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Anna's Applied Neuroscience

20 Community Place #4
Morristown NJ 07960
201-919-1483

PRIMARY CLIENT INFORMATION

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PRIMARY INSURED

Insurance Self Pay EAP Third Party

May we call at work?

Yes

Primary Insurance Information

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SECONDARY INSURED ("If Applicable")

May we call at work?

Yes

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Terms And Conditions

Social Media Po...
Telehealth Info...
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Social Media Policy

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%3cdiv contenteditable%3d%27false%27 unselectable%3d%27on%27 class%3d%27unselectable%27%3e%3cp%3e%3cstrong%3e%3cspan style%3d%22font-size%3a 18px%3b%22%3eApplied Neuroscience NJ Social Media Policy%3c/span%3e%3c/strong%3e%3cbr%3e%3cbr%3eThis document outlines Applied Neuroscience NJ Therapy’s policies related to use of%3cbr%3esocial media and communication beyond the realm of the therapy session. Please%3cbr%3ediscuss any questions or concerns you may have with your therapist.%3cbr%3e%3cbr%3e%3cstrong%3eEmail/Phone Calls/Text Messages%3c/strong%3e%3cbr%3e%3cbr%3ePlease use either Applied Neuroscience NJ work email or if you do not have that email%2c%3cbr%3ecall the business number 201-919-1483 to contact your therapist for administrative%3cbr%3ereasons only %28modifying appointments%2c billing information%2c etc.%29.%3cbr%3eApplied Neuroscience NJ may opt to utilize text messaging with a phone overlay service%3cbr%3efor the sole purpose of confirming appointments / noting appointment changes.%3cbr%3ePlease do not email or text content related to the counseling sessions or assessments%2c%3cbr%3eunless otherwise discussed. Email communication is secure and HIPAA compliant%2c but%3cbr%3etext communication is not completely secure or confidential. Any emails or texts%3cbr%3ereceived from you and any responses sent to you become a part of your legal record.%3cbr%3ePlease note that all emails or voice messages left through the answering service will be%3cbr%3eresponded to within 12-24 hours of receipt%2c during office hours. If there is a life or death%3cbr%3esituation please dial 911.%3cspan style%3d%22font-size%3a 1em%3b%22%3e%3c/span%3e%3c/p%3e%3cp%3e**Please do not use either the work email%2c text%2c or the answering service for%3cbr%3eemergencies%2c but rather call 911 and alert your therapist once safely connected to an%3cbr%3eappropriate emergency service.%3cbr%3e%3cbr%3e%3cstrong%3eSocial Media - Friending/Following%3c/strong%3e%3cbr%3e%3cbr%3eApplied Neuroscience NJ will NOT accept friend or contact requests from current or%3cbr%3eformer clients on any social networking site %28Facebook%2c LinkedIn%2c etc.%29. Adding clients%3cbr%3eas friends on these sites can compromise your confidentiality and the therapeutic%3cbr%3erelationship.%3cbr%3eApplied Neuroscience NJ will NOT follow any client on Twitter%2c Instagram%2c blogs%2c or%3cbr%3eother apps/websites. If there is content you wish to share from your online life with your%3cbr%3etherapist%2c please bring it into the sessions where it can be explored privately.%3c/p%3e%3cp%3eI have read and understand the Applied Neuroscience NJ policy above and will adhere%3cbr%3eto its specifications.%3c/p%3e%3c/div%3e

Date: I have read and I agree to the Social Media Policy

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Anna's Applied Neuroscience

20 Community Place #4
Morristown NJ 07960
201-919-1483

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. What would your partner say?

5. Length of these relationship:

6. Can you tell me a little bit about yourself and your family/culture/upbringing?

7. Can you tell me a little bit about what intimate relationships look like for you?

8. Do you have any dependents?

9. Therapy before:

10. Psychiatry before:

11. Medications (type & dosage frequency):

12. Alcohol and Drug Use (type & dosage frequency):

Describe use:

13. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

14. Recreational drugs: Yes No

Describe use:

15. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

16. Self Harming Behaviours: Yes No

Describe, including most recent incident:

17. Violence Towards Others: Yes No

Describe, including most recent incident:

18. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

19. Experience of life being threatened by person, accident, or natural disaster: Yes No

20. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

21. Actions taken concerning above risks:

22. Religious Affiliation/Denomination:

23. Occupation:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. City Year Employee: (site name, site grade level, & program manager):

27. Availability:

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee: Insurance and/or Sliding scale amount:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

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Anna's Applied Neuroscience

20 Community Place #4
Morristown NJ 07960
201-919-1483

Intake

1. Occupation:

Youth worker:

No describe

Yes describe

2. If City Year Employee: (site name, site grade level, & program manager):

3. How did you hear about us?

4. What type of therapy are you seeking? Individual Couples Family Hybrid Group

5. What brings you in?

6. Client stated strengths

7. Can you tell me a little bit about yourself and your family/culture/upbringing?

8. Tell me a little bit about your community & social supports

9. Do you have any dependents?

10. Therapy before:

11. Psychiatry before:

12. Medications (type & dosage frequency):

13. Alcohol and Drug Use (type & dosage frequency):

Describe use:

14. Marijuana/Cannabis products: Yes No

Do you have a medical marijuana card? Yes No

Describe use:

15. Recreational drugs: Yes No

Describe use:

16. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

Access to any weapons, if so type:

17. Self Harming Behaviours: Yes No

Describe, including most recent incident:

18. Violence Towards Others: Yes No

Describe, including most recent incident:

19. Physical/Emotional/Sexual abuse in the past: Yes No

Describe:

20. Experience of life being threatened by: Person Accident Natural Disaster

21. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

22. Actions taken concerning above risks:

23. Religious Affiliation/Denomination:

24. Preferred Location:

25. School: (grade/year, graduation date & current GPA):

26. Availability:

27.Insurance and/or Sliding scale amount:

Everything below is for Office Staff Only to Complete

28. Clinician assigned:

29. Initial Appointment:

30. Client Informed of Fee:

31. Client Informed of 2 business day cancellation policy: Yes No

32. Who did the intake:

32. Youth worker: Yes No

33. Describe if not occupation (under occupation)

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Anna's Applied Neuroscience

20 Community Place #4
Morristown NJ 07960
201-919-1483

Intake

1. How did you hear about us?

2. What type of therapy are you seeking? Individual Couples Family Hybrid

3. What brings you in?

4. Suicidality:

Ideation: Yes No

Describe, including whether ideation has occurred in the last 2 weeks:

Planning: Yes No

Describe, including whether planning has occurred in the last 2 weeks:

Attempts: Yes No

Describe including year(s) of occurrence and outcome:

Means: Yes No

5. Violence Towards Others: Yes No

Describe, including most recent incident:

6. Hospitalizations for Psychiatric Reasons: Yes No

Describe, including year of occurrence, diagnosis (if possible) and resulting treatment:

7. Client Informed of Fee: Insurance and/or Sliding scale amount:

8.Client Notes

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Anna's Applied Neuroscience

20 Community Place #4
Morristown NJ 07960
201-919-1483

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Anna's Applied Neuroscience

20 Community Place #4
Morristown NJ 07960
201-919-1483

Intake

Intake Question

Referral Source

Are you currently on active duty? Yes No

Military Branch

Highest Level of Education

Employment status

Are you currently enrolled in school or job training program?

Are you currently using? Yes No

Routine of administration types:

During the past 30 days, how many days have you used any of the following:

Cocaine/crack

Marijuana/Hashish

Heroine

Morphine

Dilaudid

Demerol

Fentanyl

Percocet

Darvon

Codeine

Tylenol 2, 3, 4

OxyContin/Oxycodone

Non-prescription methadone

Hallucinogens/psychedelics, PCP, LSD, Mushrooms, or Mescaline

Methamphetamine or other amphetamines

During the past 30 days, how many days have you used any of the following:

Benzodiazepines: diazepam, alprazolam, Triazolam, and etizolam

Barbiturates: Metharbital and pentobarbital sodium

Non-prescription GHB

Ketamine

Other tranquilizers, downers sedatives, or hypnotic

Inhalants

Other illegal drugs

Drug of Choice-Diagnosis

Behavioral Health

Children's Services Referral Yes No

If Children's Services referral, do you have an active Children's Services case? Yes No

# of children that you have

Crime Justus status

Probation Yes No

Parole Yes No

PROB 45 Yes No

Human Trafficking

Is there a history of Sexual Abuse?

Program Placement (Level of Care)

Sober Housing Needed Yes No

Sober Housing Provided Yes No

Medical Intake Questions

If female, are you pregnant? Yes No

Medicated Assisted Treatment (MAT)

Hypertension

Diabetes

STI's

UTI's

Cellulitis

COPD

Asthma

Blood dyscrasia

City

State

Zip code

County

Is there a history of drug use? Yes No

In the past 30 days, where have you been living most of the time?

Are you currently employed?

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Notes

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Expiration Date:

Address:

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Electronic Signature

Anna's Applied Neuroscience

20 Community Place #4 Morristown NJ 07960 201-919-1483

PRIMARY CLIENT INFORMATION

PARTNER INFO

PRIMARY INSURED

Primary Insurance Information

SECONDARY INSURED ("If Applicable")

Anna's Applied Neuroscience

20 Community Place #4 Morristown NJ 07960 201-919-1483

Anna's Applied Neuroscience

20 Community Place #4 Morristown NJ 07960 201-919-1483

Anna's Applied Neuroscience

20 Community Place #4 Morristown NJ 07960 201-919-1483

Anna's Applied Neuroscience

20 Community Place #4 Morristown NJ 07960 201-919-1483

Anna's Applied Neuroscience

20 Community Place #4 Morristown NJ 07960 201-919-1483

20 Community Place #4
Morristown NJ 07960
201-919-1483

20 Community Place #4
Morristown NJ 07960
201-919-1483

20 Community Place #4
Morristown NJ 07960
201-919-1483

20 Community Place #4
Morristown NJ 07960
201-919-1483

20 Community Place #4
Morristown NJ 07960
201-919-1483

20 Community Place #4
Morristown NJ 07960
201-919-1483