Practice Policies:

Welcome to our Practice Policies Page where we present you with forms and policy documents that refer to the various types of therapy services we provide. Please click on the item below to be taken directly to the section of the page that contains the document you wish to see. You are encouraged to review these documentsy prior to your first visit. You are also given the ability to download and print the document if you wish.

  1. Go to the Intake History Document (1 page)
  2. Go to the Symptoms Checklist Document (2 pages)
  3. Go to the Client Information Financial Policy (3 pages)

Intake History Document

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INTAKE HISTORY  

                            Date: ___/___/___

Patient Name  ____________________________________________________________

                                              (Last)                                        (First)                                                                             (Middle)                                                                           

Address _____________________________________________Phone ______________

City/State/Zipcode_________________________________________________________

Referred By __________________________ Relation to Patient ___________________

Date of Birth ___________    Birthplace ___________Year Coming to Atlanta _________

 

        EDUCATION

High School ___Some College __  Associates___Bachelors ___Masters __ Post-Graduate Education/Degree __  Other___ Please Explain__________________________________

High School Attended________________College or University Attended____________

 

                                                                  WORK HISTORY

 

Employer ____________________________ City/State_____________________________

Circle one:   Full-Time     Part-Time                     Years Employed_______ Salary___________

Previous Employer_____________________ City/State_____________________________

Years Employed_______________________Reason for Leaving_____________________ 

 

   MILITARY SERVICE

 

None___ Branch_________ Rank_________  Length of Service (years) _______________

Discharge Type/Date ________________________ Compensation____________________

                                                                                                          

     COURT RECORD

 

Arrests____________________________ Time Served_____________________________

Tickets/Violations/Fines______________________________________________________

Lawsuits/Civil Action_________________________________________________________

 

                  MARITAL STATUS

 

Present Status______________How Long_________ Spouse Age____Employment History: Currently employed? _____   Where ______________How Long (years)________________ Salary____________ Education _____________Past Employment_____________________

Child(ren)/Gender/Age________________________________________________________

Step and/or Adopted Child(ren)/Gender/Age______________________________________

                            

     FAMILY HISTORY

 

MOTHER: Living___Deceased___If Deceased: Year____Cause of Death_______________

If Living: Age___ Location_________________With Whom__________________________

Employed?____Where___________Past Employment_______________________________

FATHER:   Living___ Deceased____   If Deceased: Year___ Cause of Death______________

If Living: Age___ Location_________________ With Whom__________________________

Employed? ____Where? __________Past Employment______________________________

Siblings/Gender/Age_________________________________________________________

__________________________________________________________________________

 

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Symptoms Checklist Document

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SYMPTOMS CHECKLIST:     Please mark all items as they apply to you.  Check only those items that affect you at least once or twice per week.

 

___Headaches                                                                                           ___Overeating

___Constipation                                                                                      ___Excessive urination

___Loose bowel movements                                                           ___Cold hands or feet

___Hot flashes                                                                                          ___Blushing

___Voice quivering or shaking                                                       ___Lump in throat

___Dry mouth                                                                                            ___Stuttering

___Tightness in jaw                                                                               ___Grinding of teeth

___Soreness of muscles                                                                      ___Lower back pains

___Weakness in parts of your body                                            ___Heavy feeling - arms/legs

___Pains in heart or chest                                                                  ___Heart racing

___Smoking                                                                                                ___Allergies

___Itching/Hives                                                                                      ___Tightness in stomach

___Sweaty palms                                                                                     ___Nausea or upset stomach

___Feeling tense or nervous                                                           ___Trouble getting your breath

___Shakiness                                                                                             ___Extreme fear of places or events

___Bad dreams                                                                                         ___Feeling fearful

___Your mind going blank                                                                ___Feeling inferior to others

___Difficulty making decisions                                                       ___Difficulty concentrating

___Poor appetite                                                                                    ___Thoughts of ending your life

___Easily annoyed or irritated                                                        ___Worrying or stewing about things         

___Easily crying                                                                                        ___Loss of interest in things

___Loss of sexual functioning                                                        ___Difficulty in falling asleep

___Uncontrollable outbursts of temper                                  ___Fatigue

___Loss of sexual interest or desire                                           ___Desire to end your life

 

List all medications you are currently taking.  Please include vitamins, herbs, supplements, and over-the-counter medicines.

            Name of Medication                                          Dosage Amount/ Times per day                                          Usefulness

_____________________________________       ______________________________                         _____________

_____________________________________       ______________________________                         _____________

_____________________________________       ______________________________                         _____________

_____________________________________       ______________________________                         _____________

 

List all medications previously taken for the above indicated symptoms: ____________________

_________________________________________________________________________________

 

List all health and medical conditions and surgeries (current and past) for which you have been diagnosed, treated for, or prescribed medications.  Please include dates.

______________________________________     ______________________________________ ______________________________________     ______________________________________

______________________________________     ______________________________________

______________________________________     ______________________________________

______________________________________     ______________________________________

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Client Information Financial Policy Document

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Buckhead Counseling, Psychiatry, & Psychotherapy

Scott Patterson, M.D., P.C., CGP, FAPA

Eleanor Brower, R.N., PhD, CGP 

 

Directions:  Please read these three pages; initial each page on the bottom right, and sign where indicated.

Date:____/____/____

 

CLIENT INFORMATION 

Client Name:  ___________________________________________________

                             (First)                          (MI)                     (Last)

Social Security Number: ____________________  Referred by: ____________________

Highest Level of Education:__________________ Occupation: ____________________

In Case of an Emergency Call: ______________________________________________

                                                   (Name)                                             (Phone)

 

FINANCIAL POLICY

I understand that all charges are due at the time service is rendered and that I am responsible for all charges incurred.  I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR MISSED APPOINTMENT CHARGES UNLESS THE THERAPIST IS NOTIFIED 48 HOURS IN ADVANCE.  Insurance does not cover missed appointments.  Patients are responsible for the full fee (see last page).

 

Brief professional services and phone consultations will be billed at our standard rates in 15” increments.    Some procedures may require our office staff or Dr. Patterson or Dr. Brower to provide exceptional services outside the normal visit.  Please be aware that some, and perhaps all, of these type services may not be covered by insurance carriers if they do not consider them reasonable and necessary.  You are responsible for all services not covered by your insurance company.

 

OUR OFFICE WILL NOT ENTER INTO A DISPUTE WITH YOUR INSURANCE COMPANY OVER YOUR CLAIM.  OUR OFFICE WILL FILE YOUR CLAIM ONE TIME.  You will receive a statement every month your account shows a balance due.  In the event your insurance has not paid within 45 days; the balance will be transferred to your personal balance, which must be paid before your next scheduled appointment.  Your insurance policy is a contract between you and your insurance company; therefore, your balance is your responsibility.

 

INTEREST

We reserve the right to charge interest in the amount of 1.5% monthly (18% annually) as provided by state law on all past due account balances.

___________________________

Client Signature/Date

 

RE-FILING PROCESSING FEE

We cannot bill any insurance company appropriately without correct patient and insurance information.  We ask that you provide insurance identification and patient information at your first visit and thereafter whenever there are changes.  If claims are denied due to incorrect information, a $25 refiling fee will be charged to the patient.

 

MEDICATION REFILL POLICY

During your appointments, prescriptions for medications and refills are given in a supply sufficient to last until your next scheduled appointment, which should be made prior to your leaving the office.

 

If you do not make a future appointment at the time of your visit, it is necessary to call 2 weeks in advance of the time that you will be out of medication so that we can find an appointment time that will prevent your running out of medication.  We will make every effort to find an appointment for you within those two weeks. 

 

If there is a problem such as…loss of prescription, cancelled appointment, going out of town, forgetting to call, missed appointment, didn’t call two weeks in advance…then Drs. Patterson and Brower will either wait until the next scheduled appointment to write your prescription (if clinically safe) or write/call in the prescription for a charge of $25 to cover phone and chart time.

 

RETURN CHECK FEES

A $35 processing fee will be charged for checks returned as insufficient funds, stop payment on an issued check and checks drawn on a closed account.  This charge is applied to your personal account balance and must be paid within 14 days of notification to avoid further action.

 

*It is a criminal offense to present a check for payment that is drawn on a closed account.

 

COLLECTION AGENCY

Our office will attempt to collect on past due accounts and returned checks.  If our efforts are unsuccessful, we will forward your account to a collection agency for assistance in resolving these matters.

Thank you for understanding our Office Policies.  Please let us know if you have any questions or concerns.

I have read and understand this Financial Policy and Medication Policy.

Signed: ________________________________________  Date: __________________

Witness: _______________________________________  Date: __________________

 

 

I voluntarily request counseling and understand that whatever I say in my psychotherapy sessions will be held in strictest confidence and will not be shared with anyone unless I give written consent to do so.  However, as required by law, there are two exceptions to confidentiality in these sessions.  These are:  1) if I disclose plans to physically injure or kill another person or myself, I understand my therapist is required by law to inform that person or the necessary authorities of my intent; 2) if I disclose that a minor child, adolescent, or elderly person is currently being physically or sexually abused, my therapist is required by law to notify the Child Protective Agency.

 

If I have a life threatening emergency I will call 911 or report to a hospital.

 

Signed: ________________________________________  Date: __________________

Witness: _______________________________________  Date: __________________

 

FEE SCHEDULE

Psychiatric Evaluation/Individual Psychotherapy

  1. Dr. Brower (50 minutes):  $200/$150
  2. Dr. Patterson (50 minutes):  $250/$200
  3. Psychotherapy with Medication Evaluation (25 minutes):  $100
  4. Group Psychotherapy (90 minutes):  $65

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