Self Control & Tolerance

Comportment

Set Goals & Follow Through

Cognition

Self Respect, Integrity & Compassion

Character

Communication Skills & Perspective

Communication

Whole Brain Living

Holistic Neurodevelopment

INSURANCE INFORMATION



If yes, please provide the following information
CLAIM TO:


If yes, please provide the following information

Biopsychosocial History

Presenting Problems

Primary:
Secondary:
Current Symptom Checklist (Rate intensity of symptoms currently present)
Mild: Impacts quality of life, but no significant impairment of day-to-day functioning
Moderate: Significant impact on quality of life and/or day-to-day functioning
Severe: Profound impact on quality of life and/or day-to-day functioning
Symptom
Impact
None
Mild
Moderate
Severe
Symptom
Impact
None
Mild
Moderate
Severe
Aggressive Behaviour
Agitation
Anorexia
Appetite Disturbance
Binging/Purging
Circumstantial Symptoms
Concomitant Medical Condition
Conduct Problems
Delusions
Depressed Mood
Dissociative States
Elevated Mood
Elimination Disturbance
Emotional Trauma Perpetrator
Emotional Trauma Victim
Emotionality
Fatigue/Low Energy
Generalized Anxiety
Grief
Guilt
Hallucinations
Hopelessness
Hyperactivity
Irritability

Emotional/Psychiatric History

Prior outpatient psychotherapy:

YesNo
Prior Provider Name
City
State
Diagnosis
Intervention/Modality
Beneficial?

Has any family member had outpatient psychotherapy?:

YesNo

Prior inpatient treatment for psychiatric, emotional or substance use disorder?:

YesNo
Inpatient Facility Name
City
State
Diagnosis
Intervention/Modality
Beneficial?

Has any family member had inpatient treatment for a psychiatric, emotional or substance use disorder?:

YesNo

Prior or current psychotropic medication usage?:

YesNo
Medication
Dosage
Frequency
Start Date
End Date
Physician

Has any family member used psychotropic medications?:

YesNo

Family History

Family of Origin
Present during childhood

Relationship
Present Entire Childhood
Present Part of Childhood
Not Present at All
Mother
Father
Stepmother
Stepfather
Brother(s)
Sister(s)
Other

Describe Parents:

Father's Full Name
Father's Occupation
Father's Education
Father's General Health
Mother's Full Name
Mother's Occupation
Mother's Education
Mother's General Health

Parents Current Marital Status:

Married to each other
Married remarriedtimes
Father involved with someone
Separated foryears
Father remarriedtimes
Mother deceased foryears. Age of patient at mother's death
Divorced foryears
Mother involved with someone
Father deceased foryears. Age of patient at Father's death
Describe 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
Age of emancipation from home:

Immediate Marital Status

Single, never married
Engaged months
Married foryears
Divorced foryears
Separated foryears
Divorce in process formonths
Live-in-foryears
prior marriages (self)
prior marriages (partner)

Intimate relationship


Never been in a serious relationship
Not currently in a relationship
Currently in a serious relationship

Relationship Satisfaction


Very satisfied with relationship
Satisfied with relationship
Somewhat satisfied with relationship
Dissatisfied with relationship
Very dissatisfied with relationship

List all persons living in patient's household:

Name
Age
Sex
Relationship to Patient

List biological/adopted children not living in the same household as patient:

Name
Age
Sex
Relationship to Patient
Frequency of visitation of above:
Describe any past or current significant issues in intimate relationships:
Describe any past or current significant issues in other immediate family relationships:

Medical History (Check all that apply for patient)

Describe current physical health:

GoodFairPoor
List name of primary care physician:
List name of primary care psychiatrist (if any):
List Non-Psychiatric Medications Currently Being Taken (give dosage and reason):
Name
Dosage
Reason
List any known allergies:

Is there a history of any of the following in your family:

Tuberculosis
Heart Disease
Birth Defects
High Blood Pressure
Emotional Problems
Alcoholism
Behaviour Problems
Drug Abuse
Thyroid Problems
Diabetes
Cancer
Alzheimer’s Disease/Dementia
Mental Retardation
Stroke
Describe any other chronic or serious health problems:
Describe any serious hospitalization or accidents:
Year
Age
Reason
List any abnormal lab test results:
Year
Result

Substance Use History (Check all that apply for patient)

Family alcohol/drug abuse history:
Father
Stepparent/Live-In
Mother
Uncle(s)/Aunt(s)
Grandparent(s)
Spouse/Significant Other
Sibling(s)
Children
Other:
Substance Use Status:
No history of abuse
Active Abuse
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
Patient Treatment History:
Outpatient
Age (s)
Inpatient
Age (s)
12-Step Program
Age (s)
Stopped on Own
Age (s)
Other
Age (s)
Substances Used
First Use Age
Last Use Age
Current Use
Frequency
Amount
Alcohol
Amphetamines (Speed)
Barbiturates (Owners)
Cocaine
Crack Cocaine
Hallucinogens (e.g. LSD)
Inhalants (e.g. Glue, Gas)
Marijuana or Hashish
Opioids
PCP
Prescription
Other
Consequences of Substance Abuse:
Hangovers
Binges
Loss of control over amount used
Suicide Attempts
Seizures
Withdrawal Symptoms
Job loss
Suicidal Impulse, Thoughts
Blackouts
Medical Conditions
Sleep Disturbance
Relationships Conflicts
Accidental Overdose
Increase in Tolerance
Assaults
Arrests
Other:

Developmental History (check all that apply for child/adolescent patient)

Problems During Mother's Pregnancy:
None
German Measles
Alcohol Use
High Blood Pressure
Emotional Stress
Drug Use
Kidney Infection
Bleeding
Cigarette Use
Other:
Birth:
Normal Delivery
Caesarean Delivery
Difficult Delivery
Complications
If there were complications, please explain:
Infancy Problems:
None
Sleep Problems
Feeding Problems
Toilet Training Problems
Birth Weight: Lbs oz
Childhood Health:
Chicken Pox, Age:
Whooping Cough, Age:
Diphtheria, Age:
German Measles, Age:
Scarlet Fever, Age:
Mumps, Age:
Red Measles, Age:
Lead Poisoning, Age:
Poliomyelitis, Age:
Rheumatic Fever, Age:
Tuberculosis, Age:
Pneumonia, Age:
Congenital Issues:
Autism
Mental Retardation
Ear Infections
Asthma
Allergies
If yes, please explain:
Significant Injuries
If yes, please explain:
Chronic, Serious Health Problems
If yes, please explain:
Delayed Developmental Milestones (Check only those milestones that did not occur at expected age):
Sitting
Feeding Self
Controlling Bowels
Tolerating Separation
Rolling Over
Speaking Words
Sleeping Alone
Playing Cooperatively
Standing
Speaking Sentences
Dressing Self
Riding Tricycle
Walking
Controlling Bladder
Engaging Peers
Riding Bicycle
Other:
Emotional Behaviour Problems (check all that apply):
None
Hyperactive
Indecisive
Extreme Worrier
Drug Use
Animal Cruelty
Immature
Self Injurious Acts
Alcohol Abuse
Assaults Others
Bizarre Behaviour
Impulsive
Chronic Lying
Disobedient
Self Injurious Threat
Easily Distracted
Stealing
Repeats Words of Others
Frequently Tearful
Poor Concentration
Violent Temper
Not Trustworthy
Lack of Attachment
Often Sad
Fire Setting
Hostile Angry Mood
Distrustful
Breaks Things In Anger
Social Interaction:
Normal Social Interaction
Inappropriate Sex Play
Isolates Self
Dominates Others
Alienates Self
Associates with Acting Out Peers
Very Shy
Other
If you checked other, please explain:
Intellectual/Academic Functioning
Normal Intelligence
Authority Conflicts
Mild Retardation
High Intelligence
Attention Problems
Moderate Retardation
Learning Problems
Underachieving
Severe Retardation
Current or Highest Education Level:
Describe any other developmental problems or issues:

Socio-Economic History

Living Situation
Housing Adequate
Housing Overcrowded
Housing Dangerous/Deteriorating
Homeless
Dependant on Others for Housing
Living Companions Dysfunctional
Social Support System
Supportive Network
Few Friends
Substance-Use-Based-Friends
No Friends
Distant from Family of Origin
Military
Never in Military
Served in Military - No Incident
Served in Military - With Incident
Employment
Employed and Satisfied
Unemployed
Supervisor Conflicts
Employed but Dissatisfied
Co-worker Conflicts
Unstable Work History
Financial Situation
No Current Financial Problems
Large Indebtedness
Poverty or below poverty Income
Impulsive Spending
Relationship Conflicts Over Finances
Legal History
No Legal Problems
Arrest(s) Not Substance-Related
Court Ordered This Treatment
Now On Parole/Probation
Arrest(s) Substance Related
Jail/Prison Time(s)
If you checked Jail/Prison, what was the total time served:
Please describe your last legal difficulty:
Sexual History
Heterosexual Orientation
Homosexual Orientation
Bisexual Orientation
Currently Sexually Active
Currently Sexually Satisfied
Currently Sexually Dissatisfied
Age of your first sexual experience: Age First Pregnancy/Fatherhood:
History of Promiscuity Age: to
History of Unsafe Sex Age: to
Additional Information:
Cultural/Spiritual/Recreational History
Cultural Identity (e.g. ethnicity, religion):
Describe any cultural issues that contribute to the current problem and/or should be taken into account during the treatment planning:
Currently active in community/recreational activities?
Formerly active in community/recreational activities?
Currently engaged in hobbies?
Currently participate in spiritual activities?
If you checked any of the above, please describe:

Sources of Data Provided Above:

Patient self-reporting for allA variety of sources
Presenting Problems/Symptoms:
Patient Self Reporting
Patient's Parent/Guardian
Other
If you checked other, please describe:
Family History:
Patient Self Reporting
Patient's Parent/Guardian
Other
If you checked other, please describe:
Developmental History:
Patient Self Reporting
Patient's Parent/Guardian
Other
If you checked other, please describe:
Emotional/Psychiatric History:
Patient Self Reporting
Patient's Parent/Guardian
Other
If you checked other, please describe:
Medical/Substance Use History
Patient Self Reporting
Patient's Parent/Guardian
Other
If you checked other, please describe:
Socioeconomic History
Patient Self Reporting
Patient's Parent/Guardian
Other
If you checked other, please describe:

Office Policy and Payment Options

Thank you for choosing Fraley & Associates, PLLC as your mental health care provider. Payment for professional services is due at the time treatment is provided. Every effort will be made to provide a treatment plan, which fits your timetable and budget to give you the best possible outcome. We accept cash, personal checks, debit cards and most credit cards. We offer 5% discount when payment is made in full at the time of service by cash or personal checks.

Medical Insurance
On the day of treatment, we will collect from you the estimated amount insurance is not expected to pay. If we have received all of your insurance information on the day of the appointment, we will be happy to file a claim for you. Mental health insurance plans are designed to share in the cost of your mental health, not to completely pay for those costs. Your mental health coverage is determined not by your medical needs, but by the agreement negotiated by your employer with the insurer. We are not responsible for how your insurance company handles your claim or what they ultimately pay for. You are responsible for any balance on your account still owing after 45 days. MOST IMPORTANTLY, please keep us informed of any insurance changes such as policy name, company address or change of employment. Regardless of your insurance company’s determination of usual and customary rates (UCR) or amount of assignment (allowable fees), you are required to pay the amount charged for your treatment, we will estimate your portion at the time of service. This is an estimate and any amount not paid by your insurance is payable by you.

Returned Checks
Checks returned by your bank for non-sufficient funds (NSF) or closed account will be subject to a $25.00 returned check fee. Your account will be debited for the amount of the check along with any prompt payment discount and the returned check fee.

Finance Charge
Any balances remaining unpaid on your account after 90 days from the date of service are subject to a FINANCE CHARGE at the periodic rate of 1.5% per month, which is an annual percentage rate of 18%. The finance charge applied to personal and insurance balance is determined by taking the balance you owed at the end of 90 days and subtracting all payments and credits received during the present billing cycle. This includes balances outstanding to insurance. Current and/or new services are not included In determining financing charges. By signing, you have read and agree to all the terms listed above. Thank you for choosing Fraley & Associates, PLLC for your mental health treatment.

Reduced Fee Agreement

This is a reduced fee agreement between Fraley & Associates, PLLC and .

This agreement is as follows:

Intake Information

 

Date:

Insurance Information

The normally confidential relationship between therapist and client does not cover disclosures of child or elder abuse, either sexual or physical, homicide or suicide. Your fee will be established during the first consultation.
24-HOUR CANCELLATION NOTICE MUST BE GIVEN OR CHARGE WILL BE MADE You are responsible for all charges incurred for services rendered.

Dr. Lynn A. Fraley PhD

DIPLOMATE, AMERICAN ACADEMY OF EXPERTS IN TRAUMATIC STRESS LICENSED CLINICAL MENTAL HEALTH PRACTICIONER

In an effort to help you become a more informed consumer and to be in full compliance with the laws of Idaho and Washington, the following represents general information on my background, experience, theoretical orientation, approach to services, and fee structure. It is my desire that you obtain the best service possible to meet your current needs. Please know your decision to enter into counseling is voluntary and you have the right to terminate services at any time and I will provide a referral to another therapist. You may ask questions about any procedure and refuse any technique. I am a Board Certified Expert in Traumatic Stress by the American Academy of Experts in Traumatic Stress. I am a Nationally Certified Counselor by the National Board of Certified Counselors Inc.; I hold a specialty Board certification in Sexual Abuse. I am licensed in the states of Washington and Idaho as a Clinical Mental Health counselor and hold my PhD in Clinical Psychology with a specialty certification in Neuropsychology and training in Behavioural Medicine, and my Master’s degree in Guidance and Counseling from Whitworth College as well as an MA in Psychology from Fielding Graduate University. I also hold a Bachelor’s of Science degree in Child Development and Family Studies from the University of Idaho. Policies are based on current American Counseling Association code of ethics. My experience as a counselor includes working with child and adult survivors of all types of abuse, substance abuse, dependency issues, divorce & blended family structures as well as more severe and long-term mental illnesses. I have spent a number of years as a resident therapist in a Level III Residential Treatment Facility as well as serving clients on an individual basis in private practice. I am experienced in dealing with a variety of issues including anxiety, depression, borderline personality, conduct disorder, anger management, domestic violence, sexual assault & abuse, grief, post-traumatic stress disorder, marriage, separation & divorce, as well as parenting issues to name a few. I have been trained in a variety of different modalities and prefer to take an eclectic approach, which allows me to tailor counseling techniques to you and your specific situation. I have experience in Object Relations, Cognitive-Behavioural Therapy, Play Therapy, Family Systems, Gestalt, Psychodrama and Guided Imagery. I have experience with large and small groups as well as individual therapy. With regards to fees, I charge $375.00 for a clinical hour of consisting of 45 minutes face to face therapy and 15 minutes of chart review. A sliding scale is available upon request. Written notes may or may not be kept on your session as is agreed upon between us. My fees are payable at the time the counseling session. If requested, you will be provided with a billing statement after each session for submission to your insurance carrier. Any fees associated with collection procedures, which are required are the sole responsibility of the client. A missed appointment without 24-hour notice will result in you having to pay for the session. Payment options are available upon request. What you say to me during therapy is privileged communication and within limits, is strictly confidential. I can release information specifically for billing purposes to your insurance carrier. I can release information if you give me written consent to do so and will advise you as to any risk I think could be associated with this release. I am required by law to reveal any information that a child is being abused or that you are a danger to yourself or others, or that you are unable to meet your basic needs. For example, if you threaten bodily harm or death to another person, I will inform the intended and the police. PLEASE BE ADVISED - If a referral to a collection agency becomes necessary, the nature of the therapeutic relationship between us will become evident. Should you require further clarification or elaboration on any of the information in this document, I will be happy to explain further until you are satisfied. Complaints may be filed by calling the Idaho Bureau of Occupational Licensing at 208-334-3233, via email at inv@ibol.idaho.gov, or online at ibol.idaho.gov and filling out the online complaint form.