INTAKE FORM

PATIENT INFORMATION FORM

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Intake Form

WELCOME to Martino Psychotherapy & Associates. I am pleased to have the opportunity to work with you. I would like to take this opportunity to go into our Attendance and Cancellation policy, in addition to other regulations within the practice.


Attendance and Cancellation Policy

Appointment times are set to accommodate my patient’s schedules as often as possible. To get the most from therapy and to properly assist you, it is best that you keep your appointments on a regular basis. If a patient is not participating in therapy for 5 consecutive weeks, the clinician reserves the right to discharge patient from caseload with prior notice. If a patient discharges from therapy and is interested in participating in therapy again in the future, they will be placed on the waiting list. It is my policy to charge a full fee for missed appointments, unless I am given 24 hour notice. If you are using insurance, there will be a $85 fee, as we cannot charge insurance for missed appointments. For Saturday appointments, where demand for appointments is high, I require a 48 hour cancellation. If you are more than 15 minutes late, you are subjected to paying the full session fee unless you are paying OOP (out of pocket.)

Consent for Treatment and Limits of Liability


Limits of Services and Assumption of Risks:


Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life may be risks of therapy sessions. Your clinician will respect your privacy and will discuss subjects based on your comfort level. 


Limits of Confidentiality:

What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your verbal/written consent or the verbal/written consent of your legal guardian.


The following is a list of exceptions:

  • Duty to Warn and Protect 
If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.
  • Abuse of Children and Vulnerable Adults 
If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities. 
  • Prenatal Exposure to Controlled Substances 
Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.
  •  Insurance Providers
 Insurance companies and other third-party payers are given information that they request regarding services to the clients.

 Authorization for Electronic Communication (Email, Text.)


I request that Martino Psychotherapy & Associates, communicate with me regarding my treatment through electronic communications (e-mail or text message). I understand that this means my therapist will send my protected health information to me through electronic communication. This information includes: appointments, diagnosis, medications, progress and other individually identifiable information about my treatment to me via electronic communications. I understand there are risks inherent in the electronic transmission of information by e-mail, on the internet, via text message, or otherwise, and that such communications may be lost, delayed, intercepted, corrupted or otherwise altered, rendered incomplete or fail to be delivered. I further understand that any protected health information transmitted via electronic communications pursuant to this authorization will not be encrypted. As the electronic transmission of information cannot be guaranteed to be secure or error-free and its confidentiality may be vulnerable to access by third parties, The Office of Martino Psychotherapy shall not have any responsibility or liability with respect to any error, omission, claim or loss arising from or in connection with the electronic communication of information by her to me. After being provided notice of the risks inherent in use of electronic communications, I authorize Martino Psychotherapy to communicate electronically with me, which will include the transmission of my protected health information electronically. I authorize the transmission of my protected health information electronically as described above. 

Court Case/Custody Proceedings


I can make a referral to a custody expert, but I am not a custody expert myself. I do not attend court proceedings. Under no circumstance will I ask that Martino Psychotherapy gets involved in issues of custody/court cases.


I understand Martino Psychotherapy does not get involved in court-related matters or proceedings as this is not within her scope of practice.

Additional Fees


I do not charge for brief phone calls (less than 10 minutes) but extensive calls over 10 minutes will be prorated as per my session rate. If I am required to provide a verbal report to a physician, psychiatrist, counselor, or other professionals, a consultation of 10 minutes or longer will be charged or prorated as per my session rate. Same applies to emails.


Telehealth (doxy, phone call, virtual)


I consent to engaging in telehealth at Martino Psychotherapy as part of my psychotherapy. I understand that “telehealth” includes the practice of psychotherapy, assessment, diagnosis, consultation, treatment, transfer of medical data, and psychoeducation using interactive audio and video through the telehealth platform of doxy.me. Telehealth is offered when the therapist and client are unable to meet in person for an extended period of time and is deemed appropriate by both parties. I understand that doxy.me is HIPAA compliant to protect my privacy and confidentiality,
which is further explained in the informed consent and HIPAA forms previously signed.
The laws that protect the confidentiality of my medical information also apply to telehealth. I understand that information disclosed within sessions and the written records pertaining to those sessions are confidential between the client and therapist. My written consent is required to release any information that is shared within the session, except for when disclosure is required by law, as described in the Policies and Procedures form, as well as in the notice of privacy practices that were previously received. Teletherapy appointments are considered
outpatient services and are not a substitute for emergency or crisis services. If there is
a crisis or mental health emergency, I will call 911 or I will go to the nearest emergency
room. I also understand that I MUST be in New Jersey to engage in teletherapy and I
need to be in a secure and confidential location for my session.


BCBS, Out of Network Payment Clients (Insurance only)


Some insurance companies will reimburse the practice for out of network services and send the check directly to the home address of the client. If these checks are received by me, I understand it is my obligation to hand in these checks to the practice or I will be charged what the insurance company has reimbursed directly to the client.

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