:

Employment/Occupation:

Education:

Resources/sources of support:

Spirituality/religion:

Leisure/Recreation interests:

Past or present legal issues:

Who do you consider your family?

MENTAL HEALTH HISTORY

OTHER HISTORY

Have you ever been in psychotherapy? If yes, explain.

Briefly note any significant events in your life:

Any history of Psychiatric medication? If yes, explain.

Ever been Psychiatrically hospitalized? If yes, explain.

Any family members with mental health histories?

Any family members with substance abuse histories?
**All provided information is kept confidential per HIPPA regulations.

Christopher Carter, LICSW

8 Faneuil Hall Marketplace, 3rd floor, Boston MA 02109

Psychotherapist



PHQ-9 SELF-ASSESSMENT
Patient: _____________________________________
Clinician: ___________________________________ Date: ____________ Visit #: ________


Over the past two weeks how often have you been bothered by any of the following problems? Please check the box that best describes your feelings.

Not at All

Several Days

More than half the days

Nearly every day

1.

Little interest or pleasure in doing things













2.

Feeling down, depressed or hopeless













3.

Trouble falling or staying asleep, or sleeping too much













4.

Feeling tired or having little energy













5.

Poor appetite or overeating













6.

Feeling bad about yourself – that you are a failure or have let you or your family down













7.

Trouble concentrating on things, such as reading the newspaper or watching television













8.

Moving or speaking so slowly that other people may have noticed? Or the opposite – being so fidgety or restless that you have been moving around more than usual













9.

Thoughts that you would be better off dead or of hurting yourself in some way















If you checked off any problems, please circle how difficult these problems have made it for you to do your work, take care of things at home, or get along with other people.
Not at all difficult A little difficult Very difficult Extremely difficult
In the past two years have you felt depressed or sad most days, even if you felt okay sometimes?

(Circle one)  Yes No



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