Rev 01/17 dt rcâ€™d:___________ by: ___ prov/s:_____________ dt:_________
Please return this packet to the office during business hours. We will copy your I.D. and insurance card/s at that time.
Lisa B. Shaffer, Psy.D
Licensed Psychologist #0498
Client Name: ____________________________________
1489 W. Warm Springs Rd., Ste. 110 Henderson, NV 89014 PH: 702-806-8618/FAX: 800-567-4105
Client Birth Date: _______________Social Security Number: _______________________ Mailing Address:
____________, _______ _____________
_________________, ____, __________
Home phone: _______________ Cell: ______________Other Number: ______________ Is it okay to leave a message for you at the numbers listed above? Circle: __YES / NO__ Email: __________________________________________________________________ Preferred method(s) of contact (Circle): Home phone Client Age: ______
Marital Status: ______________________
School Grade (if applicable):______ Client or Parent Employer:_____________________ Employment Position/Title: __________________________________________________ Client Employment status (circle): Student Full-time Part-time Unemployed Homemaker Ethnic origin: _________________________ Religion: ________________ Active? Y / N Please list members of your household (everyone living in your home - related or not):
Name of Person Living in the Home:
Relationship to Client:
Siblings, parents or children who have moved out of the home or who are not living in the home:
Name of Person Not Living in the Home:
Relationship to Client:
Person (not living with you) in case of emergency: Name:__________________________ Relationship: ____________________________
Address: _________________________________________________________________ Who referred you for services and/or how did you find out about Dr. Shaffer? ____________ _________________________________________________________________________ When did the problem/s first start? _____________________________________________ Does anyone you know receive services at this clinic? / Who? _______________________ If applicable, what is your relationship to this person? _____________________________ Clinical History: ALL previous mental health treatment: outpatient or inpatient, substance abuse or gambling: Date/s
Reason/Type of Treatment
Doctor, Place, State?
List any medications you are taking for mental health issues only: Doctor ________________ Medication
/mg /mg /mg /mg List any medications you are taking for medical issues only: Doctor/s: ___________________ Medication
For what condition Start Date
/mg /mg /mg /mg Allergies (medication and/or food): ______________________________________________ If you have been diagnosed with a mental health disorder, what diagnoses are in your treatment records?
___________________________ How long have you been diagnosed? _________________ Which doctor/s diagnosed you? ______________________Where? _____________________
Adjustment difficulties Cultural issues Academic problems Death of friend/family (circle) Violating the rights of others Repeating actions often Dependency in relationships Fear of abandonment Aggression / hurtful Argumentative / defiant Impulsive / reactive Binge / purge eating habits Excessive (too much) eating Poor eating / not eating Sexual dysfunction Sexual activity (child/teen) Sense of detachment Flashbacks to trauma Frightening waking images Nightmares Legal issues or involvement Chronic physical pain Financial stress Physical abuse history Emotional abuse history Sexual abuse history Victim of neglect Runaway / disappearances
Trauma ________________ High levels of anxiety Shortness of breath Trembling / shaking Heart pounding Fear of being around others Panic attacks Difficulty leaving the house Nervousness Excessive talking Excessive activities Rapid change of ideas Low Self-esteem High self-esteem Elevated mood Excessive energy Depressed mood Moodiness / irritability Mental retardation Lying Truancy/no work or school Loss of relationship _______ Mood swings Fire setting (# times_____) Cruelty to animals Theft / stealing Homicidal (killing) thoughts Suicidal (self harm) thoughts
Worthlessness Loss of interest Loss of energy Feel persecuted Paranoia (fear of others) Hallucinations Caffeine use Nicotine use Drug use (not prescribed) Alcohol use Forgetfulness Confusion Poor memory Poor attachment Encopresis (soiling) Enuresis (wetting) Hyperactivity Distractibility Learning disorder Gambling Suicide attempts Tantrums, length: ____ Poor sleep (not enough) Excessive (too much) sleep Cutting self Burning self Head banging Other injuries to self
**Please place a number 1, 2 and 3 next to the items checked above to indicate the areas of MOST concern. Additional information pertaining to the issues identified above: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Developmental History: Has the client ever had issues related to early development? If so, please describe (i.e. low birth weight, poor attention or concentration, learning issues, slow to talk or walk etc.): ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
*If this form is completed on behalf of a child or adolescent or another person, please tell us the Name of the person completing this form: ___________________________________________
*If client is a minor child, please list both biological parents below or guardian/s if the child is not in parent’s custody. Guardians, you will need to submit an official document detailing your custody in order to schedule an appointment. Without such document, we will be unable to schedule your child. Please note who has LEGAL custody and who has PHYSICAL custody: Circle:
Guardian: _____________________Relationship: _____________ Custody: legal or physical Guardian: _____________________ Relationship: _____________ Custody: legal or physical Family History: - For Adults and Children List all family and then make a note of any major illnesses including symptoms: psychiatric, neurologic, alcoholism, drug abuse, suicide, suicide attempts, divorces and relationship issues:
Client’s Mother: Age_____ Symptoms:
_________________________________________________________________________ Client’s Father: Age_____ Symptoms: _________________________________________ _________________________________________________________________________ Client’s Maternal Grandmother: Age_____ Symptoms: ____________________________ _________________________________________________________________________ Client’s Maternal Grandfather: Age_____ Symptoms:
_________________________________________________________________________ Client’s Paternal Grandmother: Age_____ Symptoms: ____________________________ _________________________________________________________________________ Client’s Paternal Grandfather: Age_____ Symptoms:
_________________________________________________________________________ Brothers – circle “M” for male / Sisters – circle “F” for female: M / F Name: _________ Age: _____ Symptoms: ________________________________ M / F Name: _________ Age: _____ Symptoms: ________________________________ M / F Name: _________ Age: _____ Symptoms: ________________________________ M / F Name: _________ Age: _____ Symptoms: ________________________________ M / F Name: _________ Age: _____ Symptoms: ________________________________ If client is an adult: List children and symptoms: M / F Name: _________ Age: _____ Symptoms: ________________________________ M / F Name: _________ Age: _____ Symptoms: ________________________________ M / F Name: _________ Age: _____ Symptoms: ________________________________ M / F Name: _________ Age: _____ Symptoms: ________________________________ M / F Name: _________ Age: _____ Symptoms: ________________________________ If client is an adult, list spouse: Name______ Age_____
Lisa B. Shaffer, Psy.D. Licensed Psychologist #0498 Payment / Insurance Information
Client:________________________ Birth Date: _______ Social Security # ____________ Address: __________________________________________________________________ Phone: (_____)___________ Gender: M___ F___
Status: Single__ Married__ Other__
Patient Relationship to Insured: Self__ Spouse__ Child__ Other__ Financially Responsible Person: Self__ Parent/Guardian__ Spouse__ Other ___________ Responsible Person: ________________________________________________________ Birth Date: ___________ Social Security # _________________Phone:______________ Mailing Address: ____________________________________________________________ Employer: _________________________________________________________________ Employer Address: __________________________________________________________
Primary Insurance: Primary Cardholders Name:
Primary Cardholders Place of Employment: ______________________________________ Insurance Company: ________________________________________________________ Insurance Mailing Address: ___________________________________________________ Claims Phone Number for Insurance Company: ___________________________________ Group Number: ______________________
Policy Number: _______________________
Secondary Insurance: Insurance Company: ________________________________________________________ Insurance Mailing Address: ___________________________________________________ Claims Phone Number for Insurance Company: ___________________________________ Group Number: ______________________
Policy Number: _______________________
If you have insurance and would like to utilize the benefits for treatment, we will bill the insurance company. However, you may be required to pay a deductible or a co-payment at the time of service. Any claim unpaid by your insurance will be your responsibility. IMPORTANT: If you are using Medicaid, you must inform us of all insurance you carry. Otherwise, you risk non-payment of all fees and thus, you will be responsible for the full fees associated with services at this clinic. If you do not want to use your insurance, you will be billed full fee. I/We agree to pay the established fee for services at the time of each appointment unless prior arrangements are made with the office staff. I authorize the release of any medical or other information necessary to process an insurance claim. I also authorize payment of medical benefits to Dr. Lisa B. Shaffer.
Signature: __________________________________________ (Adult or Guardian of Child)
Lisa B. Shaffer, Psy.D. Licensed Psychologist #0498 Minor Treatment Consent Form Name of minor: _____________________________________ Due to the sensitive nature of psychotherapy and assessments, it is important to verify that all parties with legal or physical custody of the minor are informed of the services sought with our agency. Please initial the appropriate item below that is applicable to your family/the minor. Our staff will be happy to answer any questions you may have. A)_____ (No court records & no contact from other party) I attest that I am the sole guardian of this minor. There have been no court proceedings regarding custody and therefore, I do not have court documents to present to this agency. If this situation changes, I will notify this agency.
B) _____ (Sole legal and physical custody) I attest I have sole legal and physical custody of this minor and the court documentation pertaining to this matter is attached.
C)_____ (Joint legal custody) Please provide the contact information for the non-custodial guardian: Name: _________________________ Relationship to minor: __________________ Phone number/s: _________________________ __________________________ Address: ___________________________________________________________
Initial here indicating that the non-custodial guardian is aware of your plan to seek mental health services for this child. We may need to contact the non-custodial guardian to verify this information.
D)_____ (Temporary guardianship or DCFS/Probation cases) I attest that the minor’s parent/guardian allows me to seek care for this child or the courts have assigned me or my agency the right to seek psychotherapy or assessment services for this minor. (*Please attach a notarized document with the parent/guardian’s signature or court order allowing you to seek care for the minor). The biological parent’s information is as follows;
Name: _________________________ Relationship to minor: __________________ Phone number/s: _________________________ __________________________ Address: ___________________________________________________________ (Person completing the minor’s information packet:) I hereby swear that the above information is true and correct. I understand that I may be held legally liable for any misrepresentation of custody or fraudulent statements.
_____________________ __________ (Print Name)
Lisa B. Shaffer, Psy.D. Licensed Psychologist, License #0498
CONSENT FOR TREATMENT
ame of client(s): _____________________________________________ ame of Adult (if client is a minor): ______________________________ Date(s) of Birth: ______________________________________________ .
I,________________________________________ authorize Dr. Lisa B. Shaffer to provide mental health services for myself or for the above named person. If the person named above is a minor or an adult who is legally incompetent, I certify that I am the legal guardian of such person and have the legal right to approve of such services. (your initials) Although the client listed above is the identified patient, I understand that Dr. Shaffer may work with family members of the above named person, including, but not limited to: parents, stepparents, siblings, grandparents, spouses, or children of the above named person. I understand that Dr. Shaffer may choose to include these individuals in treatments as she feels necessary. _______ (your initials) I understand that if I am divorced or separated and share joint legal custody with my ex-spouse, s/he is entitled to the information obtained during our child(ren)â€™s treatment, including, but not limited to, progress notes, assessments, records received, or a summary letter generated by Dr. Shaffer detailing treatment. I understand what I say to Dr. Shaffer regarding my child may be told to the other parent or written in a treatment summary. I understand that Dr. Shaffer may write progress reports and assessments for the purpose of treatment planning. I understand that these reports may be utilized in Family Court and/or given to other professionals and school personnel. (your initials) I understand that if the client listed above is my child or an individual who is under eighteen years of age and in my care, the law may provide me the right to examiner his/her treatment records. I understand it is Dr. Shafferâ€™s policy to request an agreement from parents/guardians that they knowingly and voluntarily agree to give up access to the minorâ€™s records. I understand she will provide me only with general information about her work with my child/minor unless she feels there is a high risk that my child/minor will seriously harm him/herself or someone else. In this case, Dr. Shaffer will notify me of her concern. Before giving me any information, Dr. Shaffer will discuss the matter with my child/minor, if possible, and do her best to handle any objections s/he may have with what she is prepared to discuss. (your initials) I understand that most information disclosed to Dr. Shaffer is protected by federal and state regulations governing confidentiality and cannot be disclosed to others without my consent. I understand that due to Nevada State Regulations, there are legal exceptions in which my consent is not necessary to disclose information to others, including:
In cases of past or present suspected child abuse or neglect, a report must be made to Child Protective Services no later than 24 hours after the information is revealed. In cases of abuse or neglect of a person older than 60 or of a disabled person or legally incompetent person, a report must be made to local law enforcement agencies. In cases where a client is in imminent risk of harming self or others, or when a person with mental illness needs hospitalization, confidentiality may be suspended for the protection of self or others and/or treatment of mental illness. In cases when a person appears to have been injured by a knife, firearm or burn, this information must be reported to local law enforcement or local fire department officials respectively. Confidentiality may also be suspended when a client's treatment is part of a legal claim or defense, or when required by federal or state laws; when information about a deceased person's mental health services is necessary for determining the validity of a will; when a person is court ordered for psychological evaluation; and in situations where a client's case is investigated by the Board of Examiners as part of an investigation or hearing. _________(your initials)
I understand the laws and standards of Dr. Shaffer’s profession require that she keep treatment records. According to NRS 629.051, Dr. Shaffer maintains records of client’s for 5 years following termination, unless the client is a minor, in which case the records are maintained for 5 years past the age of majority (or until the client is 23 years of age). After 5 years, Dr. Shaffer may choose to dispose of my health records in a legally and ethically appropriate manner. I understand if I request copies of my health care records, Dr. Shaffer may charge me .60 cents per page. (your initials) I understand my case may be staffed with other professionals for the purpose of treatment (your initials) planning. I understand tape recording is never allowed during any sessions with Dr. Shaffer or her employees. (your initials) I authorize Dr. Shaffer's staff to leave phone messages about scheduling or canceling (your initials) appointments.  Yes  No I understand that appointments are scheduled every 45 or 60 minutes. My appointment time is set aside for me and if I am late, I realize that my session will be shortened. (your initials) I understand that Dr. Shaffer makes every attempt to return telephone messages within 24 hours. If I am in crisis or need to speak with Dr. Shaffer prior to the next scheduled appointment, she may hold a brief session via the telephone. Any phone calls over 10 minutes will be charged at her normal hourly rate. (your initials) I understand Dr. Shaffer’s fees for a 45-minute “treatment hour” is $200.00, or $250.00 for a 55minute appointment. Her fee for the first (intake) session is $300.00. I understand that if my therapy is court-ordered, she may request I submit a retainer at the onset of therapy. My fees will be deducted from this retainer, and I will be notified when I need to submit additional funds. Any monies left over at the end of treatment will be reimbursed to me along with an invoice detailing (your initials) services rendered.
In addition to weekly appointments, I understand Dr. Shaffer charges fees for other professional services I may need, though she will break down the hourly cost to the quarter hour if she works for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meeting with other professionals I have authorized, preparation of records or treatment summaries, and the time spent performing any other service I may request of her. I understand many of these services are not covered by insurance and will be billed to me directly. If I become involved in legal proceedings that require Dr. Shafferâ€™s participation, I understand I will be expected to pay for her professional time in advance. I understand Dr. Shafferâ€™s court fees are per half day ($2500) or full day ($5000) for expert or fact (your witness testimony, preparation, travel and attendance at any legal proceeding. initials) If I wish to submit information to Dr. Shaffer, I understand I may use e-mail communication at my discretion. However, due to confidentiality issues, I understand I may likely not receive a reply as (your initials) Dr. Shaffer does not typically use e-mail as a form of communication. I understand that at Dr. Shaffer's discretion, further appointments may not be allowed if my account is in arrears. I also understand that if my account is not paid in full within a reasonable period of time, a collection agency will be notified. I agree to pay all collection costs and if a suit is filed, attorney fees, interest and courts costs. (your initials) I understand that if I do not appear for an appointment, or call to cancel 24 hours before my scheduled time, I will be charged for that session. I also understand that if I miss multiple or excessive appointments as determined by Dr. Shaffer, this case may be terminated from this office and an appropriate referral will be made. If this occurs, I understand I may be unable to reopen my (your initials) case with Dr. Shaffer for a minimum of 90 days. -----------------------------------------------------------------------------------------------------------------For Fee-for-Service Clients (if applicable): If Dr. Shaffer is not a provider with my insurance, or if I choose to not use my insurance, I understand that all payments are required in full at time of service. Before the end of the first visit, Dr. Shaffer and I will discuss if this office will bill my insurance as an out-of-network provider or if I will submit my receipts for reimbursement from my insurance. I understand that no matter which method we choose, Dr. Shaffer is not responsible for my insurance reimbursing my out-of(your initials) pocket costs.
__________________________________________________ (Client Signature, including minors)
__________________________________________________ (Legal Guardian Signature if minor or incompetent)
Lisa B. Shaffer, Psy.D. Licensed Psychologist #0498 Informed Consent Acknowledgment Use and Disclosure of protected Health Information: Protected Health Information (“PHI”) may not be used or disclosed in violation of the Health Insurance Portability and Accountability Act (“HIPAA”) Privacy Rule (45 C.F.R.parts 160 and 164) or in violation of state law. I have reviewed the detailed “Use and Disclosures of PHI” document including the minimum necessary requirement, psychotherapy notes authorization, patient rights and administrative requirements. I understand I have the right to retain a copy of this document for my records. I also understand I have the right to ask questions and discuss this information with my practitioner. Consent for Treatment: I have reviewed/received the document titled “Consent for Treatment” outlining the following; psychological services, meetings, professional fees, billing and payments, insurance reimbursement, contacting me, professional records, treatment of minors and confidentiality.
_______________________________________________ Signature of adult client or minor’s guardian
Lisa B. Shaffer, Psy.D. Licensed Psychologist #0498 To My Clients Sometimes it is difficult for clients to know what to do in crisis situations. In order to assist you, I have attempted to offer these recommendations for critical situations you may experience. Medical Emergency: If you are experiencing physical symptoms that are of a serious concern to you, the first thing to consider is to call your primary care physician. If you are in immediate need of medical attention or are experiencing a life-threatening medical emergency, immediately call 911 and the police will contact emergency services to come to your house to assess and if needed, transport you to a medical facility. Emotional Crisis/Emergency: A severe emotional crisis involves experiencing extreme distress that may require hospitalization or an evaluation for such. This does not mean talking to your therapist when you are upset. Instead, it means that you are experiencing a serious emotional emergency such as uncontrollable crying, paranoia, selfharming behaviors or life threatening danger to yourself or someone else. If you are in crisis, please call 911 immediately. If you or others are not in danger and you would like to schedule a time to meet with me, please contact my office. The following list of phone numbers is provided to assist you: Emergency Services:
Nevada Crisis Call Center:
National Suicide prevention:
Spring Mountain Treatment Center:
Red Rock Behavioral