This is the secure (SSL) password protected online non-clinical intake form for the office of Robert Odell, LICSW. It will take about 15 mins. to complete.
After the form is sent, I will arrange a phone conversation with you, usually within your indicated times. I will answer your questions, and secure a first appointment time.
A valid credit, debit or checking account must be provided to secure the appointment . My policy is identical to hotel reservations, as a guarantee in the event you do not appear for your appointment. E-mail reminders are issued twice within 5 days of your appointment.
DIGITAL SIGNATURES: The intake form requires digital signatures. They might not resemble your normal handwritten signature. They serve as legal confirmations that you have understood key parts of the form. You can have a hard copy to discuss any terms during our first appointment.
These are the forms to be completed:
Please be sure to read or review all informational pages.
Robert Odell, LICSW
If insurance is being used, and you are not the policyholder, please enter policyholder information:
Subject to my review of the attached Disclosure Statement, I freely consent to receive, or discontinue with proper notice, diagnostic and treatment services from Robert Odell, LICSW. I have been given information regarding my rights and responsibilities as a client. I may address any concerns or grievances with Robert Odell, or the Washington Department
My signature below conﬁrms my understanding and agreement to the terms above, and to receive services from Robert Odell, LICSW.
Credit/debit card or bank checking account information (including pre-tax medical ﬂex accounts) is used for the personal guarantee of payment. Account number is transferred to a digitally encrypted format. The only circumstances under which the account will be accessed are:
You are entitled to receive a written receipt for any payments you have made.
Robert Odell, LICSW
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I am required by law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices, legal obligations, and your rights concerning your health information ("Protected Health Information" or "PHI"). I will follow the privacy practices that are described in this Notice. If I amend this Notice, I will provide you with the amended Notice for your information and signature.
For more information about my privacy practices, or for additional copies of this Notice, please let me know your questions as soon as they arise.
I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
II. MY INDIVIDUAL RIGHTS
III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE
If I change this Notice, I will post the revised notice in the waiting area of my office and on my website at seattle-counseling.com. You may also obtain any revised notice by asking me directly.
It is your right as a client to select the mental health professional who best suits your needs. Before you sign this statement, your consent to treatment requires that you know about my services, and the terms under which I provide them.
I practice according to the Code of Ethics of the Clinical Social Work Association. A copy of this Code is available on request. Please refer to the attached summary of the ethical practices I observe.
The conﬁdentiality of our work is of utmost importance. State of Washington law holds that our communication is privileged information, identical to that between doctors and patients, or lawyers and clients. See Section II. A(b) below.
If your mental health insurance beneﬁt requires a review of treatment to authorize additional sessions, then certain information about you may have to be shared with an insurance or managed care company. I will always review these disclosures with you in advance. Please review the information about my patient Privacy Practices mandated by the 1996 Federal law known as Health Insurance Portability and Accountability Act (HIPAA).
Education, training & experience
I received my Masters degree from the University of Southern California School of Social Work. In this program, I completed two one-year clinical internships: a Los Angeles County community mental health clinic serving indigent, severely/persistently mentally ill and homeless populations; and, a corporate employee assistance program (EAP), providing assessment, counseling and referral for personal, work-related and chemical dependency problems.
My post-graduate clinical experience includes individual & family therapy in a South Central Los Angeles psychiatric hospital. I then practiced in a Los Angeles court mandated residential treatment center for adolescent boys, including sex offenders, providing individual, group and family treatment.
I have provided individual and family therapy, case management and emergency room psychiatric assessments throughout Seattle, for Fairfax Hospital. In 1998, I began an ofﬁce practice in an adjacent clinic, working with psychiatrists, psychologists, nurses, clinical social workers, marriage & family therapists and mental health counselors. I have practiced independently and privately since 1999.
My continuing education has included training in relationship therapy, human sexuality, ethics, clinical supervision, workplace trauma debrieﬁng, abuse prevention and reporting, suicide prevention.
Appointment cancellation, rescheduling and changes. Your appointment is an agreement to meet on that date and time. If you do not appear, your credit or debit account will be charged via the pre-authorization in the Personal Responsibility for Payment form.
I accept voice mail and e-mail, for changing or canceling appointments. For Monday appointments, notify me no later than Thursday 12P; for Tuesday, no later than Friday 12P.] If you are late, and do not notify me by phone, I will remain in the ofﬁce for a maximum of 30 minutes past the appointment time.
For a late cancellation (less than 48 hours notice): If you reschedule within 4 business days, I charge a fee equal to 75% of what I normally receive from you and/or your insurance carrier. After four business days, the full cancellation fee will be charged. If I fail to appear, without notice, for your appointment, either your insurance co-payment, or your private fee for the next appointment will be waived. (See below,¶2 of Special Ofﬁce Policies, for Emergency Service notice)
Prior to signing below you have the opportunity to ask Robert Odell for further explanation, or have received same, for any of above disclosure information and ofﬁce policies.
PLEASE NOTE APPOINTMENT CANCELLATION POLICY - 48 BUSINESS HOUR REQUIRED NOTICE
My primary goal is to develop the closest possible treatment relationship with you in the most ethical environment I can create. Disclosure of these professional and personal ethics to you seeks to prevent relationship practices that I believe can hurt or destroy treatment. If you have questions or concerns about any of these policies, please discuss them with me as soon as possible.
Emergency Service for Critical Incidents: I am contracted with several emergency service networks that help victims of incidents that can cause emotional and psychological trauma. These include robberies, industrial accidents, large layoffs and sudden deaths. I may be called to the scene of an emergency on the same day it occurs, or a day or two after an incident.
I must provide these services on a particular date, but make every effort to maintain my scheduled ofﬁce appointments. However, if schedule changes are unavoidable, I will immediately call all affected clients to reschedule appointments.
If called to the scene on the same day an incident occurs, I may not be able to reach you in time to prevent your coming to your scheduled appointment. The likelihood of this happening is quite small. If this does occur, your rescheduled appointment will have any copayment or coinsurance waived.
Please also be aware that I may receive emergency text messages from these service networks at any time. This is the only interruption to our appointment that I allow. When I receive a message during an ofﬁce appointment, I will notify you and then respond as brieﬂy as possible. The interruption lasts less than two minutes, and I will make up this time to you during the appointment.
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