Patient Intake

All of our forms are fully HIPAA compliant and are encrypted before sending to provide you with complete security and privacy.

Step 1 of 7

Patient's Information
Last Name*
First Name*
Optional
Middle Initial Nickname
Social Security Number
Birthdate*
MM slash DD slash YYYY
Sex
- Male
- Female
MOTHER’S MAIDEN NAME

(FOR PURPOSES OF IMMUNIZATION REGISTRY)
Patient's Address
Patient's Physical Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing/Mailing Address
If different from Physical

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient's Contact Information
Home Phone*
Day Phone
Alternate Phone
Email*
Preferred method of notifications
- Phone
- Text
- E-mail
- Automated Recordings
(check all that apply)
Patient's Emergency Contact Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Relationship
Contact Phone Number

Responsible Party's Information (if different than patient)
Name
Last Name First Name Previous Last Name Nickname
Social Security Number
Birthdate
MM slash DD slash YYYY
Sex
- Male
- Female
Relationship to Patient

(FOR PURPOSES OF IMMUNIZATION REGISTRY)
Responsible Party's Address (if different than patient)
Billing/Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Insurance
Type of Primary Coverage
- Medi-Cal
- Medicare
- Private Insurance
- None
Name of Insurance Company
Policy Number
Group Number
Address of Insurance Company
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Effective Date
MM slash DD slash YYYY
Expiration Date
MM slash DD slash YYYY
File/Image upload
Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.
Insurance card, ss card, identification card, etc

Name of Medication	Current Dosage/Frequency	Start Date	Actions

There are no Entries.

Notice of Privacy Practices

We are committed to protecting your personal health information in compliance with the Federal law.
We may use or disclose your personal health information for these purposes:

For Treatment, Payment, Health Care Operations, Appointment Reminders, Health Related Services and Treatment Alternatives, Fundraising Activities, Individuals Involved in Your Care or Payment for Your Care, Research, Organ and Tissue Donation, As Required By Law, To Avert a Serious Threat to Health or Safety, Military and Veterans, Workers’ Compensation, Public Health Activities, Health Oversight Activities, Lawsuits and Disputes, Law Enforcement, Coroners, Health Examiners and Funeral Directors.,
National Security and Intelligence Activities. Protective Services for the President and Others, and Inmates.

You have certain rights with respect to your personal health information:

Right to Inspect and Request a Copy, Right to Amend, Right to Receive an Accounting of Disclosures, Right to Request Restrictions, Right to Receive Confidential Communications, Right to a Paper Copy of this Notice.

Changes to this Notice:

We reserve the right to change this notice and to make the changed notice effective for all of the health information that we maintain about you, whether it is information that we previously received about you or information we may receive about you in the future. We will have available a copy of our current notice in our facility. Our notice will indicate the effective date on the first page, in the center of page. We will also give you a copy of our current notice upon request.

Complaints:

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. You may file a complaint by mailing us a written description of your complaint or by telling us about your complaint in person or over the telephone:

Amy Karamyan, President
Pure Autism Counseling Center INC.
19981 Soledad Canyon Rd,
Santa Clarita CA
661.360.7730
ACKNOWLEDGEMENT OF RECEIPT PRIVACY PRACTICES NOTICE AND ADVANCE HEALTH CARE DIRECTIVES INFORMATION
RECONOCIMIENTO DE RECIBO DEL AVISO DE LAS PRÁCTICAS DE PRIVACIDAD Y DIRECTIVAS POR ANTICIPADO SOBRE LA ATENCIÓN DE LA SALUD
I*
have received a copy of PURE AUTISM COUNSELING CENTER Privacy Practices Notice and Advance Health Care Directives information.
Patient’s Name
Date*
MM slash DD slash YYYY
Name of Parent or Patient’s Representative
Date
MM slash DD slash YYYY
Yo
reconozco que he recibido una copia del Aviso de las Practicas de Privacidad y Directivas por Anticipado sobre la Atención de la PURE AUTISM COUNSELING CENTER.
Nombre del Paciente
Fecha
MM slash DD slash YYYY
Nombre del padre del paciente o algún representante
Fecha
MM slash DD slash YYYY
Staff Use Only/Para Uso de Oficina Solamente:
If the information was not given to the patient or the patient’s legal representative, please indicate the reason why below:
Patient's Name
DOB
MM slash DD slash YYYY
MR #

Credit Card Authorization Form
Patient Name (if different from above)
First Last
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Credit Card Type*
- Visa
- Master Card
- Discover
- Amex
Credit Card Number*
Expiration Date*
CCV*
(LAST 3 DIGITS ON BACK OF CARD)
CARDHOLDER NAME*
Co-pay/Payment Amount*
Co pay will be charged one business day before session appointment date
I AUTHORIZE PACC MENTAL HEALTH SERVICES TO CHARGE THE AGREED AMOUNT LISTED ABOVE TO MY CREDIT CARD PROVIDED HEREIN. I AGREE THAT I WILL PAY FOR THIS SERVICE IN ACCORDANCE WITH THE ISSUING BANK CARDHOLDER AGREEMENT.
Initials:*
Comments
This field is for validation purposes and should be left unchanged.

Patient Intake

All of our forms are fully HIPAA compliant and are encrypted before sending to provide you with complete security and privacy.

Step 1 of 7

Patient's Information

Patient's Address

Patient's Contact Information

Patient's Emergency Contact Information

Patient's Additional Information

Responsible Party's Information (if different than patient)

Responsible Party's Address (if different than patient)

Primary Insurance

Consent for Treatment

Health Questioner

A. Risk History

Type of Risk:

VII. EDUCATION/EMPLOYMENT/FINANCIAL HISTORY:

VIII. SPIRITUAL/RELIGIOUS HISTORY:

IX. PSYCHIATRIC/COUNSELING HISTORY:

X. Substance Abuse History (If necessary):

Alcohol

Amphetamines

Barbiturates

Benzodiazepines

Cannabis

Cocaine/Crack

Crystal Meth

Designer Drugs

Hallucinogens

Heroine/Methadone

Inhalants

Other Opiates

Over-the-counter

XI. LEISURE/RECREATION:

XIII. MEDICAL HISTORY:

Fill the table

Notice of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT PRIVACY PRACTICES NOTICE AND ADVANCE HEALTH CARE DIRECTIVES INFORMATION

RECONOCIMIENTO DE RECIBO DEL AVISO DE LAS PRÁCTICAS DE PRIVACIDAD Y DIRECTIVAS POR ANTICIPADO SOBRE LA ATENCIÓN DE LA SALUD

Credit Card Authorization Form