Dr. Gail Reece


Helping put the pieces together...


Intake Paperwork


Please copy this paperwork, read it carefully and then fill it out and bring it to your first appointment.


Put cursor on text. Right click, click on select all, right click, click on copy. Move cursor to blank word processor page. Right click. then click on paste....print. Read carefully, there are several places you should sign.




Office of Dr. Gail Reece at Miller Psychological Associates


6740 Jamestown Drive, Alpharetta, GA 30005


Telephone (678) 339-1221




Admitting Form



Date____________



Name________________________________ Date of Birth________________



Address_________________________________________________________



City_____________________________________Zip_____________________



Home Phone___________________ Work or cell Phone__________________



Can we leave messages at these numbers?____________________________



E-mail Address___________________________________________________



Employer/School_________________________________________________



Marital Status_____________



Spouse/Parent’s Name____________________________________________



Person to contact in case of an emergency____________________________



Phone number for emergency contact_______________________________



How were you referred to our office?________________________________



Person responsible for bill if different from above:



Name_______________________________Relationship________________



Address_______________________________________________________



Home Phone__________________ Work or cell Phone_________________



I agree to stay current with payments.



24 hour cancellation policy



Therapy time has been specifically reserved for your use. Regardless of reason, any appointments that are not cancelled at least 24 hours in advance of the appointment time will be billed at the rate equal to one half of your session cost. Billing you at one half of the cost creates a situation where the financial burden is shared equally between you and your therapist. Please do not ask your therapist to make the entire financial sacrifice.


Cancellations may be made by voice mail at 404 987 5579.




Signature ________________________________ Date___________________





Consent Form



I _______________ __________ hereby grant permission to Dr. Gail Reece to provide any therapy, testing, or diagnostic evaluation that may be deemed pertinent in the treatment of myself, my marriage, or my family (including my minor children). I willingly and voluntarily agree to mental health treatment and release any and all other providers and support/clerical contractors from liability claims. I understand that all fees are due at the time of service. In other words, the full fee must be paid at the start of each session. I understand that there is a 24 hour cancellation policy and I will be billed the rate of one half of the full fee for my missed appointment unless I have cancelled my appointment at least 24 hours in advance of the appointment time. I understand that there will be a $25.00 service charge for all returned checks and that all additional collection expenses are my financial responsibility if the amount of the returned check plus $25.00 is not paid in cash within 30 days. I understand that outstanding accounts will be forwarded to a collection agency. By signing this agreement, I waive confidentiality for that purpose only.



Confidentiality policy



Our confidentiality policy is highly regarded and followed. All communications between client and therapist are kept strictly confidential. Dr. Reece or any associate of Dr. Reece will respond to any request for release of information regarding all our clients by indicating that a signed written release must be obtained prior to any information being released or discussed. Otherwise we will not even acknowledge that the undersigned is a client of Dr. Reece. Exceptions to this rule are where state law requires the reporting of threats of violence, harm, or child/elder abuse and neglect (from evidence or suspicion), and when information is subpoenaed by the courts.



Requested Documents



There is a $50.00 fee for all letters, disability paperwork, and other documents similar in nature that we complete for our clients.



Waiver of Legal Testimony



Dr. Reece considers all communication, either with you or with anyone she speaks with for case coordination to be privileged information. Any trip to court or discussion with a lawyer can put the therapist in an extremely dangerous ethical and legal position. If your goal in entering counseling is to find someone to be your advocate in a legal situation, please let us know and she will assist you to the best of her ability to find the right person to help with your legal testimony. Dr. Reece is asking for your agreement at this time that you will never request a subpoena for her or an employee of hers or for any therapy records other than dates of treatment, a five Axis diagnosis, a synopsis of therapy goals and an evaluation of your general progress.



Emergency Services



In the event that I become ill or I am injured while on the premises, I authorize Dr. Reece or her associates to provide or obtain emergency medical services (i.e. call an ambulance).


My signature acknowledges agreement to conditions set forth above.




Signature:_______________________________________________




Date:_______________



Statement of Clients’ Rights



Clients have the right to be treated with dignity and respect.



Clients have the right to fair treatment; regardless of their race, religion, gender, ethnicity, age, disability, or source of payment.



Clients have the right to easily access timely care in a timely fashion.



Clients have the right to know about their treatment choices. This is regardless of cost or coverage by the member’s benefit plan.



Clients have the right to share in developing their plan of care.



Clients have the right to have a clear explanation of their condition and treatment options.



Clients have the right to information about my services and role in the treatment process.



Clients have the right to information about clinical guidelines used in providing and managing their care.



Clients have the right to ask their provider about their work history and training.



Clients have the right to give input on the Clients’ Rights and Responsibilities policy.



Clients have a right to know about advocacy and community groups and prevention services.



Clients have a right to freely file a complaint or appeal and to learn how to do so.



Clients have the right to know of their rights and responsibilities in the treatment process.



Clients have the right to list certain preferences in a provider.



Statement of Clients’ Responsibilities



Clients have the responsibility to treat those giving them care with dignity and respect.



Clients have the responsibility to give providers information they need. This is so providers can deliver the best possible care.



Clients have the responsibility to ask questions about their care. This is to help them understand their care.



Clients have the responsibility to follow the treatment plan. The plan of care is to be agreed upon by the member and provider.



Clients have the responsibility to follow the agreed upon medication plan.



Clients have the responsibility to tell their provider and primary care physician about medication changes, including medications given to them by others.



Clients have the responsibility to keep their appointments. Clients should call Dr. Reece as soon as they know they need to cancel visits. There is a cancellation fee equal to one half of the regular appointment fee for appointments not canceled at least 24 hours in advance of the appointment time. This applies regardless of reason for cancellation.



Clients have the responsibility to let their provider know when the treatment plan isn’t working for them.



Clients have the responsibility to let their therapist know about problems with paying fees and to make arrangements to pay fees as agreed.



Clients have the responsibility to report abuse and fraud.



Acknowledgement:



My signature below shows that I have been informed of my rights and responsibilities, and that I understand this information.




Client Signature_________________________________



Date__________________________________________




Please bring this completed paperwork to your first appointment.


If you are filling out paperwork for your minor child, please fill in his or her history and then add to the bottom (or on a separate sheet) family history that you believe to be important in the current situation.



Patient Name:_______________________________ Date:________



Age:______________ Birth date:________________



Name and relationship of person completing this form (if not patient)



____________________________________________________________



1. Briefly describe the problem which brought you here today:__________



_____________________________________________________________



_____________________________________________________________



2. Are you having thoughts of hurting yourself or someone else? YES NO



If yes, please explain:___________________________________________



Have you ever had thoughts of hurting yourself or someone else? YES NO



PAST TREATMENT



3. Have you ever been treated for psychiatric, substance abuse, emotional,



or behavioral problems in the past? YES NO



If yes, when, where, and with whom?_____________________________



Did you find past treatment helpful? YES NO



4. Are you currently under the care of a psychiatrist, therapist, or your


primary care provider for a psychiatric problem? YES NO



5. Are you currently taking any psychiatric medications? YES NO



If yes, please list name(s) and dosage(s):__________________________



___________________________________________________________



Have you ever taken any psychiatric medications? YES NO



If yes, please list name(s) and dosage(s):__________________________



___________________________________________________________



MEDICAL PROBLEMS



6. Do you have any current medical problems? YES NO



If yes, please list:____________________________________________



__________________________________________________________



Have you ever had any significant medical problems? YES NO



If yes, please list:____________________________________________



7. Would you like information from today’s visit communicated to your


primary care provider or any other medical doctor? YES NO



8. Are you currently taking medication for medical problems? YES NO



If yes, please list name(s), dosage(s), and purpose:__________________



__________________________________________________________



9. Do you have any allergies and/or medication allergies? YES NO



If yes, please list:_____________________________________________



10. Do you have a history of head injury, seizures, or loss of consciousness?



YES NO Please explain:_________________________________



11. (Women only) Are you pregnant? YES NO



12. Do you have any pain management issues? YES NO



SUBSTANCE ABUSE



13. Have you ever been treated for drug or alcohol abuse, or any other


addictions? YES NO



14. Do you currently attend support groups? YES NO



15. Please circle any of the following that you have used in the past 30 days: tobacco, alcohol, marijuana, tranquilizers, sleeping pills, pain killers, heroin, cocaine/crack, methamphetamines/speed, methadone, LSD, PCP, Ecstasy, inhalants.



16. Have you ever experienced withdrawal symptoms? YES NO



17. Have you ever had a DUI? YES NO



LEGAL ISSUES



18. Do you have any current legal issues? YES NO



19. Are you currently on probation/parole? YES NO



20. Do you have a DFACS worker? YES NO



EMPLOYMENT/EDUCATION



21. Please circle current employment status: full time, part time, unemployed, homemaker, student, disabled, retired.



22. Are you currently on leave from work or seeking medical leave/disability?



YES NO



23. Please circle educational background: current student, did not complete high school, graduated high school, GED, some college, graduated college, advanced degree.



24. Did you experience difficulties in school? YES NO



FAMILY/RELATIONSHIPS



25. Please list anyone who lives in your home, his/her age, and relationship



______________________________________________________________



______________________________________________________________



26. Does anyone in your immediate or extended family have psychiatric, emotional, substance abuse, or behavioral problems? YES NO



If yes, please explain:_______________________________________



_________________________________________________________



27. Do you have a history of sexual or physical abuse? YES NO



28. Do you have any domestic violence issues? YES NO



29. What are your hobbies/interests?__________________________



________________________________________________________



30. Is your support network: Good Moderate Poor



31. Do you have any difficulties or concerns about how you get along with other people? YES NO



32. Do you have difficulties with spiritual or religious matters?


YES NO



33. Do you have any sexual orientation/gender issues or concerns?


YES NO



TREATMENT ACCESS/MOBILITY



34. Are there any financial concerns that would affect your ability to access treatment? YES NO



35. Do you have access to transportation? YES NO



36. Do you have any disabilities, special needs, or other restrictions


that may impact your treatment or access to treatment? YES NO



Patient (or person completing this form)



Signature ____________________________________________



Date ________________________________________________
























Dr. Gail Reece - Reece Counseling - Mental Health Counselor in Georgia
Professional Counseling Services - Marriage counseling - Addiction counseling
6740 Jamestown DriveAlpharetta, GA 30005
Phone : 678 339 1221
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