Please enable JavaScript in your browser to complete this form.For your convenience, please complete and submit the Registration Forms using our secure online process. Submitting this form online will allows us to prepare in advance for your visit and help us to provide the best care possible.I have already scheduled an appointment with a therapist at Affiliated Counseling ServicesI would like someone to contact me to set up an appointment at Affiliated Counseling ServicesName *FirstMiddleLastPreferred Name (If different from above)Birthday *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security Number *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *How may we utilize this phone number? *Call VoicemailText messagesDo not contact me at this phone numberEmail *How would you like us to contact you? Select all that apply *PhoneEmailTextDo not contact meHow would you like to receive appointment reminders? *TextEmailDon't Remind meBirth Sex *MaleFemaleOther/UnknownGender Identity *SelectMaleFemaleTransgender Male/Trans Man/FTMTransgender Female/Trans Woman/MTFGenderqueer, neither exclusively male nor femaleOtherPrefer not to sayMarital Status *MarriedSingle OtherName of spouse or significant other *FirstMiddleLastSexual Orientation *SelectLesbian, Gay, or HomosexualStraight or HeterosexualBisexualUnknownOther Prefer not to sayEmployment *Employed Full TimeEmployed Part TimeStudentUnemployed/OtherCurrent Employer/SchoolHighest Level of Schooling/DegreeAre you religious?YesNoNot surePrefer not to sayReligionWhom may we thank for referring you? *Google or Internet searchSomeone I know Another healthcare providerFacebook or Social MediaAnother wayName of person or healthcare provider who referred you:Emergency Contact Name *FirstLastEmergency Contact Phone *Relationship to you (the client) *SelectSpouseParentChildOtherInsuranceName of Primary Insurance Company *AetnaHighmark/ Blue Cross Blue ShieldMedicareUPMCUPMC for You (Erie County)United HealthcareOtherNot InsuredPlease Indicate Name of Insurance Company *Member ID/Policy Number *Group NumberThe Primary Member of this Insurance plan is *MyselfMy SpouseMy ParentOtherPlease indicate relationship to clientWho is the primary member of this insurance policy? *FirstLastPrimary insured's date of birth (if not self)Name of Secondary Insurance Company *I do not have secondary insuranceAetnaHighmark/ Blue Cross Blue ShieldMedicareUPMCUPMC for You (Erie County)United HealthcareOtherMember ID/Policy NumberGroup NumberThe primary member of this Insurance plan is *MyselfMy SpouseMy ParentOtherPlease indicate relationship to client Primary insured's date of birth (if not self) (copy)Who is the primary member of this insurance policy? (copy)FirstLastTotal number of individuals living in your home *Number of Adults (18 and over) in your home *Number of Children (under 18) in your home *Have you ever received psychiatric care? *YesNoIf yes with whom? For what reason? What were the results? Primary Care PhysicianPCP Contact Information or locationLast ExaminedMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MedicationsIf you would prefer to bring a list in with you for your first session, please note that it will be provided at time of service. Please indicate the name of your medications, dosage, the reason for taking and if it is used as directed. Health ConditionsPlease list any health conditions that you are currently receiving treatment for: Current and prior alcohol, tobacco, or other drug use:List any allergies you have: Legal History (have you been arrested or involved in any court cases): Is your condition related to employment? *YesNoDate of IncidentMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you involved in a worker’s compensation case? *YesNoDate of IncidentMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is your condition related to an auto accident? *YesNoDate of IncidentMM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Briefly describe your main reason for seeking help and any other additional information you feel may be useful: NextAdult Checklist of ConcernsChecklist of concerns- Select all that apply *Abuse—physical, sexual, emotional, neglect (of children or elderly persons), cruelty to animals Aggression, violenceAlcohol useAnger, hostility, arguing, irritabilityAnxiety, nervousnessAttention, concentration, distractibilityCareer concerns, goals, and choicesChildhood issues (your own childhood)CodependenceConfusionCompulsionsCustody of childrenDecision making, indecision, mixed feelings, putting off decisions Delusions (false ideas)DependenceDepression, low mood, sadness, cryingDivorce, separationDrug use—prescription medications, over-the-counter medications, street drugsEating problems—overeating, undereating, appetite, vomiting EmptinessFailureFatigue, tiredness, low energyFears, phobiasFinancial or money troubles, debt, impulsive spending, low incomeFriendshipsGamblingGrieving, mourning, death, lossGuiltHallucinations (auditory or visual)Headaches, other kinds of painsHealth, illness, medical concerns, physical problemsHousework/chores—quality, schedules, sharing dutiesInferiority feelingsInterpersonal conflictsImpulsiveness, loss of control, outburstsIrresponsibilityJudgment problems, risk takingLegal matters, charges, suitsLonelinessMarital conflict, distance/coldness, infidelity/affairs, remarriage, different expectations, disappointmentsMemory problemsMenstrual problems, PMS, menopauseMood swingsMotivation, lazinessNervousness, tensionObsessions, compulsions (thoughts or actions that repeat themselves)Oversensitivity to rejectionPanic or anxiety attacksParenting, child management, single parenthoodPerfectionismPessimismProcrastination, work inhibitions, lazinessProvide care for a sick/disabled relative or friend Relationship problems (with friends, with relatives, or at work)School problems Self-centerednessSelf-esteemSelf-injurySelf-neglect, poor self-careSexual issues, dysfunctions, conflicts, desire differences, other Shyness, oversensitivity to criticismSleep problems—too much, too little, insomnia, nightmaresSmoking and tobacco useSpiritual, religious, moral, ethical issuesStress, relaxation, stress management, stress disorders, tensionSuspiciousnessSuicidal thoughts—past or currentTemper problems, self-control, low frustration toleranceThought disorganization and confusionThreats, violenceWeight and diet issuesWithdrawal, isolatingWork problems, employment, workaholism/overworking, can’t keep a job, dissatisfaction, ambitionNext Adverse Childhood Experience (ACE) Questionnaire Finding your ACE Score While you were growing up, during your first 18 years of life: Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you Or Act in a way that made you afraid that you might be physically hurt? *YesNoDid a parent or other adult in the household often push, grab, slap, or throw something at you? Or ever hit you so hard that you had marks or were injured? *YesNoDid an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way or try to or have oral, anal, or vaginal sex with you? *YesNoDid you often feel that no one in your family loved you or thought you were important or special or your family didn’t look out for each other, feel close to each other, or support each other? *YesNoDid you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you or your parents were too drunk or high to take care of you or take you to the doctor if you needed it? *YesNoWere your parents ever separated or divorced? *YesNoWas your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her; or sometimes or often kicked, bitten, hit with a fist, or hit with something hard; or ever repeatedly hit over at least a few minutes or threatened with a gun or knife? *YesNoDid you live with anyone who was a problem drinker or alcoholic or who used street drugs? *YesNoWas a household member depressed or mentally ill or did a household member attempt suicide? *YesNoDid a household member go to prison? *YesNoNow add up your "Yes" answers from the ten questions above: *This is your ACE ScoreNextI have read and understand the cancellation policy. In the case of a non-emergency cancellation with less than one business day’s notice a fee of $100 will be assessed and is my responsibility to pay before my next appointment. I understand that this policy is subject to change. *Fees must be paid in full before your next scheduled appointment. If they are not paid in full or payment arrangements have not been made with our office, your next appointment will be cancelled without notice and given to another waiting client. You will not be eligible to schedule an appointment until payment has been received or arrangements have been made. After two or more missed sessions (no show) or three late-notice cancellations (less than one business day’s notice), you are subject to dismissal from our office. Please note that late fees are not reimbursable by insurance companies and will be your responsibility to pay. I certify that I, and/or my dependent(s), have insurance coverage with the named company and assign directly to Dr. Richard C. Blackford, PhD, PC all insurance benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid for by insurance or not. I authorize the use of my signature on all insurance submissions. The above-named psychologist may use my health care information and may disclose such information to the named Insurance Company or Companies and their agents for obtaining payment for services and determining insurance benefits or the benefits payable for related services. *Clear SignatureSignature of Client, Parent, Guardian or Personal Representative authorizing insurance submissionYour signature below indicates that you consent to be treated, you have read this agreement and agree to its terms, and also serves as an acknowledgment that you have received the HIPAA notice form described above. *Clear SignatureName *Please print name of Client, Parent, Guardian, or Personal Representative Relationship to Client *Today's Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MessageSubmit
