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Application for
Comprehensive Cognitive-Behavioral Therapy Groups

Local Arizona Therapy Program

Please return completed packet to our address:

Thomas A. Richards, Ph.D.
Social Anxiety Institute
2058 East Topeka Drive
Phoenix, AZ 85024

Phone: (602) 230-7316 

APPLICATION REGISTRATION

The third page will give us more information about you.  Don't let it and the few other forms stress you out, but be as complete as possible.  If you are not complete in your answers, we may ask you to fill out another form.  This saves you money because when you come in for your diagnostic appointment, we will have narrowed down problems and can save valuable time and money.

Also, as you will hear in individual sessions, we do everything we can to decrease your initial anxiety about the meetings here.  Actually, this is simply trying to get you to be more rational about this because nothing that we do is going to be that anxiety-provoking. You will not be put on the spot, introduced to a large group, or anything else that I know might cause anxiety until you feel ready and choose to work on these things through the group or a subgroup (a smaller part of the regular group).

As you know, I suffered from social anxiety into my 40s myself, and nothing you say or feel is going to be misunderstood or considered strange.

Again, we will spring no surprises on you. You will come knowing what to expect, and even after you are here, we continue to operate in this way. If we were to use pressure, force, or pushing, then the therapy would not work. We will always operate on the encouraging, motivating, helpful side of the coin. As you feel ready, we will work "up" our hierarchy of anxieties until situations that cause you social anxiety now, no longer have the negative emotional pull associated with them.

We are looking forward to talking with you and seeing you.

Sincerely,
 

Thomas A. Richards, Ph.D.
Psychologist/Clinic Director

Date ___________________________ Home Phone ___________________

Name_________________________________________________________                                           

Social Security Number ________________*E-MAIL ADDRESS* __________________

Address ___________________________________________________

City ________________ State _____________ Zip ________________

Sex  M ___ F ___ Age _____ Birthdate ______________ Single ___

Married ___ Partnered ___ Widowed____ Separated ___ Divorced ____

Patient Employed By: _________________________________________________________

Occupation _________________________________________________________________

Business Address_____________________________________________________________

Whom may we thank for referring you?
___________________________________________________________________________

In case of emergency who should be notified? ____________________________________
Phone ____________________________

Physician’s Name, Address, Phone_______________________________________________

*PRIMARY INSURANCE

Person Responsible for Account

__________________________________________________________________________
       Last Name                           Initial                         First Name                                                

Relation to Patient_______________________________Birthdate ____________________

Soc. Sec. #___________________________

Address ( If different from patient’s)

___________________________________________________________________________

City ______________________________ State _______________Country _____________

Zip ____________________________

Phone __________________________

Person Responsible Employed by ________________________________________________

Occupation ______________________________________________________

Business Address _____________________________________________________________

Insurance Company __________________________________________________________

Benefits Verification Phone __________________________

Insured/ Subscriber # ______________________________________

Contract / Plan # ______________________ Group # _____________________

Claims Dept. Address

__________________________________________________________________________

City _____________________________ State _______________Country _____________

Zip ____________________________

Is patient covered by additional insurance? ___ Yes ___ No

Subscriber Name _______________________________________________________

Relation to Patient _________________________ Birthdate ______________

Soc. Sec. # _______________________

Subscriber Address

___________________________________________________________________________

City ______________________________ State _______________Country _____________

Zip ____________________________  Phone _____________________

Subscriber Employed by _____________________________________________________

Business Phone ____________________________________

Insurance Company _______________________________________

Benefits Verification Phone __________________________

Subscriber # _______________________________

Contract / Plan # ______________________ Group # ________________

I, the undersigned certify that I (or my dependent) have coverage with

 ____________________________________________________________________

Name of Insurance Compan(ies)

and assign directly to Dr. Richards all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

_________________________________________________________________________
Responsible Party Signature                      Relationship                                    Date

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THERAPEUTIC SERVICES AGREEMENT

I understand I remain fully responsible for payment.  Payment is expected when services are rendered unless other written arrangements have been made with the office.  A sliding fee scale is sometimes available depending on current client usage. 

For individual appointments, a 24 hour cancellation notice is needed if you cannot keep the appointment.  A $50 fee will be charged if the appointment is cancelled with less than a 24 hour notification.   

I plan to use insurance _____ regular payment _____ sliding fee ______.   The Comprehensive CBT program is fully explained publicly on the internet here.

The office will assist in your obtaining insurance reimbursement by signing appropriate forms, if requested. Because all insurance plans are different, I will be responsible for my obligations under my own insurance plan. I authorize and assign payments directly to Dr. Richards and authorize the use of this signature on all insurance submissions. Please note: Insurance companies are not always forthcoming – therefore, we do not ever have a guarantee from them that they will reimburse you.  It is in your best interest to check on insurance yourself.

Dr. Richards specializes solely in social anxiety disorder, and is not a forensic, family, or general psychologist and does not become involved in legal actions. If you are currently in a legal proceeding or contemplate involvement in one, please find a psychologist who specializes in this type of psychology.

Psychologists maintain confidentiality, which means that what is discussed in the office is not repeated or made public to anyone. Please note: U.S. courts have made the following exceptions to confidentiality: (1) child sexual abuse, (2) intent to harm or injure yourself or another person.

Payment for sessions may be made by cash, check, Visa, MasterCard, or money order. Your timely attention to this matter is greatly appreciated. 

Because this is a closed group program, we need at least eight committed people dedicated to overcoming social anxiety in each therapy group. 

 

Client’s signature ________________________________

Date __________________________________________

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INFORMATION QUESTIONS

Are you allergic to any medications (prescribed or over the counter)?  ____   If so, what? _______________________________________________________

Medications you are currently taking.  Please note dosages and frequency of dosages.
_______________________________________________________________

______________________________________________________________

_____________________________________________________________

I plan to pay for the session by _____ check _____ Visa _____ MasterCard

I would like to join the therapy group starting  ___________________________________

How far along in the audio therapy series "Overcoming Social Anxiety" are you?  

Don't have it yet _______  On session # ______

Please answer the next set of questions on another paper or as a file on your computer, so that you can print and send them along with your application packet.  Please answer these questions FULLY.  The more complete your answer is, the better able it will be to tell your current condition.

1.    How much negative thinking ("automatic negative thinking", anticipatory anxiety thoughts, beating yourself up, etc.) is going on in your mind?   Do you have any way to stop this negative thinking?

2.    Is your anxiety related to most all social events?   Or, is is limited to a few, such as fear of public speaking, and/or making introductions?

3.    Is is harder meeting a stranger or doing things with people you already know?

4.    How much anticipatory anxiety do you have concerning future social events?   What kind of situations cause you the most anxiety?

5.    Are you dealing with another anxiety disorder currently?  (Panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and post-traumatic stress disorder are the other anxiety disorders.  You can find the definitions on The Anxiety Network: "Definitions of the Anxiety Disorders".   (This program ONLY treats social anxiety disorder (social phobia) and is not designed to be used for other anxiety disorders.

6.    What is it harder for you to do?   _____ Introduce yourself to a stranger

                                                    _____ Give a speech or a presentation

7.    Have you ever felt like you were around people too much and "needed more space"?

8.    At the moment, I have ____ friends that I do things with and enjoy being around.

9.    I have had ____ relationships (mutual physical attractions) after developing social anxiety.

10.  I am able to be relatively calm and social on the following occasions:

A)

B)

C)

11.  We all have our lives restricted by social anxiety.  How is social anxiety restricting your life right now?   (What important things do you think it is preventing you from doing now?)

12.    My blood pressure is typically ______ normal   _____ low  _____ high.

13.    How does caffeine affect you?

14.   Are you hypersensitive to medications?

15.  How many jobs have you had since high school, what were they, and about how long did each last?

16.  Do you have the audio therapy series Overcoming Social Anxiety: Step by Step?   Y / N
      If so how far along are you in the audio series?
 

17.   Please write anything else you want us to know about you and the effects of social anxiety in your life.

Now, please rate yourself on your AVOIDANCE of these situations, using the following scale.

0 = Never,  1 = Occasionally  2 = Often,  3 = Usually

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