INTEGRAL

Mental Health Counseling

IntegralRegistry@gmail.com

PATIENT REGISTRATION FORM

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Patient information

PATIENT'S FULL NAME DATE OF BIRTH - GENDER

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Tania Ortiz - Sanchez 08/18/1994 Female

ADDRESS

2920 Ericsson st
East Elmhurst , NY 11369
United States

SOCIAL SECURITY #

060843309

PHONE # PHONE #

( 347 ) 260-4229

EMAIL

Tanortsan@gmail.com

Emergency contact :

NAME RELATIONSHIP PHONE NUMBER

Judy Sanchez Mother ( 917 ) 299-2625

If patient is younger than 18 years old

MOTHER'S NAME FATHER'S NAME

Insurance Information

INSURANCE CARRIER ID #

SSI BENEFITS DISABILITY BENEFITS

HOW DID YOU HEAR ABOUT OUR PRACTICE ?

Online

if Referred * If he fered

NAME PHONE
>

Who Made this Appointment ?

NAME PHONE

Tania Ortiz - Sanchez ( 347 ) 260-4229

EMPLOYER OCCUPATION

Northport Medical center Advanced medical support

SCHOOL

Medical History

PRIMARY PHYSICIANS PHONE #

Jorge Alvarado ( 347 ) 565-5556

( option of NIA )

PSYCHIATRY PHONE #

& NIA )
(option
OTHER PHONE #

HAVE YOU EVER RECEIVED MENTAL HEALTH TREATMENT ?

Yes

NAME OF THERAPIST /PSYCHIATRIC /PSYCHOLOGIST PHONE #

Comprehensive counseling

CURRENT MEDICATIONS

BILL INFO .

* * Bottom of this ps. is missing signatures **

Please, input as below
*
*

X
Date
or Parent / legal Guardan
( Print Patient Name mm dd i yr
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consent / signature
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 - Center title
2 FEE AND FINANCIAL POLICY

We accept cash , check or money order . All copays , deductibles or self- pay amounts are due at the beginning of
each appointment .
Beware , as it is included in our cancellation policy . If you miss an appointment or if you do not provide with 24
hours ' advance notice of cancellation of an appointment ( except in the case of emergency ), you will be charged for
the missing appointment or late cancellation $ 40.00
If you request any letters , forms , or any other paperwork to be completed , such a disability forms , please be advise
that there is a fee for paperwork . Our fee is :

* INMIGRATION LETTERS OR REPORTS$ 500.00

the fees
* CLINICAL REPORTS $ 250.00 Center
* EVALUATIONS /CLEARANCE FOR SEX REASSIGNMENT SURGERY $ 600.00
* ATTENDANCE IN COURT( SUBPOENA) CAN BE APPLIED
Under the Health Insurance Portability and Accountability ACT ( HIPPA ) , a covered entity can charge reasonable
cost- based fees for providing medical records to patients ( 45 CFR 164.52 ( c ) ) .
Fees are expected at the time of the services. Written Psychotherapists letters regarding your care , assistance
excuse letter, or communicate with your insurance company , this is not extra charge .
We are happy to write you a receipt for taxes , flex spending , or insurance reimbursement .

Center Title
3 ) CANCELLATION / NO SHOW POLICY FEE FORM

To our patients :
Therapy is a continuous process , which necessitates your commitment to attendance every week , or the necessary
amount of times you have arranged with your therapist .
We are asking our patients to let us know 24 hours in advance if they cannot come to their appointment . Please call
your therapist or the office so we can discuss a makeup session .
If you cannot arrange a makeup session , you will be charged $ 40.00 . Additionally , if two consecutive appointments
are missed the same appointment time is not guaranteed .

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PATIENTS
FOR OUR
NOTICE
IMPORTANT
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Date
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Patient full Name or dd 14.00 )
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IMPORTANT NOTICE FOR OUR PATIENTS &

Allpatients andx or representatives will be held responsible for notifying out practice immediately of any changes or
terminations with current insurances. Failure to da so will hold patient responsible for alltherapy session payments
that were not covered by the insurance on file .
Thank you for your cooperation .

Form 7 Center Title

HIPAA Compliance Patient Consent

Our Notice of Privacy Practices provides information about how we may use or disclose protected health
sihT
information . The notice contains a patient's rights section describing your rights under the law . You ascertain that
by your signature that you have reviewed our notice before signing this consent . The terms of the notice may
change , if so , you will be notified at your next visit to update your signature /date . You have the right to restrict how
your protected health information is used and disclosed for treatment , payment or healthcare operations . We are
not required to agree with this restriction , but if we do , we shall honor this agreement .
The HIPAA ( Health Insurance Portability and Accountability Act of 1996 ) law allows for the use of the information for eritnE

treatment, payment , or healthcare operations . By signing this form , you consent to our use and disclosure of your
protected healthcare information and potentially anonymous usage in a publication . You have the right to revoke
this consent in writing , signed by you . However , such a revocation will not be retroactive .
xoB

By signing this form , I understand that: - > Center +

larger
Protected health information may be disclosed or used for treatment , payment , or healthcare
operations .
• The practice reserves the right to change the privacy policy as allowed by law . seeG
• The practice has the right to restrict the use of the information , but the practice does not have to
agree to those restrictions .
• The patient has the right to revoke this consent in writing at any time and all full disclosures will
then cease .
The practice may condition receipt of treatment upon the execution of this consent . stim

-MAY WE PHONE , EMAIL , OR SEND A TEXT TO YOU TO CONFIRM APPOINTMENTS .

Yes

-MAY WE LEAVE A MESSAGE ON YOUR ANSWERING MACHINE AT HOME OR ON YOUR CELL PHONE .

Yes etarapeS

-MAY WE DISCUSS YOUR MEDICAL CONDITION WITH ANY MEMBER OF YOUR FAMILY .

No esap
,
Inventory Center title
( Title ) BSI Brief Synoton
Below is a list of problems and complaints that people sometimes have . Please read each ddA

one carefully . After you have done so , select one of the numbered descriptors that best
o describes . MUCH THAT PROBLEM HAS BOTHERED OR DISTRESSED YOU DURING THE PAST

WEEK, INCLUDING TODAY . Do not skip any items .

NERVOUSNESS OR SHAKINESS INSIDE

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Quite A Bit
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2
FAINTNESS OR DIZZINESS

Not at All
motto
THE IDEA THAT SOMEONE ELSE CAN CONTROL YOUR THOUGHTS sucs
uep n
A Little Bit sp
 Moderately

TROUBLE REMEMBERING THINGS

Quite A Bit

FEELING EASILY ANNOYED OR IRRITATED

Quite A Bit

PAINS IN HEART OR CHEST

A Little Bit

FEELING AFRAID IN OPEN SPACES OR ON THE STREETS

Quite A Bit

THOUGHTS OF ENDING YOUR LIFE

Not at All

FEELING THAT MOST PEOPLE CANNOT BE TRUSTED

Quite A Bit
ok

POOR APPETITE

A Little Bit

SUDDENLY SCARED FOR NO REASON

A Little Bit

TEMPER OUTBURSTS THAT YOU COULD NOT CONTROL

Quite A Bit

FEELING LONELY EVEN WHEN YOU ARE WITH PEOPLE

Extremely

FEELING BLOCKED IN GETTING THINGS DONE

Quite A Bit

FEELING LONELY

Extremely

FEELING BLUE

Quite A Bit

FEELING NO INTEREST IN THINGS

Quite A Bit

FEELING FEARFUL

Quite A Bit

YOUR FEELINGS BEING EASILY HURT

Extremely

FEELING THAT PEOPLE ARE UNFRIENDLY OR DISLIKE YOU

Extremely
NAUSEA OR UPSET STOMACH

Not at All

FEELING THAT YOU ARE WATCHED OR TALKED ABOUT BY OTHERS

Extremely

TROUBLE FALLING ASLEEP

Not at All

HAVING TO CHECK AND DOUBLE - CHECK WHAT YOU DO

Extremely

DIFFICULTY MAKING DECISIONS

Extremely

FEELING AFRAID TO TRAVEL ON BUSES , SUBWAYS , TRAINS

A Little Bit
ce
TROUBLE GETTING YOUR BREATH

Not at All

HOT OR COLD SPELLS

Not at All

HAVING TO AVOID CERTAIN THINGS , PLACES , OR ACTIVITIES BECAUSE THEY FRIGHTEN YOU

Extremely

YOUR MIND GOING BLANK

Quite A Bit

NUMBNESS OR TINGLING IN PARTS OF YOUR BODY

Not at All

THE IDEA THAT YOU SHOULD BE PUNISHED FOR YOUR SINS

Quite A Bit

FEELING HOPELESS ABOUT THE FUTURE

Extremely

TROUBLE CONCENTRATING

Moderately

FEELING WEAK IN PARTS OF YOUR BODY

Not at All

FEELING TENSE OR KEYED UP

A Little Bit

THOUGHTS OF DEATH OR DYING

Not at All

HAVING URGES TO BEAT , INJURE , OR HARM SOMEONE

A Little Bit
 Quite A Bit

FEELING VERY SELF - CONSCIOUS WITH OTHERS

Quite A Bit

FEELING UNEASY IN CROWDS , SUCH AS SHOPPING OR AT A MOVIE

Extremely

NEVER FEELING CLOSE TO ANOTHER PERSON

Quite A Bit

SPELLS OF TERROR OR PANIC

Moderately

GETTING INTO FREQUENT ARGUMENTS

Quite A Bit Okſ

FEELING NERVOUS WHEN YOU ARE LEFT ALONE

Not at All

OTHERS NOT GIVING YOU PROPER CREDIT FOR YOUR ACHIEVEMENTS

Extremely

FEELING SO RESTLESS YOU COULDN'T SIT STILL

Not at All

FEELINGS OF WORTHLESSNESS

Quite A Bit

FEELING THAT PEOPLE WILL TAKE ADVANTAGE OF YOU IF YOU LET THEM

Moderately

FEELINGS OF GUILT

Extremely

THE IDEA THAT SOMETHING IS WRONG WITH YOUR MIND

Extremely

This consent was signed by

NAME

Tania Ortiz - Sanchez

CONSENT

by clicking here, I understand or I submit my electronic signature ... etc .

DATE

05/11/2021