Registration Form: Name * First Name Last Name SEX * D.O.B MM DD YYYY Age * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone Country (###) ### #### Parent's Cell Phone Country (###) ### #### Patient's Cell Phone Country (###) ### #### Parent's Email Mother's Name First Name Last Name Mother's D.O.B MM DD YYYY Father's Name First Name Last Name Father's D.O.B MM DD YYYY Patient's Birthplace Parent Employer Name First Name Last Name Employer Address Address 1 Address 2 City State/Province Zip/Postal Code Country Reason For Visit Emergency Contact Name * PERSON TO CONTACT IN CASE OF AN EMERGENCY Relationship Home Phone * Country (###) ### #### Work Phone Country (###) ### #### Physician's Name (if applicable) First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### PRIMARY Insurance Name (if applicable) Certificate/Policy # Group # Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Insured’s Name First Name Last Name Relation to Insured Insured’s D.O.B MM DD YYYY Effective Date MM DD YYYY Expiration Date MM DD YYYY AUTHORIZATION TO RELEASE MEDICAL INFORMATION: I certify that all information above is true and correct. I authorize and direct, Jasmine Trangucci, LCSWR, PLLC, to release to insurance carriers, or others who are financially liable for my medical/mental health care, all information needed to substantiate reimbursement for such medical care and permit representatives thereof to examine and make copies of all records relating to such care and treatment. I hereby agree to pay Jasmine Trangucci, LCSWR, PLLC in full directly for her services. I understand that I am responsible for charges not covered by my policy or plan. NOTICE OF PRIVACY PRACTICES FORM (HIPAA) ACKNOWLEDGEMENT I certify that I was given a copy of Jasmine Trangucci, LCSWR, PLLC, HIPAA Notice of Privacy Practices Form. * Agree to sign I Agree Date MM DD YYYY FEE/CANCELLATION POLICY : I hereby agree to pay Jasmine Trangucci, LCSWR, PLLC, in full directly for her services. I understand that I am responsible for charges not covered by my policy or plan. Unless other arrangements are made, payment or if applicable co-payment is expected upon receipt of services. Please be advised that insurance plans do not cover cancelled or missed sessions. Therefore, in the event of missed or cancelled session, regardless of the reason for cancellation, without 24 hours advanced notice, you will be billed and are responsible for the full fee of $100.00 for the session(s) offered. By signing below, I attest that I understand and agree to the fee policy and that I am aware that I am ultimately responsible for any charges incurred for services rendered. * Agree To sign I Agree Date MM DD YYYY EMAIL CONSENT FORM: Email communication can offer an efficient way to communicate, from appointment reminders to providing updates and information that allows the therapist and the patient to avoid some of the frustrations of telephone communications. However, this medium is not without its risks. RISKS OF USING EMAIL/Text Messaging: Transmitting patient information by email has a number of risks that patients should consider before using email. These include, but are not limited to, the following risks: ● Email/Text messages can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients. ● Backup copies of email/text messages may exist even after they are sent or the recipient has deleted his or her copy. ● Employers and on-line services have a right to inspect email/text messages transmitted through their systems. ● Email can be used to introduce viruses into computer systems. ● Emails/Text messages may not be secure, and therefore it is possible that the confidentiality of such communications may be breeched by a third party. ● Email/Text messages can be intercepted, altered, forwarded, or used without authorization or detection. GUIDELINES FOR USE OF EMAIL/TEXT MESSAGING COMMUNICATION: Jasmine Trangucci, LCSWR, PLLC cannot guarantee, but will use reasonable means, to maintain security and confidentiality of email/Text messaging information sent and received. Jasmine Trangucci, LCSWR, PLLC will not be liable for improper disclosure of confidential information that is not caused by intentional misconduct. Patients must acknowledge and consent to the following conditions: ● Email/Text message is not appropriate for urgent matters or an emergency situation. Instead, please call Jasmine Trangucci, LCSWR, PLLC ● Jasmine Trangucci, LCSWR, PLLC cannot guarantee that any particular email/text message will be read and responded to within any particular period of time. ● Email/Text message should be concise. The patient should schedule an appointment if the issue is too complex or sensitive to discuss via email/text messages. ● Jasmine Trangucci, LCSWR, PLLC will check email/text messages on a regular basis. However, there may be exceptions to this. In addition, there can be server problems or line/connection problems. ● Jasmine Trangucci, LCSWR, PLLC will not check email/text messages when out of the office, on vacation or in training. ● Most email messages will be filed in the patient record. ● Jasmine Trangucci, LCSWR, PLLC will not forward patient identifiable emails/text messages to others outside the practice without the patient’s prior written consent, except as authorized or required by law. ● Jasmine Trangucci, LCSWR, PLLC will never distribute a patient’s email address to a third party. ● Jasmine Trangucci, LCSWR, PLLC is not liable for breach of confidentiality caused by the patient or any third party. ● Patient will use caution when using your employer’s computer. ● Patient will inform provider of changes in your email address/phone number. I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the use of email communication and/or text messages, and I am willing to accept the risks involved with insecure email communication and consent to the conditions and instructions outlined. I understand that the use of more secure communications, such as phone or fax, is always an alternative available to me. Agree to sign I Agree Email Phone (###) ### #### Date MM DD YYYY Form Submitted!
