__________________________________________

Associates in Behavioral Diagnostics and Treatment

ADULT INTAKE
TODAY’S DATE: _______________

PATIENT NAME: _____________________________________________________________

DOB: ___________________ AGE: ___________ GENDER: ________

HOME ADDRESS: _____________________________________________________________

CITY, STATE, ZIP: ____________________________________________________________

HOME #: ______________________________ CELL WORK #: ________________________

CAN WE LEAVE A MESSAGE/VOICEMAIL? Y N BEST TIME TO CALL: _________

EMAIL ADDRESS: ____________________________________________________________

EMERGENCY CONTACT:

NAME/RELATIONSHIP: __________________________________________________

PHONE NUMBER: _______________________________________________________

PRIMARY CARE PHYSICIAN: _________________________________________________

PHONE # OF PCP: __________________________ FAX # OF PCP: _____________________

INSURANCE COVERAGE
_____Self Pay/No Insurance _____Medical Assistance _____Commercial Insurance
INSURANCE PROVIDER: ______________________________________________________
PRIMARY MEMBER NAME & DOB: _____________________________________________
EMPLOYER: __________________________________________________________________
ID#: ______________________________ GROUP #: _________________________________
CLAIMS ADDRESS: ___________________________________________________________
CLAIMS PHONE #: ____________________________________________________________

WHO REFERRED YOU? ______________________________________________________

ASSOCIATES IN BEHAVIORAL DIAGNOSTICS AND TREATMENT

PHONE: 412-329-7778 • FAX: 412-262-1555 • WWW.AIBDT.COM
WHAT ARE YOUR PRIMARY CONCERNS AT THIS TIME? ______________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
MEDICAL/PSYCHIATRIC HISTORY
HAVE YOU EVER BEEN DIAGNOSED WITH A MAJOR MEDICAL CONDITION? Y N
If Yes, please describe: ____________________________________________________
HAVE YOU EVER BEEN DIAGNOSED WITH A PSYCHIATRIC DISORDER? Y N
If Yes, please describe: ____________________________________________________
DO YOU HAVE A PSYCHIATRIST? Y N
LIST ANY CURRENT PSYCHIATRIC MEDICATIONS: _____________________________

INDICATE HISTORY (“H”) OR CURRENT (“C”) CONCERNS WITH ANY OF THE FOLLOWING:
_____Headache/Migraine _____Stomach ache _____Staring Spells _____Asthma
_____Seizures _____Overweight _____Underweight _____Chronic Fatigue
_____Domestic Violence _____Blood Pressure _____Depression _____Anxiety
_____Sexual Abuse _____Physical Abuse _____Emotional Abuse _____Cardiac
_____Sleeping _____Self-Harm/Suicidal _____Tics _____Allergies
_____Alcohol Use _____Cigarette Use _____Drug Use Other:

FAMILY HISTORY
MARITAL STATUS: ______________________

HOUSEHOLD MEMBERS: (for more space, please write on back side)

NAME AGE GENDER RELATIONSHIP

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FAMILY PSYCHOLOGICAL HISTORY: Please list any members with any of the following:
SIBLINGS MOTHER’S FAMILY FATHER’S FAMILY
Developmental Delays
Learning Difficulty
Intellectually Disabled
ADHD (Hyperactivity)
Seizures
Tics/Tourette’s
Autism of PDD
Depression
Anxiety
Bipolar Disorder
Schizophrenia
Substance Use/Abuse
Suicide Attempt

WORK/EDUCATIONAL HISTORY
WHAT WAS YOUR HIGHEST LEVEL OF EDUCATION? ____________________________
ARE YOU CURRENTLY EMPLOYED? Y N
If so, where do you work? __________________________________________________
Occupation ______________________________________________________________
Are you having trouble at work?
________________________________________________________________________
________________________________________________________________________

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_____________________________________
Associates in Behavioral Diagnostics and Treatment

Authorization to Release Information

Patient Name: ________________________________________ DOB: _________________________

I hereby authorize AIBDT and its contractors, to ________release to and/or ________obtain from the
following diagnostic or treatment information in my records:

_____ Psychological Evaluation Report ______Psychiatric Records

_____ Psychotherapy Records ______Medical Records

_____ Educational Records ______Other:___________________

Release of information if authorization for_______ Coordination of Care

Release of information, as specified above, is authorized to the following individual or organization:

Primary Care Physician (name/fax number):

_____________________________________________________________________________________

You may revoke this authorization, in writing, at any time by sending such written notification to my
office address.

I understand that the information used, or disclosed pursuant to the authorization may by subject to re-
disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule. The
Consent will expire automatically one year from the date on which it is signed.

___________________________________ _______________________
Signature of Patient Date

___________________________________ _______________________
Signature of Parent/Guardian Date
(if patient is under age 14 years)

___________________________________ _______________________
Signature of Clinician Date

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__________________________________________
Associates in Behavioral Diagnostics and Treatment

Notice of Privacy Practices (HIPAA)

I am required by law and committed to protecting your private personal information, which may be personal information collected from you,
information about health care we provide to you, or payment of healthcare provided for you.  I will only use and disclose your personal
information as necessary to provide you with behavioral healthcare. I am also required by law to provide you with this Notice of Privacy
Practices explaining my legal duties and privacy practices with respect to information.  I am legally required to follow the terms of this notice.
The terms of this notice may change in the future, as allowed by law.  If this notice is changed, the new privacy practices will apply to your
information that I already possess, as well as, future information.  If changes are made to the notice, I will post the new notice in our reception
area and will have copies available upon request.

Uses and Disclosure of Protected Health Care Operations

I routinely use your health information inside my office in order to provide behavioral healthcare and to
obtain payment for that healthcare.  in For example: I may use and disclose medical information about you to obtain payment for behavioral
health care service.  This may incorporate releasing your protected health information to submit for payment of claims delivered to you to your
insurance carrier. Or, I may use and disclose protected personal information, such as your name, contact information, and amount due, to
collection agencies in efforts to collect payment on delinquent accounts.

Required by Law/Public Health Activities

I may use and disclose medical information about you to the full extent that public health activities are permitted by law. For example, I may use
or disclose information for the purpose of preventing or controlling disease, injury, or disability.

Abuse or Neglect/Harm of Self or Others

I may disclose your protected health information to a government authority that is authorized by law to receive reports of abuse or neglect, as I
may be obligated by law to make such reports. Or, I may disclose your protected health information if I believe that the disclosure is necessary to
prevent or lessen a serious or imminent threat to the health or safety of a person or the public or harm to oneself.

Legal Proceedings
I may disclose your protected health information in the course of any judicial proceeding, in response to an order of a court tribunal, and in
response to a subpoena or other lawful process.

Abuse or Neglect
I may disclose your protected health information to a government authority that is authorized by law to receive reports of abuse or neglect, as I
may be obligated by law to make such reports.

Others Involved in Your Healthcare

I may disclose your protected health information to a designated friend, family member or guardian (parents/guardian for minors) if previously
agreed that the individual is involved in your healthcare.

Right to Access
You have the right to look at or get copies of your protected health information, which generally includes medical and billing records as well as
decision made about your healthcare. However, you may not be able to inspect or copy any psychotherapy or case file notes. If desired, a typed
summary of case notes can be provided to you upon special arrangement and agreement with the provider.

Right to Restriction
You have the right to request a restriction on the protected health information we use or disclose about you for treatment, payment or other
healthcare operations. I will abide by the agreement unless the information is needed to provide emergency treatment to you. Any agreement of
restrictions will be in writing.

Information I Collect
I collect information about the patient, parent or guardian either directly or through a chosen party or administrator. This information includes
personal data provided on intake questionnaires or behavior symptom questionnaires that may include such information as your name, social
security number, date of birth, marital status, dependent and employment/school information. It may also include other healthcare or school
information submitted to me by other agencies/institutions upon your request. Information may also include payment claims submitted, a
diagnosis code and services provided, charges, and amounts paid.

How Information is Protected

Protected Health Information is available only to the providing clinician, consultants or other healthcare providers involved in the treatment, and
third party billing agents. I maintain physical, electronic, and procedural safeguards that comply with state and federal regulations to guard
personal financial information from unauthorized access, use, and disclosure.

Grievances
If you think that I have not properly respected the privacy of your information, you are free to

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submit a grievance to this clinician or the U.S. Department of Health and Human Services, Office for Civil Rights.  I will not retaliate against you
if you make a complaint.  

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_____________________________________
Associates in Behavioral Diagnostics and Treatment

Receipt of Privacy Practices (HIPAA)

My signature indicates that I (client and parent/guardian) have reviewed and

understand the above information, including confidentiality, and consent for
treatment.

Patient (Guardian) Signature________________________________________

Date__________

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_____________________________________
Associates in Behavioral Diagnostics and Treatment

Cancellation and Missed Appointment Policy

**Per AIBDT policy, for all missed appointments or appointments cancelled with
less than 24 hours notice, you will be billed a fee of 50% of the regular service
charge for your appointment.

Fees for missed appointments are not covered by insurance companies and will be
billed to you directly.

Please notify your clinician as soon as you are aware of upcoming vacations or
other obligations and planned absences so that (s)he may make the best use of that
time while you are away.

This policy helps us to provide availability to those in need of our services as well
as to provide the most efficient and effective care to you.

**Additionally, with multiple missed appointments, the regular appointment

time/day will no longer be reserved for you.

I have read and understand the above policy:

____________________________________ __________
Signature of Client Date

____________________________________ __________
Signature of Clinician Date

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_____________________________________
Associates in Behavioral Diagnostics and Treatment
OUTPATIENT SERVICES CONTRACT

INTRODUCTION TO SERVICES
Welcome to the practice. This document contains important information about our professional services and
business policies. Please read it carefully and ask any questions you may have. When you sign this document, it will
represent an agreement between you and the company.

If you are coming to the practice for Psychological Testing/Neuropsychological Testing:

There are a variety of tests and assessment procedures utilized for psychological testing. The types of measures and
duration of testing depend upon such things as the presenting concern, age of patient, as well as history of prior
testing. These might include IQ testing or personality, language, attention, visual motor, or memory assessment, for
example. Prior to testing being conducted, you will meet with the psychologist for a Diagnostic Interview, during
which time a full history will be taken and determination for testing needs will be made. Most insurance companies
require pre-authorization, which will be obtained by the psychologist after the initial diagnostic interview. You will
also be given a feedback session, to review testing results, and a written report of results following the testing. Your
signed permission will be obtained to release these results to other professionals as needed, such as the PCP.
Psychological testing often leads to better understanding of diagnosis, functional impairment, or reasons for distress
or unwanted behaviors. But there are no guarantees of results.

If you are coming to the practice for Psychotherapy/Counseling:

Psychotherapy and Behavioral/Educational Consultation are not easily described in general statements. It varies
depending on the personalities of the psychologist/counselor and the patient, as well as the particular problems you
bring forward. There are many different methods we may use to deal with the problems that you hope to address.
Psychotherapy or Behavioral/Educational Consultation, unlike a medical doctor visit, calls for a very active effort on
your part. In order for the therapy to be most successful, you will have to work on things we talk about both during
our sessions and at home. In general, the providers from the practice work within a framework called Cognitive
Behavioral Therapy, which is a therapeutic approach that is well researched and supported for many psychological
and behavioral conditions. Other counseling approaches, such as interpersonal therapy or client centered therapy,
may be integrated within the treatment approach.

Psychotherapy and Behavioral/Educational Consultation can have benefits and risks. Since therapy often involves
discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger,

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frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for
people who go through it. Therapy or Behavioral/Educational Consultation often leads to better relationships,
solutions to specific problems, and significant reductions in feelings of distress or unwanted behaviors. But there are
no guarantees of what you will experience.

The first few sessions will involve an evaluation of your needs. By the end of the evaluation, your clinician will be
able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide
to continue with therapy. You should evaluate this information along with your own opinions of whether you feel
comfortable working with your therapist. Therapy and Behavioral/Educational Consultation involves a large
commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have
questions about the procedures, they should be discussed whenever they arise. If your doubts persist, your therapist
will be happy to help you set up a meeting with another mental health professional for a second opinion.

MEETINGS
If you are here for psychological testing or neuropsychological testing services, there have been three individual
sessions pre-arranged to complete this service. For psychotherapy and Behavioral/Educational Consultation, you
will have a weekly or biweekly appointment scheduled, depending on your needs. Each regular session lasts 50-
minute, although some sessions may be longer or more frequent as needed. Once an appointment hour is scheduled,
you will be expected to pay for it unless you provide 24 hours advance notice of cancellation or unless you and the
psychologist/counselor both agree that you were unable to attend due to circumstances beyond your control. In that
event, we will try to find another time to reschedule the appointment, if possible.

PROFESSIONAL FEES AND PAYMENTS

The fees for services will vary depending on the services requests and the type of provider you see. In general, the
hourly fee for a Psychologist is $175 for an initial appointment and $150 per session, either individual or family
session, after that. The fee for a Professional Counselor or Social Worker is $125 for the first session and $125.00
per hour, either individual or family, after that. If your clinician is contracted with your behavioral insurance
provider, (s)he will agree to accept the contracted reimbursement amount specified by your insurance provider if
less than the above stated amount. The fee for private pay psychological testing, which is generally conducted for
Learning Disabilities, is $750.00. You may request a Fee Schedule for other services as needed. You will be
expected to pay for each session, or co-pay/deductible/co-insurance, determined by your insurance provider, at the
time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when
they are requested. [In circumstances of unusual financial hardship, the psychologist/counselor may be willing to
negotiate a fee adjustment or payment installment plan.] There will be an additional fee of $35 for each returned
check.

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If you go more than two appointments without making payments, you will have to contact the office to arrange
scheduling of any future appointments, as there will no longer be a standing appointment for you. If your account
has not been paid for more than 60 days and arrangements for payment have not been agreed upon, the company has
the option of using legal means to secure the payment. This may involve hiring a collection agency or going through
small claims court. [If such legal action is necessary, its costs will be included in the claim.] In most collection
situations, the information released includes the patient’s name, the nature of services provided, and the amount due.

All payments can be made by cash, credit card (Visa, Master, or Discover), or check in the name of “Associates in
Behavioral Diagnostics and Treatment" or "AIBDT").

INSURANCE REIMBURSEMENT
If you have a health insurance policy, it will usually provide some coverage for mental health treatment. The
clinician will assist in this process to help you receive the benefits to which you are entitled; however, you (not your
insurance company) are responsible for full payment of fees. It is very important that you find out exactly what
mental health services your insurance policy covers, if any. This includes determining if your mental health
coverage has been carved out to another company or provider. You should also be aware deductibles that you may
have to meet as well as any authorization that may be required. The clinician will obtain the authorizations as
needed. This process may include releasing the diagnosis as well as additional clinical information, such as
treatment plans or summaries, or copies of the entire record in some cases. This information will become part of the
insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep
such information confidential, your clinician, and AIBDT, LLC, have no control over what they do with it once it is
in their hands. In some cases, they may share the information with a national medical information databank. I will
provide you with a copy of any report I submit, if you request it. For services not covered by your insurance, we
will discuss and sign additional consent for agreement of out of pocket expenses.

CONTACTING ME
You will be given the individual contact information for your psychologist/counselor. Generally, this is a cell phone
number. You may also call the main office number at 412-329-7778. Your therapist may not be immediately
available by telephone, although telephone messages are checked regularly between 9 AM and 5 PM. We will make
every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are
difficult to reach, please inform your clinician of some times when you will be available. If you are unable to reach
your clinician and feel that you cannot wait for a return phone call, contact your primary care physician or the
nearest emergency room and ask for the psychiatrist on call. You can also contact Allegheny County Mental Health
Crisis Line at 1-888-424-2287. If your clinician will be unavailable for an extended time, you will be provided with
the name of a colleague here in the office to contact, if necessary.

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PROFESSIONAL RECORDS
The laws and standards of Psychology and Professional Counseling require that treatment records be kept. You are
entitled to review your therapy health records, or your clinician can prepare a summary for you instead. However,
you may not photocopy any psychotherapy notes or other documents in the mental health file. Because these are
professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your
records, it is recommended that you review them with your psychologist/counselor together, so that you can discuss
the contents. Patients will be charged an appropriate fee for any professional time spent in responding to information
requests.

MINORS
If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine
your treatment records. If your parents agree to give up rights to access your records, the clinician will provide them
only with general information about our treatment, unless there is concern with high risk that you will seriously
harm yourself or someone else. In this case, your clinician is required by law to release information to them and
possibly to protection agencies. Before giving your parents any information, the clinician will discuss the matter
with you, if possible, and do his/her best to handle any objections you may have. It is also noted that PA State Low
allows minutes 14 years and older the right to consent for mental health treatment.

CONFIDENTIALITY
In general, the privacy of all communication between a patient and a provider is protected by law, and the
Psychologist/Counselor can only release information about our work to others with your written permission. But
there are a few exceptions.

In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In
some proceedings involving child custody and those in which your emotional condition is an important issue, a
judge may order the Psychologist or Counselor to testify if he/she determines that the issues demand it.

There are some situations in which the Psychologist and Counselors are legally obligated to take action to protect
others from harm, even if this involves revealing information about a patient’s treatment. For example, if the
clinician believes that a child [elderly person, or disabled person] is being abused, (s)he must [may be required to]
file a report with the appropriate state agency.

If the clinician believes that a patient is threatening serious bodily harm to another, (h)she may be required to take
protective actions. These actions may include notifying the potential victim, contacting the police, or seeking
hospitalization for the patient. If the patient threatens to harm himself/herself, the clinician may be obligated to seek
hospitalization for him/her or to contact family members or others who can help provide protection.

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While this written summary of exceptions to confidentiality should prove helpful in informing you about potential
problems, it is important that you discuss any questions or concerns that you may have at your next meeting. Your
Psychologist/Counselor will be happy to discuss these issues with you if you need specific advice, but formal legal
advice may be needed because the laws governing confidentiality are quite complex.

Your signature below indicates that you have read the information in this document and agree to abide by its terms
during our professional relationship.

My signature indicates that I (client and parent/guardian) have reviewed and understand the above information,
including confidentiality, and consent for treatment.

Client Name and DOB ________________________________________________

Patient Signature ________________________________________ Date__________

Provider’s Signature (Witness) _______________________________ Date ________

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