Intake Form

Step 1 of 12

Email(Required)

Full Name(Required)

Today's Date(Required)

MM slash DD slash YYYY

Social Security Number(Required)

Please enter a number greater than or equal to 0.

Address Line 1(Required)

Address Line 2

City(Required)

State(Required)

Zip Code(Required)

Please enter a number greater than or equal to 0.

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Marital Status

Single

Married

Divorced

Widowed

Separated

Other

Home Phone Number

Work Phone Number

Cell Phone Number

May we contact you at these numbers and leave messages?(Required)

Yes

Pharmacy Name(Required)

Pharmacy Phone Number(Required)

Who is your employer?(Required)

What is your occupation?(Required)

Are you currently on a leave of Absence, Disability or FMLA?(Required)

Yes

Referral information

Primary Care Provider(Required)

Primary Care Provider's Phone Number(Required)

Therapist(Required)

Therapist's Phone Number(Required)

School/Contact Information

Where do you or your child attend school:(Required)

Primary contact at school (counselor, teacher, advisor, etc):(Required)

Commercial Insurance and Payment

Please review and know your co-pay and applicable deductible as described in your health insurance policy manual. Any and All Payments are required at the time of your visit – before seeing James Geer (this includes insurance cards that say you do not pay the provider at the time of the visit).

Deductibles are your responsibility and required prior to appointments.

We do not bill your insurance company first when you have a deductible.

Billing

A valid credit or debit card is required and kept on file for unpaid balances over 60 days. This card will also be charged $125.00 for missed appointments/late cancellations, as per our policy and $25.00 for off schedule medication refills.

Any outstanding balances must be paid prior to your appointment.

On rare occasions it has been necessary for us to employ a third party billing agency to collect unpaid balances. Service fee surcharges for collections are added to delinquent accounts.

Cost to do any paperwork is $150.00

Cost for a letter is $75.00

Appointment Cancellations and No Shows

48 hours notice is required for cancellations or rescheduling of appointments. Cancellations that are made inside of 24 hours of the appointment time are considered “late cancellations.”

Monday appointments that are cancelled on Friday – Sunday are considered late cancellations as we are closed on Friday’s.

No Show and Late Cancellations are charged $125 for medication checks and $225 for evaluation and extended appts directly to your credit/debit card that is on file.

Medication Refills Outside of Scheduled Appointments

Follow-Up appointments are scheduled at particular times to evaluate the safety and effectiveness of medications that you are taking.

Appointments are frequent during medication starts and changes but become less frequent as treatment progresses.

Refills requests due to missed appointments are called in to your pharmacy after your appointment is re-scheduled. A $25 service fee is required.

Medication Changes

Appointments are a time to have detailed discussions about your treatment progress; medication effectiveness and information gathering in order provide the best care. Your appointment is a time specifically carved out to re-evaluate your response to treatment and to talk about any concerns, ask questions and for you to be heard – your opinion about medication that you are taking is expected and necessary to help steer your treatment – you are the center of your treatment. Prior to leaving, a verbal or written guideline is provided about what you should expect while starting or changing medication. If you are having problems, questions or side effects from medication, we encourage you to call the office to discuss this .

Medication changes, switching, increasing or decreasing doses, adding other medications are only discussed during face-to-face appointments.

We do not provide detailed medication consultations over the phone.

Disability/FMLA and Official Treatment Documents

Documents are prepared on a case-by-case basis for established patients and are billed prior to completion.

We do not meet with patients for the sole purpose of gaining FMLA or Disability.

Official letters of endorsement regarding mental illness or psychiatric care for court purposes, legal purposes, employment etc. for new patients cannot be adequately determined during the first several months of treatment

Please type your full name below for an electronic signature acknowledging your understanding and agreement to my treatment policies.(Required)

Select today's date(Required)

MM slash DD slash YYYY

Insurance Information

Please select your insurance company from the list below, if it is not listed, please select other and specify your insurance name.(Required)

Aetna

United Behavioral Healthcare (UBC)

Other (please specify)

Highmark Health Options Medicaid

Blue Cross Blue Shield

Amerihealth Caritas (Medicaid)

Delaware First Health (Medicaid)

Medicare

Do you have a Secondary Insurance? If, so please the put information below.(Required)

Insurance Card Information

Member ID(Required)

Group ID(Required)

Policy Holder Name(Required)

Policy Holder's Date of Birth(Required)

MM slash DD slash YYYY

Policy Holder's Social Security Number(Required)

Please enter a number greater than or equal to 0.

Annual Deductible Amount(Required)

Please enter a number greater than or equal to 0.

Has the deductible been met?(Required)

Yes

Has the deductible been met?(Required)

Please enter a number greater than or equal to 0.

Co-Pay Amount(Required)

Please enter a number greater than or equal to 0.

Co-Insurance Amount(Required)

Please enter a number greater than or equal to 0.

Health Savings Account(Required)

Yes

Emergency Contact

Emergency Contact Name(Required)

Relationship(Required)

Phone Number(Required)

Please type your full name below for an electronic signature to give permission to contact this person for emergencies.(Required)

General Policies

Treatment Policies and Agreements

Give 48 hours notice in the event that I cannot make an appointment.We do not meet with patients for the sole purpose of gaining FMLA or Disability.

Pay co-pays and balances at each appointment.

Abstain from using illicit drugs while being treated in our office.

I understand that falsifying mental health symptoms in order to gain a prescription for controlled substances is a felony offense. The Office of Drug Diversion and The DEA will be notified.

I understand that medication refills and telephone medication checks are not done over the phone or by electronic means.

Medication that needs to be called in off-hour due to cancelled or no show appts are charged $225.00.

Communicating clinical or necessary information (documents, charts, medication records, evaluation forms, etc.) may be sent to: jgeerpsych@gmail.com.

Controlled Substances that have been stolen, destroyed, lost or misplaced will NOT be refilled. These medications are to be handled with diligence and responsibility and kept in a safe, secure place.

Random medication counts and drug screening if there is suspicion of abuse, misuse or illicit drug use in conjunction with controlled substances being prescribed to you.

Taking medication as prescribed; not changing doses or taking more medication than is prescribed – Increasing the dose or taking more medication that have been prescribed without communication to us, will result in your immediate discharge.

Attending scheduled appointments is expected. 2 or more no showed or late cancelled appointments inhibits a responsible treatment approach and may result in your discharge from treatment.

Please type your full name below for an electronic signature acknowledging your understanding and agreement to my treatment policies.

Select today's date(Required)

MM slash DD slash YYYY

A valid credit card is required for ALL commercially insured patients.This card will only be charged for missed appointments as outlined in our policy and/or for unpaid balances. You will be notified about any charges and provided with a receipt.

Credit Card Number(Required)

Please enter a number greater than or equal to 0.

Expiration(Required)

Please enter a number greater than or equal to 0.

CCV(Required)

Please enter a number greater than or equal to 0.

Name on Card(Required)

Please type your full name to electronically sign to consent for credit card usage.(Required)

Safety Contract

Date(Required)

MM slash DD slash YYYY

Name(Required)

In the event that I am feeling in anyway unsafe, unable to predict actions that would jeopardize my safety or the safety of others – I make a pledge and a promise that I will talk to the following person:*(Required)

If I am unable to reach this person, I will call 911 or I will call Mobile Crisis at: 800-652-2929 or I will call the CAPES Unit at Wilmington Hospital: 302-428-2118.

Please type your full name to electronically sign to the safety contract. (Patient)(Required)

Please type your full name to electronically sign to the safety contract. (Witness)(Required)

Release of Protected Information

Patient Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Cell Number(Required)

Address Line 1(Required)

City(Required)

State(Required)

Zip Code(Required)

Please enter a number greater than or equal to 0.

Release Treatment Policies and Agreements

I authorize J Geer Psychiatry, 1601 Milltown Road, Unit 12, Wilmington, DE 19808, Fax: 302-502-3257 Facility Phone: 302-502-3255.
To disclose: Psychiatric and Medical Treatment Notes, Labs, Medications, Imaging studies, Opinions, Therapeutic treatment and relative history. Unrestricted communication is authorized between Bancroft Behavioral Health, Inc. and the authorized agency, hospital, attorney or other provider listed below.
*It is our aim to collaborate with everyone involved in your treatment so that we may provide the best treatment*

Please list the name(s) of the person(s) or organization(s) for information exchange:

Therapist(Required)

Therapist's Phone Number(Required)

Therapist's Fax Number(Required)

Primary Care Provider(Required)

Primary Care Provider's Phone Number(Required)

Primary Care Provider's Fax Number(Required)

Family Member or Other(Required)

Family Member or Other's Phone Number(Required)

Family Member or Other's Fax Number Number(Required)

I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: _________________. If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure. I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

Please type your full name to electronically sign to the release for information.(Required)

Consent to Treatment

I acknowledge that I have received, have read (or have read to me), and understand the “Client Information” packet and/or other information about the services that I am considering. I have had all my questions answered fully.
I do hereby seek and consent to take part in the treatment by J Geer Psychiatry. I understand that developing a treatment plan with this facility and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I also consent to drug screens to determine the use of illicit drugs which may interfere and/or interact with psychotropic medication. Failure to comply with random drug screens may result in discharge from treatment.
I am aware that I may stop my treatment with this facility at any time. The only thing I will still be responsible for paying is for the service that I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment (for example, if my treatment has been court-ordered, I will have to answer to the court).
I am aware that an agent of my insurance company or other third-part payer may be given information about the type(s), cost(s), date(s) and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the provider(s) may stop my treatment.
My signature below shows that I understand and agree with all of these statements.

Please type your full name to electronically sign the consent to treatment form.(Required)

Select today's date(Required)

MM slash DD slash YYYY

Notice of Privacy Practices

Please check the appropriate box, and type your electronic signature.(Required)

I have read and/or understand my rights under the HIPPA Act of 1996.

I waive my right to read about guarantees under the HIPPA Act of 1996.

Please type your full name to electronically to acknowledge your HIPPA right mentioned above.(Required)