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Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

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%3cp%3eTHIS NOTICE DESCRIBES HOW MEDICAL AND PSYCHOLOGICAL INFORMATION ABOUT%3cbr%3eYOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS%3cbr%3e%3cbr%3eINFORMATION.%3cbr%3ePLEASE READ IT CAREFULLY.%3cbr%3eNOTICE OF PRIVACY POLICY%3cbr%3e%3cbr%3eThe following is the privacy policy %28“Privacy Policy”%29 of Miriam L. Robinson Licensed Clinical Social%3cbr%3eWorker LLC %28“Covered “Entity”%29 as described in the Health Insurance Portability and Accountability Act of 1996 and%3cbr%3eregulations promulgated thereunder%2c commonly known as HIPAA. HIPAA requires Covered Entity by law to maintain%3cbr%3ethe privacy of your personal health information and to provide you with notice of Covered Entity’s legal duties and%3cbr%3eprivacy policies with respect to your personal health information. We are required by law to abide by the terms of this%3cbr%3ePrivacy Notice.%3cbr%3e%3cbr%3eYour Personal Health Information%3cbr%3e%3cbr%3eWe collect personal health information from you through treatment%2c payment and related healthcare operations%2c%3cbr%3ethe application and enrollment process%2c and/or healthcare providers or health plans%2c or through other means%2c as applicable.%3cbr%3eYour personal health information that is protected by law broadly includes any information%2c oral%2c written or recorded%2c that%3cbr%3eis created or received by certain health care entities%2c including health care providers%2c such as physicians and hospitals%2c as%3cbr%3ewell as%2c health insurance companies or plans. The law specifically protects health information that contains data%2c such as%3cbr%3eyour name%2c address%2c social security number%2c and others%2c that could be used to identify you as the individual patient who is%3cbr%3eassociated with that health information.%3cbr%3e%3cbr%3eUses or Disclosures of Your Personal Health Information%3cbr%3e%3cbr%3eGenerally%2c we may not use or disclose your personal health information without your permission. Further%2c once%3cbr%3eyour permission has been obtained%2c we must use or disclose your personal health information in accordance with the%3cbr%3especific terms that permission. The following are the circumstances under which we are permitted by law to use or%3cbr%3edisclose your personal health information.%3cbr%3eWithout Your Consent%3cbr%3eWithout your consent%2c we may use or disclose your personal health information in order to provide you with%3cbr%3eservices and the treatment you require or request%2c or to collect payment for those services%2c and to conduct other related%3cbr%3ehealth care operations otherwise permitted or required by law. Also%2c we are permitted to disclose your personal health%3cbr%3einformation within and among our workforce in order to accomplish these same purposes. However%2c even with your%3cbr%3epermission%2c we are still required to limit such uses or disclosures to the minimal amount of personal health information%3cbr%3ethat is reasonably required to provide those services or complete those activities.%3cbr%3eExamples of treatment activities include%3a %28a%29 the provision%2c coordination%2c or management of health care and related%3cbr%3eservices by health care providers%3b %28b%29 consultation between health care providers relating to a patient%3b or %28c%29 the referral of%3cbr%3ea patient for health care from one health care provider to another.%3cbr%3eExamples of payment activities include%3a %28a%29 billing and collection activities and related data processing%3b %28b%29 actions%3cbr%3eby a health plan or insurer to obtain premiums or to determine or fulfill its responsibilities for coverage and provision of%3cbr%3ebenefits under its health plan or insurance agreement%2c determinations of eligibility or coverage%2c adjudication or%3cbr%3esubrogation of health benefit claims%3b %28c%29 medical necessity and appropriateness of care reviews%2c utilization review%3cbr%3e%3cbr%3eactivities%3b and %28d%29 disclosure to consumer reporting agencies of information relating to collection of premiums or%3cbr%3ereimbursement.%3c/p%3e%3cp%3e%26nbsp%3b%3c/p%3e%3cp%3eExamples of health care operations include%3a%3cbr%3e%28a%29 development of clinical guidelines%3b %28b%29 contacting patients with information about treatment alternatives or%3cbr%3ecommunications in connection with case management or care coordination%3b %28c%29 reviewing the qualifications of and%3cbr%3etraining health care professionals%3b %28d%29 underwriting and premium rating%3b %28e%29 medical review%2c legal services%2c and auditing%3cbr%3efunctions%3b and %28f%29 general administrative activities such as customer service and data analysis.%3cbr%3eAs Required By Law%3cbr%3eWe may use or disclose your personal health information to the extent that such use or disclosure is required by%3cbr%3elaw and the use or disclosure complies with and is limited to the relevant requirements of such law. Examples of%3cbr%3einstances in which we are required to disclose your personal health information include%3a %28a%29 public health activities%3cbr%3eincluding%2c preventing or controlling disease or other injury%2c public health surveillance or investigations%2c reporting adverse%3cbr%3eevents with respect to food or dietary supplements or product defects or problems to the Food and Drug Administration%2c%3cbr%3emedical surveillance of the workplace or to evaluate whether the individual has a work-related illness or injury in order to%3cbr%3ecomply with Federal or state law%3b %28b%29 disclosures regarding victims of abuse%2c neglect%2c or domestic violence including%2c%3cbr%3ereporting to social service or protective services agencies%3b %28c%29 health oversight activities including%2c audits%2c civil%2c%3cbr%3eadministrative%2c or criminal investigations%2c inspections%2c licensure or disciplinary actions%2c or civil%2c administrative%2c or%3cbr%3ecriminal proceedings or actions%2c or other activities necessary for appropriate oversight of government benefit programs%3b%3cbr%3e%28d%29 judicial and administrative proceedings in response to an order of a court or administrative tribunal%2c a warrant%2c%3cbr%3esubpoena%2c discovery request%2c or other lawful process%3b %28e%29 law enforcement purposes for the purpose of identifying or%3cbr%3elocating a suspect%2c fugitive%2c material witness%2c or missing person%2c or reporting crimes in emergencies%2c or reporting a death%3b%3cbr%3e%28f%29 disclosures about decedents for purposes of cadaveric donation of organs%2c eyes or tissue%3b %28g%29 for research purposes%3cbr%3eunder certain conditions%3b %28h%29 to avert a serious threat to health or safety%3b %28i%29 military and veterans activities%3b %28j%29 national%3cbr%3esecurity and intelligence activities%2c protective services of the President and others%3b %28k%29 medical suitability determinations%3cbr%3eby entities that are components of the Department of State%3b %28l%29 correctional institutions and other law enforcement%3cbr%3ecustodial situations%3b %28m%29 covered entities that are government programs providing public benefits%2c and for workers’%3cbr%3ecompensation.%3cbr%3eAll Other Situations%2c With Your Specific Authorization%3cbr%3eExcept as otherwise permitted or required%2c as described above%2c we may not use or disclose your personal health%3cbr%3einformation without your written authorization. Further%2c we are required to use or disclose your personal health%3cbr%3einformation consistent with the terms of your authorization. You may revoke your authorization to use or disclose any%3cbr%3epersonal health information at any time%2c except to the extent that we have taken action in reliance on such authorization%2c%3cbr%3eor%2c if you provided the authorization as a condition of obtaining insurance coverage%2c other law provides the insurer with%3cbr%3ethe right to contest a claim under the policy.%3cbr%3eMiscellaneous Activities%2c Notice%3cbr%3eWe may contact you to provide appointment reminders or information about treatment alternatives or other%3cbr%3ehealth-related benefits and services that may be of interest to you. We may contact you to raise funds for Covered Entity.%3cbr%3eIf we are a group health plan or health insurance issuer or HMO with respect to a group health plan%2c we may disclose your%3cbr%3epersonal health information to be sponsor of the plan.%3cbr%3e%3cbr%3eYour Rights With Respect to Your Personal Health Information%3cbr%3e%3cbr%3eUnder HIPAA%2c you have certain rights with respect to your personal health information. The following is a brief%3cbr%3eoverview of your rights and our duties with respect to enforcing those rights.%3cbr%3eRight To Request Restrictions On Use Or Disclosure%3cbr%3e%3cbr%3eYou have the right to request restrictions on certain uses and disclosures of your personal health information%3cbr%3eabout yourself. You may request restrictions on the following uses or disclosures%3a to carry out treatment%2c payment%2c or%3cbr%3ehealthcare operations%3b %28b%29 disclosures to family members%2c relatives%2c or close personal friends of personal health%3cbr%3einformation directly relevant to your care or payment related to your health care%2c or your location%2c general condition%2c or%3cbr%3edeath%3b %28c%29 instances in which you are not present or your permission cannot practicably be obtained due to your incapacity%3cbr%3eor an emergency circumstance%3b %28d%29 permitting other persons to act on your behalf to pick up filled prescriptions%2c medical%3cbr%3esupplies%2c X-rays%2c or other similar forms of personal health information%3b or %28e%29 disclosure to a public or private entity%3cbr%3eauthorized by law or by its charter to assist in disaster relief efforts.%3cbr%3eWhile we are not required to agree to any requested restriction%2c if we agree to a restriction%2c we are bound not to%3cbr%3euse or disclose your personal healthcare information in violation of such restriction%2c except in certain emergency%3cbr%3esituations. We will not accept a request to restrict uses or disclosures that are otherwise required by law.%3cbr%3eRight To Receive Confidential Communications%3cbr%3eYou have the right to receive confidential communications of your personal health information. We%3cbr%3emay require written requests. We may condition the provision of confidential communications on you%3cbr%3eproviding us with information as to how payment will be handled and specification of an alternative address or%3cbr%3eother method of contact. We may require that a request contain a statement that disclosure of all or a part of the%3cbr%3einformation to which the request pertains could endanger you. We may not require you to provide an explanation of%3cbr%3ethe basis for your request as a condition of providing communications to you on a confidential basis. We must permit%3cbr%3eyou to request and must accommodate reasonable requests by you to receive communications of personal health%3cbr%3einformation from us by alternative means or at alternative locations. If we are a health care plan%2c we must%3cbr%3epermit you to request and must accommodate reasonable requests by you to receive communications of%3cbr%3epersonal health information from us by alternative means or at alternative locations if you clearly state that the%3cbr%3edisclosure of all or part of that information could endanger you.%3cbr%3eRight To Inspect And Copy Your Personal Health Information%3cbr%3eYour designated record set is a group of records we maintain that includes Medical records and billing records%3cbr%3eabout you%2c or enrollment%2c payment%2c claims adjudication%2c and case or medical management records systems%2c as%3cbr%3eapplicable. You have the right of access in order to inspect and obtain a copy your personal health information contained%3cbr%3ein your designated record set%2c except for %28a%29 psychotherapy notes%2c %28b%29 information compiled in reasonable anticipation of%2c%3cbr%3eor for use in%2c a civil%2c criminal%2c or administrative action or proceeding%2c and %28c%29 health information maintained by us to the%3cbr%3eextent to which the provision of access to you would be prohibited by law. We may require written requests. We must%3cbr%3eprovide you with access to your personal health information in the form or format requested by you%2c if it is readily%3cbr%3eproducible in such form or format%2c or%2c if not%2c in a readable hard copy form or such other form or format. We may provide%3cbr%3eyou with a summary of the personal health information requested%2c in lieu of providing access to the personal health%3cbr%3einformation or may provide an explanation of the personal health information to which access has been provided%2c if you%3cbr%3eagree in advance to such a summary or explanation and agree to the fees imposed for such summary or explanation. We%3cbr%3ewill provide you with access as requested in a timely manner%2c including arranging with you a convenient time and place to%3cbr%3einspect or obtain copies of your personal health information or mailing a copy to you at your request. We will discuss the%3cbr%3escope%2c format%2c and other aspects of your request for access as necessary to facilitate timely access. If you request a copy%3cbr%3eof your personal health information or agree to a summary or explanation of such information%2c we may charge a%3cbr%3ereasonable cost-based fee for copying%2c postage%2c if you request a mailing%2c and the costs of preparing an explanation or%3cbr%3esummary as agreed upon in advance. We reserve the right to deny you access to and copies of certain personal health%3cbr%3einformation as permitted or required by law. We will reasonably attempt to accommodate any request for personal health%3cbr%3einformation by%2c to the extent possible%2c giving you access to other personal health information after excluding the%3cbr%3einformation as to which we have a ground to deny access. Upon denial of a request for access or request for information%2c%3cbr%3ewe will provide you with a written denial specifying the legal basis for denial%2c a statement of your rights%2c and a description%3cbr%3eof how you may file a complaint with us. If we do not maintain the information that is the subject of your request for%3cbr%3eaccess but we know where the requested information is maintained%2c we will inform you of where to direct your request for%3cbr%3eaccess.%3c/p%3e%3cp%3e%26nbsp%3b%3c/p%3e%3cp%3eRight To Amend Your Personal Health Information%3cbr%3eYou have the right to request that we amend your personal health information or a record about you contained in%3cbr%3eyour designated record set%2c for as long as the designated record set is maintained by us. We have the right to deny your%3cbr%3erequest for amendment%2c if%3a %28a%29 we determine that the information or record that is the subject of the request was not%3cbr%3ecreated by us%2c unless you provide a reasonable basis to believe that the originator of the information is no longer available%3cbr%3eto act on the requested amendment%2c %28b%29 the information is not part of your designated record set maintained by us%2c %28c%29 the%3cbr%3einformation is prohibited from inspection by law%2c or %28d%29 the information is accurate and complete. We may require that%3cbr%3eyou submit written requests and provide a reason to support the requested amendment. If we deny your request%2c we will%3cbr%3eprovide you with a written denial stating the basis of the denial%2c your right to submit a written statement disagreeing with%3cbr%3ethe denial%2c and a description of how you may file a complaint with us or the Secretary of the U.S. Department of Health%3cbr%3eand Human Services %28“DHHS”%29. This denial will also include a notice that if you do not submit a statement of%3cbr%3edisagreement%2c you may request that we include your request for amendment and the denial with any future disclosures of%3cbr%3eyour personal health information that is the subject of the requested amendment. Copies of all requests%2c denials%2c and%3cbr%3estatements of disagreement will be included in your designated record set. If we accept your request for amendment%2c we%3cbr%3ewill make reasonable efforts to inform and provide the amendment within a reasonable time to persons identified by you%3cbr%3eas having received personal health information of yours prior to amendment and persons that we know have the personal%3cbr%3ehealth information that is the subject of the amendment and that may have relied%2c or could foreseeably rely%2c on such%3cbr%3einformation to your detriment. All requests for amendment shall be sent to 5331 SW Macadam Avenue Suite 208%3cbr%3ePortland%2c Oregon 97239%3cbr%3e%3cbr%3eRight To Receive An Accounting Of Disclosures Of Your Personal Health Information%3cbr%3eBeginning April 14%2c 2003%2c you have the right to receive a written accounting of all disclosures of your personal%3cbr%3ehealth information that we have made within the six %286%29 year period immediately preceding the date on which the%3cbr%3eaccounting is requested. You may request an accounting of disclosures for a period of time less than six %286%29 years from%3cbr%3ethe date of the request. Such disclosures will include the date of each disclosure%2c the name and%2c if known%2c the address of%3cbr%3ethe entity or person who received the information%2c a brief description of the information disclosed%2c and a brief statement of%3cbr%3ethe purpose and basis of the disclosure or%2c in lieu of such statement%2c a copy of your written authorization or written request%3cbr%3efor disclosure pertaining to such information. We are not required to provide accountings of disclosures for the following%3cbr%3epurposes%3a %28a%29 treatment%2c payment%2c and healthcare operations%2c %28b%29 disclosures pursuant to your authorization%2c %28c%29 disclosures%3cbr%3eto you%2c %28d%29 for a facility directory or to persons involved in your care%2c %28e%29 for national security or intelligence purposes%2c %28f%29%3cbr%3eto correctional institutions%2c and %28g%29 with respect to disclosures occurring prior to 4/14/03. We reserve our right to%3cbr%3etemporarily suspend your right to receive an accounting of disclosures to health oversight agencies or law enforcement%3cbr%3eofficials%2c as required by law. We will provide the first accounting to you in any twelve %2812%29 month period without charge%2c%3cbr%3ebut will impose a reasonable cost-based fee for responding to each subsequent request for accounting within that same%3cbr%3etwelve %2812%29 month period. All requests for an accounting shall be sent to 4380 SW Macadam Ave. Suite 220%3cbr%3ePortland%2c Oregon 97239%3cbr%3e%3cbr%3eComplaints%3cbr%3e%3cbr%3eYou may file a complaint with us and with the Secretary of DHHS if you believe that your privacy rights have%3cbr%3ebeen violated. You may submit your complaint in writing by mail or electronically to our privacy officer%2c Miriam%3cbr%3eRobinson Licensed Clinical Social Worker LLC 4380 SW Macadam Ave. Suite 200 Portland%2c Oregon 97239%3cbr%3erobinsonlcsw@gmail.com%3cbr%3e%3cbr%3eA complaint must name the entity that is the subject of the complaint and describe the acts or omissions believed to be in%3cbr%3eviolation of the applicable requirements of HIPAA or this Privacy Policy. A complaint must be received by us or filed%3cbr%3ewith the Secretary of DHHS within 180 days of when you knew or should have known that the act or omission%3cbr%3ecomplained of occurred. You will not be retaliated against for filing any complaint.%3cbr%3e%3cbr%3eAmendments to this Privacy Policy%3cbr%3e%3cbr%3eWe reserve the right to revise or amend this Privacy Policy at any time. These revisions or amendments may be%3cbr%3emade effective for all personal health information we maintain even if created or received prior to the effective date of the%3cbr%3erevision or amendment. We will provide you with notice of any revisions or amendments to this Privacy Policy%2c or%3cbr%3echanges in the law affecting this Privacy Notice%2c by mail or electronically within 60 days of the effective date of such%3cbr%3erevision%2c amendment%2c or change.%3cbr%3e%3cbr%3eOn-going Access to Privacy Policy%3cbr%3e%3cbr%3eWe will provide you with a copy of the most recent version of this Privacy Policy at any time upon your written%3cbr%3erequest sent to Miriam L. Robinson%2c Licensed Clinical Social Worker LLC 4380 SW Macadam Ave Suite 220%3cbr%3ePortland%2c Oregon 97239 503-465-5708%3cbr%3eFor any other requests or for further information regarding the privacy of your personal health information%2c and for%3cbr%3einformation regarding the filing of a complaint with us%2c please contact our privacy officer Miriam L. Robinson Licensed%3cbr%3eClinical Social Worker LLC at the address%2c telephone number%2c listed above.%3c/p%3e%3cp%3e%26nbsp%3b%3c/p%3e%3cp%3eACKNOWLEDGMENT%3cbr%3e%3cbr%3eBy signing below%2c I acknowledge that I have received a copy of this office’s Notice of Privacy%3cbr%3ePractices Form.%3cbr%3e%3cbr%3e-----------------------------------------------------------------------------------------------------------------%3cbr%3eClient Signature Date%3cbr%3e%3cbr%3e-------------------------------------------------------------------------------------------------------------------%3cbr%3eParent/Guardian Signature Date%3cbr%3eI have read the policies and decline to retain a copy for my records%3cbr%3e%3cbr%3e---------------------------------------------------------------------------------------------------------------------%3cbr%3eClient Signature Date%3c/p%3e

Date: I have read and I agree to the HIPAA

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Secure Site

Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

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:

Secure Site

Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

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)

Secure Site

Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

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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Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

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Secure Site

Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

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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Electronic Signature

Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208 Portland OR 97239 503-465-5708

PRIMARY CLIENT INFORMATION

PARTNER INFO

PRIMARY INSURED

Primary Insurance Information

SECONDARY INSURED ("If Applicable")

Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208 Portland OR 97239 503-465-5708

Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208 Portland OR 97239 503-465-5708

Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208 Portland OR 97239 503-465-5708

Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208 Portland OR 97239 503-465-5708

Miriam L. Robinson LCSW LLC

5331 SW Macadam Ave Suite 208 Portland OR 97239 503-465-5708

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708

5331 SW Macadam Ave Suite 208
Portland OR 97239
503-465-5708