Patient Forms

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


TESTING (if different):

Biopsychosocial History

Presenting Problems

 
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
Wild
Moderate
Severe
Symptom
Impact

None
Wild
Moderate
Severe
Aggressive Behaviour
NoneWildModerateSevere
NoneWildModerateSevere
Agitation
NoneWildModerateSevere
NoneWildModerateSevere
Anorexia
NoneWildModerateSevere
NoneWildModerateSevere
Appetite Disturbance
NoneWildModerateSevere
NoneWildModerateSevere
Binging/Purging
NoneWildModerateSevere
NoneWildModerateSevere
Circumstantial Symptoms
NoneWildModerateSevere
NoneWildModerateSevere
Concomitant Medical Condition
NoneWildModerateSevere
NoneWildModerateSevere
Conduct Problems
NoneWildModerateSevere
NoneWildModerateSevere
Delusions
NoneWildModerateSevere
NoneWildModerateSevere
Depressed Mood
NoneWildModerateSevere
NoneWildModerateSevere
Dissociative States
NoneWildModerateSevere
NoneWildModerateSevere
Elevated Mood
NoneWildModerateSevere
NoneWildModerateSevere
Elimination Disturbance
NoneWildModerateSevere
NoneWildModerateSevere
Emotional Trauma Perpetrator
NoneWildModerateSevere
NoneWildModerateSevere
Emotional Trauma Victim
NoneWildModerateSevere
NoneWildModerateSevere
Emotionality
NoneWildModerateSevere
NoneWildModerateSevere
Fatigue/Low Energy
NoneWildModerateSevere
NoneWildModerateSevere
Generalized Anxiety
NoneWildModerateSevere
NoneWildModerateSevere
Grief
NoneWildModerateSevere
NoneWildModerateSevere
Guilt
NoneWildModerateSevere
NoneWildModerateSevere
Hallucinations
NoneWildModerateSevere
NoneWildModerateSevere
Hopelessness
NoneWildModerateSevere
NoneWildModerateSevere
Hyperactivity
NoneWildModerateSevere
NoneWildModerateSevere
Irritability
NoneWildModerateSevere
NoneWildModerateSevere

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

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 remarried times
Father involved with someone
Separated for years
Father remarried times
Mother deceased for years. Age of patient at mother’s death
Divorced for years
Mother involved with someone
Father deceased for years. Age of patient at Father’s death
Describe childhood family experience:
Outstanding home environmentNormal home environmentChaotic home environmentWitnessed physical/verbal/sexual abuse toward othersExperienced physical/verbal/sexual abuse from others
Age of emancipation from home:

Immediate Family

Marital Status

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

Intimate relationship

Never been in a serious relationshipNot currently in a relationshipCurrently in a serious relationship

Relationship Satisfaction

Very satisfied with relationshipSatisfied with relationshipSomewhat satisfied with relationshipDissatisfied with relationshipVery 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:

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

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 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
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

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
Birth:
Normal Delivery
Caesarean Delivery
Difficult Delivery
Complications
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
Significant Injuries
Chronic, Serious Health Problems
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
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:
Inappropriate Sex Play
Isolates Self
Dominates Others
Alienates Self
Associates with Acting Out Peers
Very Shy
Other
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:

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)
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
Currently active in community/recreational activities
Formerly active in community/recreational activities?
Currently engaged in hobbies?
Currently participate in spiritual activities?

Sources of Data Provided Above:

Patient self-reporting for allA variety of sources
Presenting Problems/Symptoms:
Patient Self Reporting
Patient’s Parent/Guardian
Other
Family History:
Patient Self Reporting
Patient’s Parent/Guardian
Other
Developmental History:
Patient Self Reporting
Patient’s Parent/Guardian
Other
Emotional/Psychiatric History:
Patient Self Reporting
Patient’s Parent/Guardian
Other
Medical/Substance Use History
Patient Self Reporting
Patient’s Parent/Guardian
Other
Socioeconomic History
Patient Self Reporting
Patient’s Parent/Guardian
Other

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 regard to fees fees, they vary depending on services and will be discussed individually with program participants. 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.

Show Buttons
Hide Buttons