Harbor Crest

Comprehensive Counseling Group
Northside Plaza  978 Route 45, Suite L7    Pomona, New York  10970   (845) 354­9200

A Comprehensive Multidisciplinary Counseling Practice  Serving Children, Adolescents and Adults

PATIENT REGISTRATION
LAST NAME ______________________________________FIRST __________________________ MI___________
ADDRESS ____________________________________________________________________________________
CITY__________________________________ STATE__________________ZIP _____________________________
HOME PH # ____________________WORK PH # _______________________CELL PH #_____________________
DATE OF BIRTH _______________ SEX_____________________SS# ____________________________________
RELATION TO INSURED:  SELF  SPOUSE  CHILD  OTHER
MARITAL STATUS:  MARRIED SINGLE  WIDOWED  DIVORCED  SEPER.
SECURE E-MAIL ADDRESS ______________________________________ for appointment reminders, news & other
information. It will only be used by Harbor Crest. This should be an address that is private for personal messages.
OCCUPATION ___________________________________FULL/PART TIME _______________________________
EMPLOYER _____________________________________________________________________________________
ADDRESS ______________________________________________________________________________________
RESPONSIBLE PARTY
LAST NAME ___________________________________FIRST _____________________ MI___________________
ADDRESS ______________________________________________________________________________________
CITY ______________________STATE _________________________ZIP _________________________________
HOME PHONE _________________________WORK PHONE ____________________________________________
DATE OF BIRTH ______________SEX _______________________SS# ____________________________________
OCCUPATION ___________________________________FULL/PART TIME _______________________________
EMPLOYER _____________________________________________________________________________________
ADDRESS ______________________________________________________________________________________
RESPONSIBLE PARTY'S INSURANCE INFORMATION
PRIMARY INSURANCE CO. _______________________________________________________________________
INSURANCE CO. ADDRESS _______________________________________________________________________
CITY ______________________STATE _______________________ZIP _______TEL. ( ) ___________________
POLICY # ____________________________________________________ GROUP # ____________\_____________
GROUP/EMP _______________ GROUP/OTHER ______ PRIVATE ______ HMO ______ PPO ________________

SECONDARY INSURANCE CO. ___________________________________________________________________

INSURANCE CO. ADDRESS _______________________________________________________________________
CITY ______________________STATE _______________________ZIP _______TEL. ( ) ____________________
POLICY # ____________________________________________________ GROUP # ____________\_____________
GROUP/EMP _______________ GROUP/OTHER ______ PRIVATE ______ HMO ______ PPO ________________
INFORMED CONSENT
Confidentiality will be respected. Certain circumstances, as follows, may not
be protected by that confidentiality in accordance with the law:
1) Suicide or danger to self
2) Homicide or danger to others
3) Child abuse

LATENESS AND CANCELLATION

If you come to a session late you will receive the remaining time in that
session. This is done to avoid encroaching on other people's appointments.

If you need to cancel 24 hours notice is required. If notice is less than 24 hours
then a “no-show” fee of $50 (fifty) dollars is due for the session will be billed to
you personally as most insurance companies will not pay for "no-shows". The
reasoning for this cancellation policy is that the appointment time is reserved
for you and was unable to be filled by others requesting an appointment. When
more than 24 hours notice is given adjustments can be made and another
person can be given the appointment. When less than 24 hours notice is given
the appointment often cannot be filled. Consistent attendance is essential for a
successful treatment program.

AUTHORIZATION TO TREAT MINORS

If a client is under the age of 18 years old, we require that his or her parent’s or
legal guardian’s consent to counsel and treat the client. By signing below you
attest to being the parent or guardian of the client and give Harbor Crest
permission to provide counseling and treatment services.

PAYMENT AND INSURANCE

Payment is due at the time of service. If you are covered by insurance please
pay any deductible or coinsurance to our receptionist. Any fees not paid by
insurance will be your responsibility to pay. For most plans, as participating
providers, payment from the insurance company will be sent directly to us. If,
for any reason, payment has been made directly to you, please bring it to our
receptionist. By signing below you authorize Harbor Crest to refer your account
to collection if you do not pay fees due, and you agree to pay for any fees for
collection in addition to the amount due. You authorize Harbor Crest
Counseling to release any medical or other information necessary to process an
insurance claim(s) and/or obtain authorization or reauthorization, including by
electronic means to process these claims. In addition you authorize insurance
benefits be paid to Harbor Crest Comprehensive Counseling Group. Please
notify our insurance promptly if you change insurance.

HIPAA
I have received and understand this practice’s Notice of Privacy Practices
written in plain language. The notice provides in detail all the uses and
disclosures of my protected health information that may be made by this
practice, my individual rights, how I may exercise these rights and the
practice’s legal duties with respect to my information.

I understand that this practice reserves the right to change the terms of its
Notice of Privacy Practices, and to make changes regarding all protected health
information resident at, or controlled by this practice. If changes to this policy
occur, this practice will provide me a revised Notice of Privacy Practices upon
request. I provide consent by signing below for the mailing of emails to the
address on the first page, and hold Harbor Crest and its employees harmless
for any problems or difficulties from those emails.

Please fill out the following:

Person responsible for paying for treatment:

________________________________________
I have read the above information and agree to be bound by its terms:

______________________________________ ____________________
Signature Date
FULL NAME: FIRST MIDDLE LAST JR./SR. ETC

MEDICAL INFORMATION AND HISTORY Height: Weight:

Please include personal and family medical history and other pertinent information on back of form.

Briefly describe reason for your visit:

List Major Health Problems: List Medications, Dosage, and Frequency:

Do you have allergies? Yes No If yes, please list

Explain Current & Previous Psychiatric & Psychological Treatment. Include Provider Name, Address & Phone
Number

Please circle any of the following items pertaining to you.

Nervousness Depression Fears Education

Shyness Sexual Problems Suicidal Career Choices
Separation Divorce Finances Health
Drug Use Alcohol Use Friends Temper
Anger Self-Control Unhappiness Nightmares
Sleep Stress Work Marriage
Relaxation Headaches Tiredness Children
Legal Matters Memory Ambition Parents
Energy Making Decisions Insomnia Stomach Troubles
Loneliness Concentration Inferiority My Thoughts
Please list those people with whom you share your home.

NAME AGE/BIRTHDAY RELATIONSHIP OCCUPATION

Do you smoke? Yes No If yes, how often?

Do you drink alcohol? Yes No If yes, how often?

Other drug use? Yes No If yes, which drugs? How often?

Thank you for taking the time to fill out these forms.