Adult Intake Form Light on Anxiety Adult Intake Form Step 1 of 3 33% Light on Anxiety Clinical Specialty Policy* I understand Light on Anxiety's clinical specialty policy and acknowledge I am seeking treatment for anxiety or a related condition. Light on Anxiety specializes in CBT & ERP based treatment for children, adolescents and adults, as well as family based interventions, with a focus on anxiety, OCD and other related mental health conditions. Light on Anxiety is not an appropriate treatment provider if you are seeking assistance with the following conditions: - Substance Related and Addictive Disorders - Self Harm - Suicidal Ideation - Homicidal Ideation - Anorexia, Bulimia or Other Eating Disorders - Bipolar and Related Disorders - Disruptive, Impulse-Control and Conduct Disorders - Schizophrenia Spectrum and Other Psychotic Disorders Patient Name* First Last Patient Date of Birth* MM DD YYYY Patient Email Address*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Emergency Contact Name*Emergency Contact Phone*To begin treatment at Light On Anxiety, it is required that you complete a release of information for your emergency contact. Note: To ensure progress on intake form is not lost, right click on the link to open the release of information in a new tab/window. Release of Information for Emergency Contact* I certify that I have a completed a release of information for my/the client's emergency contact.Is Light on Anxiety currently treating any other members of your immediate family?* No Yes If you stated yes to above, please review and consent to Light on Anxiety's policy regarding treating multiple family members I agree to this policy.Light on Anxiety is happy to be of assistance to multiple members within a family. Unless a release of information is signed, information will not be shared between Light on Anxiety therapists. Also, if ever it becomes unhelpful for Light on Anxiety to be seeing multiple family members, Light on Anxiety will provide the appropriate external referrals and assist with a care transition plan. How did you hear about Light on Anxiety?* Health Insurance Google Light on Anxiety Event Article or Media Appearance Psychology Today Provider Facebook Twitter Pinterest Friend Other If other, please indicate:If referred by a provider, please indicate the name of the health care professional who referred you:Contact Information (phone number and email address )for Referring Provider:Light on Anxiety Location*LakeviewWilmetteDeerfieldWeb-basedNote: if looking to obtain Light on Anxiety services via phone or web, we recommend you contact your insurance company to discuss rules and regulations regarding your mental health benefits. Would you like to sign up for the Light On Anxiety newsletter, to stay informed about anxiety relieving tips and tools?*YesNoFinancial & Billing InformationName of individual responsible for billing*Note: By providing this information to Light on Anxiety you authorize communication with individual financially responsible for your services for billing and administrative information exchanges. Email address for individual responsible for billing*Phone number for individual responsible for billing*Will you be using health insurance benefits to access Light On Anxiety services?*YesNoLight On Anxiety is in-network with BCBS PPO, Blue Choice PPO and Aetna. Light On Anxiety can also assist you in submitting to your out-of-network insurance provider for possible reimbursement. Name of primary insured*Relationship*SelfSpouseParentOtherAddress for primary insured* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Plan*Note: Light on Anxiety is in network with BCBS PPO, Blue Choice PPO and Aetna. Date of birth for primary insured* MM DD YYYY Insurance Claim Submission Requirement* I acknowledge that If I do not upload a picture of the front and back of my insurance card, I will be charged at Light on Anxiety’s private pay rates. Please upload a picture of the FRONT of your insurance card.*Accepted file types: jpg, gif, png, pdf.Please upload a picture of the BACK of your insurance card.*Member ID (Please be sure to include letter pre-fix to number, "X" or "XXX")*Group Number*Credit Card On FileLight on Anxiety requires that all clients maintain a credit card on file to cover any balance due after your insurance benefits are applied. For clients who are uncomfortable leaving a credit card on file through our secure billing system, clients can pay at the time of the visit for all services received. Here’s how it works: 1. We securely save your credit or debit card before or during your visit. 2. If in network, we work with your insurance plan to determine your payment amount for the visit. 3. We process the payment for you automatically and email you the receipt to the email address supplied on the intake form. Credit Card Type*VisaMastercardDiscoverAmerican ExpressName on Credit Card*Credit Card Number*Expiration Date*Security Code (3 digits on back of card)*Billing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Authorization of Fee Payment* I agree to the authorization of fee payment as described below.I authorize the payment of fees to Light on Anxiety, for services rendered. I authorize that my card is used to resolve any and all balances in full on my account for individual or consultative charges, missed/ or forgotten payments, and/or appointments cancelled/no-show within 24 hours of scheduled appointment time. I understand that this cancellation fee is not covered by insurance. I understand that payment is required at the time of service. I understand that I am required to provide up to date credit card information on file for regular appointment payments, forgotten payments, missed appointments, and out of office appointments. I understand that late payments may be subject to an additional late payment fee and ongoing noncompliance with payment terms may incur collections charges if I do not provide timely payment to resolve my balance. Signature - Authorization of Fee Payment*Required Collaborative Care With Psychotropic Medication PrescriberAre you currently taking any psychotropic medication?*YesNoIf you are taking psychotropic medication, It is required that you provide Light On Anxiety with the contact information and a release of information for the medication prescriber. Note: To ensure progress on intake form is not lost, right click on the link to open the release of information in a new tab/window. Psychiatrist / Psychotropic Medication Prescriber Name* First Last Psychiatrist / Psychotropic Medication Prescriber Phone*Psychiatrist / Psychotropic Medication Prescriber Email Release of Information for Psychotropic Medication Provider* I certify that I have a completed a release of information for my/the client's psychotropic medication provider.Recommended Collaborative Care With All Other Healthcare ProvidersIt is recommended that you provide Light On Anxiety with the contact information for all health care providers you are currently seeing or have seen in the last 6 months in order to incorporate all relevant health information into our treatment plan for you. Primary Care Physician Name First Last PhoneEmail Other Provider First Last PhoneEmail Additional Releases of InformationIf you would like Light On Anxiety to coordinate care with any other individuals or providers on your behalf, please complete an additional release of information. Note: To ensure progress on intake form is not lost, right click on the link to open the release of information in a new tab/window. Informed ConsentWhat can I expect from initial visit? The first 1-2 sessions are devoted to a comprehensive assessment of your concerns and the development of a treatment plan. After the initial assessment is completed, the treatment plan will be reviewed and recommendations will be provided regarding which Light on Anxiety therapist will be the best fit based on clinical needs and scheduling requirements. Note: the therapist who conducts the initial assessment may not be the therapist who provides ongoing treatment, but all initial findings will be thoroughly discussed and reviewed with the assigned Light on Anxiety therapist. What will treatment entail? Treatment will include one or a combination of the following: individual therapy (which can include family members), referrals to a psychiatrist for medication evaluation, specialized exposure therapy or referrals to a physician for medical evaluation. Exposure therapy may occur on a weekly basis, or may be required on a more intensive basis when your difficulties are more severe. All therapy we offer is empirically supported and provided to you because it is the treatment determined to be the most effective in assisting you in overcoming anxiety or anxiety-related conditions. What is expected of me? We expect you to come prepared to work hard and play an active role in treatment. We will serve as your anxiety coach and teach you the skills and provide you with the support to move forward in living a vital life. But it is up to YOU to do the hard and transformative work of applying these new skills in your every day life. How frequently will we meet? A treatment plan will be customized to your needs and therefore, after the initial assessment, your therapist will be able to provide you with a recommendation for treatment intensity. What if I am experiencing a clinical emergency? If you are in a mental health emergency and require immediate assistance, please go to the nearest hospital emergency room and leave a voicemail message for your therapist to notify them of the emergency (312.508.3645). If you believe that you need therapy that provides 24 hour crisis management, please discuss this with your therapist and they will help you find a referral to a program that can best meet your needs. What is your policy on electronic communication? For communication between sessions, we only use email communication and text messaging with your permission and only for administrative purposes unless we have made another agreement. This means that email exchanges and text messages with the office should be limited to administrative matters. This includes things like setting and changing appointments, billing matters, and other related issues. You should be aware that we cannot guarantee the confidentiality of any information communicated by email or text. Therefore, we will not discuss any clinical information by email or text and prefer that you do not either. Also, we do not regularly check email or texts, nor do we respond immediately, so these methods should not be used if there is an emergency. Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach out to us by phone. We will try to return your call within 24 hours except on weekends and holidays. If you are unable to reach us and feel that you cannot wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If we will be unavailalbe for extended time, we will provide you the name of a colleague to contact in my absence if necessary. Do you accept insurance? Currently, Light on Anxiety Treatment Center only contracts as an in network provider with Blue Cross Blue Shield of Illinois (BCBSIL) Preferred Provider Organization (PPO), Blue Choice PPO and Aetna. Your insurance will provide a quote of benefits, not a guarantee of payment. While the filing of insurance claims is a courtesy we extend to our in network clients, all charges are your responsibility from the date services are rendered. Reimbursement varies depending upon the level of benefits that you and your employer have chosen. Your degree of coverage is a matter between you and your insurance company and/or your employer. Light on Anxiety cannot guarantee that your insurance will cover my services. You should verify with your carrier that it will be covered and to what extent. You will be expected to pay all co-payments, deductibles, and for uncovered and ineligible services. If your insurance company has not paid a claim within 20 days of submission, you accept full responsibility for payment in full for any outstanding balance. For clients looking to obtain reimbursement from other insurers, we are happy to submit an out of network claim on behalf of the client to facilitate reimbursement of out-of-network mental health claims. Your copay is due at the time of your session. If you do not know your copay amount at the time of session, your therapist will collect the industry standard copay amount of $20 at the time of session and our billing department will make any necesary adjustments upon receiving payment from your insurance company. Your insurance company may require us to contact them to discuss your treatment and progress. We are glad to respond to brief requests for information. In the event that extensive information or written reports are requested, Light on Anxiety staff will contact you to discuss the likely fees associated with providing these services. Insurance companies may have different levels of coverage. In addition, if you are a BCBS member ID begins with CTY we recommend you contact your insurance provider to determine if you need to obtain preauthorization prior to commencing treatment at Light on Anxiety. For all other insurance plans, clients are responsible for paying Light on Anxiety directly and then Light on Anxiety can electronically submit a paid super bill on your behalf to facilitate obtaining out of network reimbursement. If you are interested in having Light on Anxiety submit a superbill to your insurance company, please provide your insurance information. Do you accept Medicare/Medicaid? Light on Anxiety Treatment Center is not a covered provider for Medicare or Medicaid. Therefore you or your legal representative accept full responsibility for payment of all charges. Usual Medicare limits to charges and services do not apply. By choosing to work with Light on Anxiety, you acknowledge that you completely forego the use of these benefits for your treatment at this center and agree that neither you nor any representative will file any claims to Medicare or Medicaid, nor will you ask the provider to do so. You acknowledge that you freely enter this contract with the knowledge of your right to obtain Medicare covered services from providers who have not opted out of Medicare, and understand that you are not compelled to enter into private contracts with providers who have not opted out of Medicare. How much will treatment cost? Light on Anxiety strives to make treatment as short term and cost effective as possible. Light on Anxiety therapists know that it is their job to get you back into your life as quickly as possible. Our current fees for light on anxiety therapy services are: Master Level Clinician: 30 minute session: $90 45 minute session: $135 60 minute session: $180 Ph.D Level Clinician: 30 minute session: $130 45 minute session: $195 60 minute session: $260 Add-on services: Light on Anxiety staff are available for home visits and other out of office exposure based work, when clinically necessary as well as for report writing and other documentation requests. These services are pro-rated in 15’ increments at the therapist’s hourly rate. Travel time to and from the office is included in the total charge. Light on Anxiety staff are also available via email, text and phone, for between session assistance. In addition, Light on Anxiety staff is available to consult with other providers and write reports. These services will also be pro-rated in 15’ increments at the therapist’s hourly rate. These calls may, or may not, be covered by insurance. What is your cancellation policy? A cancellation fee for the missed session is charged for cancellations with less than 24 hours notice. Charges for missed appointments are not covered by insurance and are your responsibility. Are there any limits to confidentiality? The information you share in therapy is confidential and will not be disclosed without your written permission except when you may pose a danger to yourself or others or as required under Illinois and Federal law. If we ever suspect you are at risk to harm yourself or others, we are required to report this to the Firearm Owners Identification (FOID) program. If you disclose information related to suspected child or elder abuse, Light on Anxiety is obligated to report it. If Light on Anxiety receives a court order signed by a judge to release your information, we are obligated to honor it. Light on Anxiety Litigation Policy I agree that I am here for treatment and that I have been advised that if I need an expert witness in my case, I should hire someone specifically for that purpose. I understand that my Light on Anxiety therapist will not serve as a witness in any type of litigation. I agree to advise my attorney that Light on Anxiety will not become involved in any litigation. I agree that should I seek the Light on Anxiety's involvement in such litigation I will be responsible for Light on Anxiety's attorney fees in consulting an attorney to avoid involvement. If ordered by the court to participate in the litigation, either in giving a deposition or testifying or if I voluntarily agree the following rules shall I apply: 1. Fees for time involved in preparing a report(s) for LOA attorney or the court must be paid in advance before such report will be written. 2. The fee for LOA testimony or deposition must be for a 3 hour block of time at $900 for the three hours. Any time exceeding the 3 hours including travel time, shall be billed at the rate of $400 per hour. Fees must be paid at least one week in advance of the testimony being given. If not paid in advance, LOA will not appear to give testimony. 3. If the testimony date is cancelled or rescheduled with less than one business day’s notice, the fee will not be returned or will still be owed. Any further rescheduling will require the payment of another 3 hour minimum fee. Consent to Treatment* I consent to treatment. I acknowledge receipt and understanding of Light on Anxiety's informed consent, and agree to all its terms and conditions.Date* Date Format: MM slash DD slash YYYY Print Name*Signature - Consent to Treatment*Informed Consent for In-Person TreatmentCompletion of this health consent form is required prior to initiating in person treatment at LOA or entering a LOA office space, in order to maximize health and safety for all. The threat of COVID-19 is ongoing throughout the United States. As a way to mitigate the risk of exposure to COVID-19, our practice has transitioned to providing most services via telecommunications technology. Use of telecommunications technology reduces the need for persons to come into close contact with each other or to be in areas where exposure to COVID-19 may occur. However, in some situations, tele-therapy services may not be adequate, and in-person services may be more appropriate. It is important to consider that, although insurance reimbursement for tele-therapy services may have been mandated during the COVID-19 pandemic, such mandates may no longer be in effect, and tele-therapy may no longer be reimbursed by your insurance company. As COVID-19 regulations continue to evolve, LOA may become legally required to disclose that we have been in contact, especially if either of us were to test positive or show signs of COVID-19 infection. If we are legally compelled to disclose information, we will inform you and will only provide the minimum necessary information (e.g., your name and the dates of our contact) required by law. In order for LOA to provide you with in-person services, the following protocols must be followed by patients/clients and providers: (1) Hand sanitizer will be provided at the office entrance and must be used upon entering the office. (2) Social distancing requirements must be met. (3) Patients and providers will be required to wear face coverings or masks while in the office as long as encouraged by the CDC. Note: If you do not have a face covering, one will be provided to you. If at any point during your treatment with Light on Anxiety you become ill, your sessions will be moved to our Web-Based Platform until you have been symptom free for 7 days or can provide a negative test result. We remain committed to following state and federal guidelines and to adhering to prevailing professional healthcare standards to limit the transmission of COVID-19 in our offices. Despite our careful attention to sanitization, social distancing, and other protocols, there is still a chance that you will be exposed to COVID-19 in our office. If, at any point, you prefer to stop in-person services or to consider transitioning to remote services, please let us know. Consent to In-Person Treatment Policy* I certify receipt and understanding of Light On Anxiety's In-Person Treatment Policy and agree to all its terms and conditions.By consenting to in-person treatment you acknowledge that there is still a potential risk of exposure and that you agree to follow the safety protocols outlined above in order to engage in in-person services. In addition, you agree that if your health status changes, you will delay entering an LOA office space/receiving in person treatment until you are no longer experiencing COVID - 19 (or any other infectious disease) symptoms and have been symptom free for the appropriate time frame, per CDC guidelines.Date* Date Format: MM slash DD slash YYYY Print Name*Signature - Consent to In-Person Treatment Policy*Informed Consent for Telehealth Based TreatmentBenefits and Risks of Telehealth Telehealth refers to providing services remotely using telecommunications technologies such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person therapy and telehealth, as well as some risks. For example: Risks to Confidentiality Because telehealth sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. We will take reasonable steps to ensure your privacy, but it is important for you to make sure you find a private place for our session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. Data Protection The nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. We will make every attempt to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth). Technology Issues There are many ways that technology issues might impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies. Appropriateness of Telehealth Usually, we will not engage in telehealth with clients who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telehealth, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telehealth work. From time to time, we may schedule in-person sessions to "check-in" with one another. We will let you know if we decide that telehealth is no longer the most appropriate form of treatment for you. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services. Emergencies and Technology Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person therapy. To address some of these difficulties, we will create an emergency plan before engaging in telehealth services. We will ask you to identify an emergency contact person who is near your location and who we will contact in the event of a crisis or emergency to assist in addressing the situation. We will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency. If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call us back. Instead, call 911, or go to your nearest emergency room. Call us back after you have called or obtained emergency services. If the session is interrupted and you are not having an emergency, disconnect from the session and we will wait two (2) minutes and then re-contact you via the telehealth platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes, call us on the phone number provided to you. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. Fees The same fee rates will apply for telehealth as apply for in-person therapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance provider does not cover electronic telehealth sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to engaging in telehealth sessions in order to determine whether these sessions will be covered. Records We will maintain a record of our session in the same way we maintain records of in-person sessions in accordance with our policies. Consent to Telehealth Treatment Policy* I certify receipt and understanding of Light On Anxiety's Telehealth Treatment Policy and agree to all its terms and conditions.This agreement is a supplement to the general Informed Consent signed earlier and does not amend or replace any of the terms of that agreement. Date* Date Format: MM slash DD slash YYYY Print Name* Signature - Consent to Telehealth Treatment Policy* Clinical HistoryFrom 0-10 (0 being the least), please indicate your level of emotional distress in the past month.*Please describe what has led you to seek therapy now.*What are your treatment goals at Light on Anxiety?*If we had a magic wand and could grant you a wish, what is the first wish that comes to mind? (Don't think too long on this one, just write your first thought.)*Please describe the history of your present problem.*Have you ever had therapy before for mental health concerns? If yes, please tell us a bit about the experience. What did you find helpful and what did you find unhelpful?*Current Psychotropic Medication and Dosage*When did you begin taking current medication?*Over the last 7 days, how many did you take your medication exactly as prescribed?*Please enter a number from 0 to 7.Have you taken any psychotropic medication(s) in the past?*YesNoPast Psychotropic Medication(s) and Dosage(s)*Please indicate the date(s) during which you took past psychotropic medication(s).*Have you ever received Intensive Outpatient Program (IOP), Partial Hospitalization Program (PHP), residential or inpatient mental health services before? If so, when and where?*Are you currently having any suicidal thoughts?*Have you ever attempted suicide? If yes, please provide brief background information such as date of attempt, means and treatment received.*Have you ever completed a neuropsychological evaluation? If so, please upload report(s) here: Drop files here or Have you ever experienced a traumatic event? If so, briefly describe experience.*Do you have a history of violent behavior, such as getting into physical altercations? If yes, please explain.*Do you have any difficulties with substance abuse? If yes, please describe such difficulties.*Medical HistoryDescribe your current physical health:*GoodFairPoorBriefly describe any past or present health concerns.*Please describe your sleep quality.*Do you exercise? If so, what kind of activity, how frequently and how long?*Family HistoryPlease describe any family history of significant psychiatric problems.*Please describe your childhood family experience:* Outstanding home environment Normal home environment Chaotic home environment Witnessed physical/verbal/sexual abuse toward others Experienced physical/verbal/sexual abuse from others Other If other, please indicate.Give a description of mother’s personality and parenting style.*Give a description of father’s personality and parenting style.*Give a description sibling relationships.*Relationship HistoryPlease select:*SingleMarriedDivorcedSeparatedWidowedCommitted relationshipPartneredEngagedRemarriedOtherIf client is parent, please indicate ages of children.How satisfied are your with current family life?Have you ever been in an emotionally, physically, or sexually abusive relationship?*Do you often feel like you have to please other people in order to maintain a friendship or relationship?*How satisfied are you with current friendships?*Developmental HistoryCheck any of the following that applied during childhood:* Delays in developmental milestones Received speech therapy Received occupational therapy Difficulty separating from caregiver when transitioning to school setting Nail biting, skin picking or hair pulling Medical problems Social challenges History of bullying History of abuse/neglect Child of alcoholic/addict School problems Alcohol/drug use Oppositional behaviors Other None of the above If other, please indicate:Feel free to elaborate on any of the above responses.Educational HistoryHighest Level of Academic Pursuit*High SchoolVocational TrainingCollegeGraduate SchoolAverage Grades:*Disciplinary problems?*Aspects of school that excel/excelled in:*Aspects of school that struggle/struggled in:*Has there ever been a period of excessive absences during the school year? If so, please explain.*History or suspected history of learning or attentional concerns:*History or bullying or teasing at school?*Overall feelings and attitude towards school:*Employment HistoryAre you currently employed? If so, where?*Do you enjoy your current line of work?*Have you ever been fired from a job? If so, please explain:*Have you ever been arrested? If so, please explain and provide a bit of background information.*Hidden QuestionsIn what ways have the strategies used to date been helpful or not?Please use the space below to add any additional information on your health history that you believe Is relevant to your current treatment.Please summarize top treatment goal(s):Emergency Contact PhoneNote: by providing this information you authorize Light on Anxiety to coordinate care with your emergency contact on your behalf if you are a harm to yourself or others. Emergency Contact PhoneNote: by providing this information you authorize Light on Anxiety to contact this person in case of emergency. Coordination of CareYesNoLight on Anxiety strives to maximize care coordination with our client's key clinical stakeholders. Would you like LOA to exchange relevant clinical updates with the provider who referred you to LOA? Note: stating yes to collaborating with referring provider is considered a release of information to coordinate care and share relevant treatment information on your behalf. SignatureBy signing this form, I consent to have LOA exchange relevant clinical information with providers listed above. Release of InformationBy electronically signing this form, I consent to have LOA exchange relevant clinical information with providers listed below. Electronic Signature: Print Name:Billing Address (Including Zip Code)Informed Consent for In-Person TreatmentCompletion of this health consent form is required prior to initiating in person treatment at LOA or entering a LOA office space, in order to maximize health and safety for all. The threat of COVID-19 is ongoing throughout the United States. As a way to mitigate the risk of exposure to COVID-19, our practice has transitioned to providing most services via telecommunications technology. Use of telecommunications technology reduces the need for persons to come into close contact with each other or to be in areas where exposure to COVID-19 may occur. However, in some situations, tele-therapy services may not be adequate, and in-person services may be more appropriate. It is important to consider that, although insurance reimbursement for tele-therapy services may have been mandated during the COVID-19 pandemic, such mandates may no longer be in effect, and tele-therapy may no longer be reimbursed by your insurance company. As COVID-19 regulations continue to evolve, LOA may become legally required to disclose that we have been in contact, especially if either of us were to test positive or show signs of COVID-19 infection. If we are legally compelled to disclose information, we will inform you and will only provide the minimum necessary information (e.g., your name and the dates of our contact) required by law. In order for LOA to provide you with in-person services, the following protocols must be followed by patients/clients and providers: (1) Hand sanitizer will be provided at the office entrance and must be used upon entering the office. (2) Social distancing requirements must be met. (3) Patients and providers will be required to wear face coverings or masks while in the office as long as encouraged by the CDC. Note: If you do not have a face covering, one will be provided to you. If at any point during your treatment with Light on Anxiety you become ill, your sessions will be moved to our Web-Based Platform until you have been symptom free for 7 days or can provide a negative test result. We remain committed to following state and federal guidelines and to adhering to prevailing professional healthcare standards to limit the transmission of COVID-19 in our offices. Despite our careful attention to sanitization, social distancing, and other protocols, there is still a chance that you will be exposed to COVID-19 in our office. If, at any point, you prefer to stop in-person services or to consider transitioning to remote services, please let us know. Phone number for individual responsible for billing Pre-Treatment GAD 7Over the past 2 weeks, how often have you been bothered by the following problems: 1. Feeling nervous, anxious or on edge*Not at allSeveral daysMore than halfNearly every day2. Not being able to stop or control worrying*Not at allSeveral daysMore than halfNearly every day3. Worrying too much about different things*Not at allSeveral daysMore than halfNearly every day4. Trouble relaxing*Not at allSeveral daysMore than halfNearly every day5. Being so restless you can't sit still*Not at allSeveral daysMore than halfNearly every day6. Becoming easily annoyed or irritable*Not at allSeveral daysMore than halfNearly every day7. Feeling afraid as if something awful might happen*Not at allSeveral daysMore than halfNearly every dayScoring - Not at all = 0 - Several days = 1 - More than half = 2 - Nearly every day = 3 GAD-7 Score5-9: Mild anxiety 10-14: Moderate anxiety >15: Severe anxiety