FORMS

Diana Weiss-Wisdom, Ph.D. psy#12476
Licensed Psychologist

(858) 259-0146

CLIENT IDENTIFICATION RECORD

DATE: _______________

NAME: ___________________________________________________________

STREET ADDRESS: ________________________________________________

CITY, STATE, ZIP: _________________________________________________

TELEPHONE: DAY: ______________________ EVENING: _______________
CELL: _____________________

DATE OF BIRTH: ________________________ SSN: ____________________

OCCUPATION: _____________________________________________________

EMPLOYER: _______________________________________________________

ADDRESS: _______________________________________________________

WHO REFERRED YOU HERE: ________________________________________

METHOD OF PAYMENT: ________SELF ________ INSURANCE

___________________ OTHER

Name of insurance company: ____________________________________

Address: ___________________________________________________________

I.D. Number: _______________________ Group Number: ________________

IN CASE OF EMERGENCY NOTIFY:

Name: ___________________________________ Phone: _______________________

Address: ________________________________________________________________

Relationship: ____________________________________________________________

240 9th Street, Del Mar, Ca. 92014 858-259-0146

_________________________________________________________________________

Diana Weiss-Wisdom, Ph.D. psy#12476
Licensed Psychologist
Confidentiality

In general, law protects the confidentiality of all communications between a client and a psychologist, and I can only release information about our work to others with your written permission. However, there are a few exceptions. In most judicial proceedings, you have the right to prevent me from providing any information about your treatment. However, in some circumstances such as child custody proceedings and proceedings in which your emotional condition is an important element, a judge may require my testimony if he/she determines that resolution of the issues before him/her demands it.

1. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a client threatens to harm himself/herself, I may be required to seek hospitalization for the client, or to contact family members or others who can help provide protection.
2. If I believe that a child, an elderly person, or a disabled person is being abused, I must file a report with the appropriate state agency.
3. If I assess the patient to be a danger to self, or unable to take care of himself/herself, I may notify the appropriate authorities.
4. In the event of failure to pay a bill in reasonable time, the name of the patient may be given to a collection agency to collect payment or may be recorded in small claims court.
5. Some legal actions initiated by the patient or the patient’s estate may result in the court ordering the release of records.
6. Records and information regarding your diagnosis and treatment must be submitted to your insurance carrier for determination of benefits and authorization for continued treatment.

Patient Name: ____________________________________________
Patient Signature: _______________________Date: _____________
Witness: _____________________________ Date: _____________

_________________________________________________________________________

Diana Weiss-Wisdom, Ph.D. psy#12476
Licensed Psychologist

FEE CONTRACT

CLIENT: __________________________________________________________

Payment is expected following each session. Under some conditions, clients may be billed monthly. If this is the case, payment is due ten (10) days after receipt of your statement. Failure to keep your account up to date may result in the discontinuation of services.
Initial: _________

Cancellations must be made 24 hours before you r scheduled appointment. Late cancellations or missed appointments will be your responsibility, as the insurance company will not pay for non-rendered services.
Initial ________

Should your account become delinquent by a three month period, and you do not comply with a mutually agreed upon schedule of payment, your account may be turned over to a collections agency.
Initial ________

I have read and understand this financial agreement, and agree to its terms.

SIGNED: ___________________________________________

DATE: ___________________________________________

Diana Weiss-Wisdom, Ph.D.

Licensed Psychologist psy#12476