Administrative hours:
M-Th- 8am-5pm, Fri- 8am- 12noon
[email protected]
Call: 480.998.2303
Fax: 480.998.3169
Toggle navigation
The Nicholls Group
Home
Services
Neuropsychological Evaluations
Academic Evaluations
Emotional/Behavioral Evaluation
Autism Spectrum Disorder
Memory Screening/Dementia Evaluation
Forensic Evaluations/Records Review
Psychotherapy/Counseling Services
COGMED
Professional
Staff
Professional Staff
Dr. Christopher Nicholls
Dr. Valerie Hoffman
Dr. Sally Logerquist
Dr. Sarah Karabatsos
Dr. Felicia Wilson
Dr. Christina Lebovitz
Dr. Cindy Miller
Maraen Foley
Leena Bui
Administrative Staff
Elise Schnackenberg
Michelle Delaferrelle
Faq
Forms
Initial Appointment Forms
Intake Form
Background History Form
Extra Office Forms
Treatment Of Minor Client Form
Exchanges of Records Form
Teacher Form
Medicare Opt-Out Patient Contract Form
Privacy Terms & Agreement
2019 HIPPA Agreement
Groups
Resources
Intake Form
Home
Intake Form
If you wish to download a PDF file of this form to print and complete by hand,
click here
.
Client Information
Client Name
Application Date
Client Address
City
State
-- Select State --
:
Alabama
:
Alaska
:
American Samoa
:
Arizona
:
Arkansas
:
California
:
Colorado
:
Connecticut
:
Delaware
:
District of Columbia
:
Federated States of Micronesia
:
Florida
:
Georgia
:
Guam
:
Hawaii
:
Idaho
:
Illinois
:
Indiana
:
Iowa
:
Kansas
:
Kentucky
:
Louisiana
:
Maine
:
Marshall Islands
:
Maryland
:
Massachusetts
:
Michigan
:
Minnesota
:
Mississippi
:
Missouri
:
Montana
:
Nebraska
:
Nevada
:
New Hampshire
:
New Jersey
:
New Mexico
:
New York
:
North Carolina
:
North Dakota
:
Northern Mariana Islands
:
Ohio
:
Oklahoma
:
Oregon
:
Palau
:
Pennsylvania
:
Puerto Rico
:
Rhode Island
:
South Carolina
:
South Dakota
:
Tennessee
:
Texas
:
Utah
:
Vermont
:
Virgin Islands
:
Virginia
:
Washington
:
West Virginia
:
Wisconsin
:
Wyoming
:
Armed Forces Europe, the Middle East, and Canada
:
Armed Forces Pacific
:
Armed Forces Americas (except Canada)
Zip Code
Home Phone/Cell Phone
Work Phone
Date of Birth
Email
Gender
Female
Male
Non-binary/Third Gender
Prefer Not To Say
Prefer to self-describe
Marital Status of Patient/Guardian:
Single
Married/Domestic Partnership
Divorced
Separated
Widowed
I authorize messages to be left on answering machine, voice mail, and/or email.
Yes
No
I would like a summary of my visit sent to my physician
Yes
No
Physician Name
Physician Address
Referred by
Referred to Dr./Group:
Notify in case of emergency:
Financially Responsible Person
Name
Relationship
-- Select One --
Parent
Relative
Friend
Other
Address
City
State
-- Select State --
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Europe, the Middle East, and Canada
Armed Forces Pacific
Armed Forces Americas (except Canada)
Zip Code
Home Phone/Cell Phone
Work Phone
Date of Birth
Eligible for Medicare or Medicaid Benefits
Yes
No
I understand that I am financially responsible for my entire bill, and the fees are due at the time of service. We ask that all patients pay at the beginning of their appointment for services scheduled.
I understand and agree that any amounts owed by me are subject to 1.5% per month (18% per year) interest, which will be added to any outstanding bill. Fees are based upon how much time is spent on activities associated with the client needs, at an hourly rate.
Therapy/consultation hours are 50 minutes long and are billed at the hourly rate. This procedure is required because of the additional time needed to write up session notes.
Psychological evaluations are charged at a rate that is one and one-half times the direct face-to-face contact time. This procedure is required because of the additional time needed to score and interpret psychological testing. Report prepartation is charged according to the time required.
We are happy to correspond with you by phone or by email, as we understand that you may have questions in between sessions or after a feedback session. Please note if that time exceed 15 minutes, you will be billed for that time. Charges will be billed in 15 minute intervals.
I understand that the providers in this office do not submit claims to any insurance companies,
I understand that I will be informed about the administrative procedure and upon request I will be given diagnostic codes, which I may submit to my insurance policy at my own discretion; and that I am responsible for any prior authorization or pre-certification required for services. Please note The Nicholls Group cannot correspond with your insurance company via phone/mail without written consent from the client or guardian.
The Nicholls Group does not provide Medicare or Medicaid services; therefore, if I am a Medicare or Medicaid beneficiary, I understand that a separate private contract will need to be signed and I wil be fully responsible for payment of all services provided.
Cancellation Policy:
The Nicholls Group requires a 72-business hour cancellation for all evaluations. If my appointment is not cancelled within 72 hours. I understand that I will be charged for the time scheduled.
For therapy and/or consultation, the Nicholls Group requires a 48-business hour notice. If my appointment is not cancelled within 48 hours, I understand that I will be charged for the time scheduled.
I understand that insurance companies do not reimburse or cover missed or late cancel expenses.
Policies for Children with Divorced Parents:
In all therapy and evaluation cases, where the child’s parents are divorced, we will need to have a full copy of the divorce decree for our records to keep on file to ensure our office is maintaining the most legal ethical practice.
We ask that both parents provide consent before an assessment or treatment begins with a minor. We also ask that both parents are involved in your child’s treatment and/or evaluation, including the progress of treatment, in order to maintain the most ethical practice. The exception to these stipulations is in the case of alleged child abuse and/or an on-going investigation, or services provided under a court order.
It is important to note that unless it is otherwise stipulated by the court or law, both parents are entitled to equal access to information (spoken or written) concerning his/her child’s psychological treatment and/or evaluation.
In order to release any records to a third party, both parents’ written consent must be obtained. Additionally, in the case of family therapy or parenting consultation, in which both parents are present to discuss their child/children, written consent from both parties is required to release records to either client or to a third party.
In many divorce cases there are court agreements that states the payment schedule for each parent; as either an amount or percentage. Please note The Nicholls Group is not responsible for collecting divided payments from each parent, and that the bill is due at the time of the service. In the case of an evaluation, each parent is responsible for the entirety of his or her portion of the bill PRIOR to the evaluation being performed.
Important Notices:
Emergency contact with The Nicholls Group may not be immediatley available and will be unavailable on weekends or nights. In case of emergency please dial 911 or go to your closest Emergency Room. The crisis network hotline is 480-787-1500 (EMPACT) or 1-800-631-1314 (crisis response network).
The Nicholls Group does not provide custody evaluations.
The Nicholls Group trains postdoctoral fellow and graduate students in Clinical Psychology from multiple universities who are practicing in our office as part of their training. These individuals are not yet licensed in psychology and therefore are working under the supervision of one of our Licensed Psychologists. If you are meeting with one of our trainees and have any concerns, please consult with the supervising provider prior to your first appointment.
The Nicholls Group engages in professional and scientific research, and reviews data gathered in the performance of our evaluations and therapies. Unless you specifically state that you do not wish us to use the information about yourself or your child, you give us permission to include such information in our research projects. Please note that all information so used is de-identified and anonymous. There is no method that you or your child’s identity could be determined.
Confidentiality:
I understand consultation, therapy, and psychological evaluations are confidential and that I must give my consent to release information to a third party. Exceptions to confidentiality include the following:
There is reason to believe a child under 18 has been the victim of abuse or neglect.
The client expresses the intent to harm themselves or is gravely disabled.
The client communicates a serious threat of imminent harm to a clearly identified victim(s).
There is a court order for records signed by a judge.
The evaluation is an independent educational evaluation requested by and paid for by the school and consented to by the parent.
For the purposes of professional consultation.
I authorize the Clinical Psychologist or member of The Nicholls Group to record a video, voice record, or take a photo of myself/ my child for the use of evaluation and professional education. Any use outside of direct clinical service will have all identifiable information removed.
Consent:
I acknowledge that I have had access to read over The Nicholls Group’s “Psychologist-Patient services Agreement,” (Found under the “Patient Forms” page at www.thenichollsgroup.com) and accept responsibility for reading this document and asking any questions that I may have regarding services provided to me. I hereby certify that I have legal authority to seek requested services and consent for the identified staff member(s) at The Nicholls Group to provide psychological services to me and/or the person for whom I am a legal guardian. I have had an opportunity to ask questions about any concerns I have regarding the above.
Signature of Client or Parent/Legal Guardian
Relationship
(if not client)
Submit
×
Signature Pad
X
Signature
