Please visit our website www.arrowheadbehavioralhealth.com for directions to our office.

Thank you for scheduling your counseling appointment with ABH.  It is our goal to provide

you with the highest quality of care.  In order to do this, we require information from you that

tells us a little about yourself and the reason you are seeking counseling.  The more

information we have initially, the more time we have to spend with you and serve your needs.

If at all possible, please return this packet to our office “PRIOR TO” the day of your first

appointment so we can process your information and establish a clinical chart. Having this

completed and established allows more time in the initial session to get to know you and your

needs.  (Bring it with you to the appointment if you did not drop it off).

  BEFORE YOUR INITIAL VISIT YOU “MUST” OBTAIN THE FOLLOWING

  INFORMATION FROM YOUR INSURANCE CARRIER AND ENCLOSE THIS WITH

  YOUR RETURNED PACKET.   DO NOT RELY ON WHAT IS PRINTED ON YOUR

  CARD, THE CLAIMS ADDRESS IS USUALLY DIFFERENT THAN WHAT IS

  WRITTEN, THEREFORE, PHONE CONTACT WILL NEED TO BE MADE TO OBTAIN

 THIS INFORMATION.  YOU MUST HAVE YOUR INSURANCE CARD WITH YOU AT

 TIME OF THE APPOINTMENT.      Thank you.

   What company administrates your outpatient “mental health benefits?”

   Company Name:  _______________________________________________________________

   Address where claims are sent: ___________________________________________________

   Street:  _______________________________________________________________________

City: ___________________________________ State:  ______________ ZIP: _____________

Do you have a deductible?    Yes ____   No ____  If so, how much?   $__________________

Your Co-Payment: ____________The number of sessions allowed for the year: __________

  Do you require an authorization? If so, you must call for it, and record

  It here:   #______________________________________________________________________

RESPONSIBLE POLICY HOLDER INFORMATION  - ALL BOXES “MUST” BE COMPLETED

PAYMENT, FEES,  &  CONSENT FOR TREATMENT

If, as a client of Arrowhead Behavioral Health, you are using your insurance benefits, you are obligated to pay any deductible and copay at the time of service. The amount of deductible and copay is determined by your individual benefit plan. While we can assist you in filing insurance claims, you are responsible for any amounts that your insurance or health benefit plan does not cover. While we will attempt to verify your benefits it is ultimately your responsibility to know what your health plan will and will not cover. Feel free to discuss insurance coverage with this office. There is a $25.00 charge on all returned checks. NFS checks must be redeemed with cash, certified check or money order. Delinquent accounts may be referred for collections and interest may be added to balances over 60 days. I also understand that if I do not show for my appointment or if I cancel my appointment with less than 24 hours notice, I will be charged for that appointment.  A client's confidentiality is important and is legally protected. There are however, circumstances that impose limitations on a client's right or ability to maintain a privileged communication. We are legally bound to report suspected child or elder abuse or neglect, and are obligated to take steps to inform others if there is a reason to believe that a client is a danger to themselves or others. Confidentiality may also be waived as a result of a court order, legal proceeding, referral to a licensing authority, or other statutory requirement. When a clinician is out of town, another professional will cover crisis calls and that professional may be advised of issues that might arise on your case. If a health benefit plan is expected to pay for some portion of the cost of services, it must be mutually understood and accepted that this office may furnish diagnostic, financial, and clinical information to insurance companies, and/or medical review organizations in order to obtain reimbursement. If you are currently on Short or Long Term disability it must be mutually understood and accepted that this office may furnish diagnostic and clinical information to your Disability Medical Review Organization if requested either by writing or telephone. Your case may be subject to a Peer Case File Review to insure the highest quality of care. In the event group counseling services are provided, it is further acknowledged that the therapist or practice cannot be held responsible for a breech of confidentiality on the part of a peer group member.

I hereby assign insurance of health benefits for treatment for my self, son, daughter, ward, or spouse to Arrowhead Behavioral Health. It is mutually under-e stood, however, that I am financially responsible to Arrowhead Behavioral Health for any charges not paid by my insurance company or third party payer.                          

CLIENT OR PARENT (if client is a minor)__________________________________________________________________________Date:____________________

I do hereby seek and consent to take part in treatment at ARROWHEAD BEHAVIORAL HEALTH.  I understand that developing a treatment plan with the therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest.  I agree to play an active role in this process.  I understand that no promises have been made to me as to the results of treatment or of any procedures provided by the therapist   I am aware that I may stop my treatment with the therapist at any time.  The only thing I will still be responsible for is paying for the services I have already received.  I understand that I may lose other services or may have to deal with other problems if I stop treatment.,  (For example, If my treatment has been court ordered, I will have to answer to the court.)  I know that I must call to cancel an appointment at least 24 hours before the time of the appointment.  If I do not cancel or do not show up, I will be charged for that appointment.

I HAVE REVIEWED THE INFORMATION ON THIS PAGE, AND THE “INFORMATION FOR CLIENTS”, AND ACCEPT THESE UNDERSTANDINGS, AND AGREE TO HAVE MY SELF, SON, DAUGHTER, WARD, AND/OR SPOUSE PARTICIPATE IN TREATMENT.

CLIENT OR PARENT (if client is minor):___________________________________________________________________________Date:___________________

CLIENT NAME: ________________________________________________________________ DATE: _______________________

Where were you born? _________________________How long in Phoenix? _________  From Where?_______________________

List all your sisters and brothers & age, from the oldest to youngest,  include yourself:  _________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Are you parents deceased?     Mother      Father      If decease---   Your age at death:   Mother ________  Father  __________

___________________________________________________________________________________________________________

Give an impression of your childhood home environment (What kind of relationship existed between the parents, between parents and children, and between children?_____________________________________________________________________

___________________________________________________________________________________________________________

Which conditions applies to you during childhood?     Bedwetting    Nail biting    Stuttering   Sleepwalking 

 Physical abuse   Emotional abuse  Sexual abuse   PLEASE EXPLAIN:  ____________________________________________

___________________________________________________________________________________________________________

Illnesses/Diseases?Accident/Surgeries during childhood:  _________________________________________________________ ___________________________________________________________________________________________________________

Highest level of education?       Grade School           Jr. High                 High School               College            Grad. School

Academic performance in:       Grade School ________ Jr. High ________  High School ___________  College ____________

Your occupation ____________________________ Are up satisfied with it? ______Does it meet your financial needs?________

Are you married?  YES    NO  If married, how long? __________  Have you ever been divorced (number of times) _________

If so, please give dates married and dates of divorce(s). ___________________________________________________________

Please explain causes for divorce(s). ___________________________________________________________________________

Do you have children from either present or past marriages?  If so , please indicate present/past, names & ages and whom they live with now: ___________________________________________________________________________________________

___________________________________________________________________________________________________________

Past hospitalization or treatment for addictions: (If yes, explain) _________________________________________________________

Past Hospitalization for psychological problems(If yes, explain) _________________________________________________________

Have you or any one in your family ever attempted suicide?(explain) _____________________________________________________

Have you ever been arrested, including DUI’s? (Explain) ______________________________________________________________

Is your present sex life satisfactory?    Yes   No, If no, please explain __________________________________________________

Describe any unpleasant memories about sexual experience(include forced or traumatic sexual incidents):

___________________________________________________________________________________________________________

Describe any sexual inhibitions or problems that you might have at this time. ______________________________________________

Provide information about any unwanted pregnancies and the consequences.______________________________________________

___________________________________________________________________________________________________________

Support Systems:     Family         Friends         Church         Self Help Groups        Other __________________________

PLEASE MARK ALL THOSE WHICH APPLY TO YOU

ANXIETY/PANIC ATTACKS with:    Heart palpitations        Sweats        Shaking         Shortness of breath        Chest Pain        Nausea      

  Dizzy/Lightheaded         Numb/tingling         Fear of going out   HOW FREQUENT ________How long has it been going on ____________

  COMPULSIVE BEHAVIORS:     cleaning, checking, hand washing, hoarding,    OBSESSIONS:     Repetitive, Ruminate, Monothematic

STRESSORS:     Money     Housing    Family Conflict      Work     Grief & Loss     Illness     Transitions     Other  ______________                            

Do you have any prior history of counseling for mental health, alcohol or drugs, marriage or family, other:  (If so. . . dates, provider, type of interventions, & responses):  __________________________________________________________________________________________

______________________________________________________________________________________________________________________

What have been your major crises of the last 1-5 years:  ______________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What has brought you in today, and why now? “BE SPECIFIC/GIVE DETAILS”:______________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What are your major strengths?: __________________________________________________________________________________________

What spiritual or religious issues are important you?  How does your culture influence you?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

CLIENT SIGNATURE: _________________________________________________________________________ DATE:  ___________________

MEDICAL HISTORY

CLIENT NAME:______________________DATE OF BIRTH:______________TODAY’S DATE:___________

Conditions

Please ü or X any of the following illnesses or medical problems you have experienced in the past or currently experience.  If you recall the year the condition started please indicate that also.

Medications

Please indicate all of the medications and over-the-counter medications you have taken or currently take.  It is important to make the therapist aware of medications taken to avoid drug interactions and optimize the success of your treatment.

Arrowhead Behavioral Health

9865 W Bell Rd.

Sun City, AZ 85351

Cancellation Policy for Counseling Appointments

Our goal is to provide quality care in a timely manner.  In order to do so we have implemented an appointment/cancellation policy.  This policy enables us to better utilize our time and your time by sustaining a smooth flow of patients.

Scheduled Appointments

(  For a scheduled appointment please call 623-876-1246.

Cancellation of an Appointment

In order to be respectful of the therapeutic needs of Arrowhead’s practice please be courteous and call the practice promptly if you are unable to attend an appointment.  This time will be reallocated to someone who is in need of the therapist’s time.

(  Call 24 hours in advance to cancel your scheduled appointment.  If you do not reach the receptionist then leave a phone message to indicate who you are and the time of the cancelled appointment.

(  Call if you are more than ½ hour late to the appointment it will be considered a no show with the $50.00 fee.

Late Cancellations or “No-Shows”

A “No-Show” is someone who misses an appointment without canceling within the prescribed 24 hours prior to the appointment.  No-shows inconvenience those patients who need access to the therapist’s time.

Disability Paperwork

When you made your appointment with Arrowhead Behavioral Health’s receptionist it was made clear—The therapists do not fill out paperwork for court or child custody issues.

REQUEST TO COMMUNICATE PATEINT CARE INFORMATION WITH YOUR PRIMARY CARE PHYSICIAN OR SPECIALIST

In an effort to provide continuity of care and as per request of your insurance company we are asking you to sign a release of information to your primary care or referring physician.  The only information that will be shared with your PCP or specialist will be related to your medication or medical concerns.  Please sign in the shaded areas.

PHYSICIAN’S NAME:______________________________________________________________

PHYSICIAN’S TELEPHONE NUMBER:______________________ FAX NUMBER:_______________

Dear Doctor__________________:

Your patient:_______________________________________, date of birth:_________________

Was seen by Arrowhead Behavioral Health for an initial assessment on:_____________ with the next visit

Scheduled on:_______________________________.

DIAGNOSIS OR PRESENTING PROBLEM:___________________________________________________

TREATMENT RECOMMENDATIONS:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICATIONS PRESCRIBED:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

If further information is required contact Arrowhead Behavioral Health’s office at: 

·          9865 W Bell Rd.

Sun City, AZ 85351

623-876-1246 or Fax 623-

Authorization To Disclose Information

To the party receiving this information:  This information has been disclosed to you from records whose confidentiality is protected by federal law.  Federal regulations 42 CFR Part 1, prohibit you making further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations.  A general authorization for release of medical or other information is not sufficient of this purpose.

FOR PATIENT RECORDS APPLICABLE UNDER FEDERAL LAW 42 CFR PART 2

___________ I want this information released to my physician.

_____________ I do not want this information released to my physician.

PATIENT’S SIGNATURE:________________________________________________        DATE:______________________________

PARENT/GUARDIAN’S SIGNATURE:________________________________________      DATE:______________________________

ARROWHEAD BEHAVIORAL HEALTH  is located just East of Access Bank and behind JB"S Restaurant at  99th Ave. and Bell Rd.  The Back building of Campana Square.

If you are coming from the 101 and Bell Rd.  turn left on 98th Ave. (Coco's is on the corner).  Then take an immediate right on Campana and go all the way to the end of the long building and turn right in to the lot.  We are the end suite of the building on the right. (ABH in yellow letters).

If you are approaching from West Bell Rd, go through the light at 99th Ave.and turn right into the JB's parking lot and drive all the way to the back building and we are in the end suite (ABH in yellow letters).

ARROWHEAD BEHAVIORAL HEALTH

9865 W. Bell Rd. Sun City, Arizona 85351

PHONE: 623-876-1246

FAX: 623-933-5463

www.arrowheadbehavioralhealth.com

We accept all major credit cards, debit cards, checks, and cash. We also take payments over the phone: