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Please complete this form and bring to first session CLIENT INFORMATION FORM Full Name ___________________________________________________ Date__________________________________ Birth date_____________ Soc Sec #__________________________ Address_______________________________________________________ City______________________________ State___________ Zip____________________________ Sex: M F Marital Status: M S D Sep Home phone______________________ Work phone_________________________ Cell ___________________________ Fax____________________________________ Email Address_______________________________________ Employer___________________________________________ Employer Address ____________________________________________________ Occupation_________________________________________________________ Responsible Party Information Full Name___________________________ Relationship to Client _____________________ Birth date________________________ Soc Sec #_____________________________ Address_________________________ City_______________________ State_________ Zip _______Home phone_____________Work phone______________ Cell phone _____________________Fax_____________ Email address_________________________ Sex: M F Marital Status M S D Separated Employer__________________________________________________ Employer Address ________________________________ Employer Phone _________________________ Referral Source How were you referred to us?_________________________________________________________________ Reason for seeking consultation? ___________________________________________________________________ What would you like to have happen as a result of therapy? _______________________________________________ Medical History Primary Care Physician __________________________PCP Phone _______________________ Physician’s Address______________________________________________________________ List any health concerns_______________________________________ List Medications _____________________________________________ Therapy History Have you received therapy before? Name _______________________Address________________________ Phone______________________Fax_________________ Was is helpful? _______________________ Are you currently seeing a psychiatrist? Name ____________________________________ Phone_________________________ Addresss_____________________________________________Fax _______________________ Are you currently taking psychotropic medication? Please list _____________________________________ Emergency Contact: Name________________________________________Relationship to Client ____________________ Home Phone_________________Work Phone______________Cell _________________________ Informed Consent I have received a copy & read I have received a copy of, understand, & I agree to Service Agreement. I consent to psychotherapy treatment at Signature ________________________________________Date _____________ Professional Service Agreement: Thank you for coming to the Fees & Billing · Premarital Workshop (150 per couple). Ask about our discount when 3 or more couples sign up together. · Individual, couples, and family therapy (50min) $70 · Individual, couples, and family therapy (25 min) $35 · Individual, couples, and family therapy (90 min) $ 110 · Group Therapy (90 min) $30 . Sliding fee possible · Email or Phone Counseling (25 min) $40, except for emails included in premarital workshop package. · Payment is due in full at the beginning of each session by cash, check, or money order. Included in the above fees are brief phone calls (under 10 min) and routine paperwork. · There will be a $25 fee for any cancelled check. Health Insurance Coverage While we don’t work directly with insurance companies, we can provide you with monthly forms to submit to your insurance company for reimbursement of any mental health therapy fees they will cover. Call your insurance company to find out if you have out of network mental health benefits. Confidentiality The information you share will be kept confidential. We will ask you to sign a release of information form before discussing your treatment, or sending records about you to anyone else. · Your confidentiality/privacy is protected by state law and by the rules of our profession, except in the following circumstances. The limits of confidentiality are: 1. If you were sent to me by a court or an employer for evaluation or treatment, the court or employer expects a report from me. You have a right to disclose only what you are comfortable disclosing. 2. If you are involved in a law suit, and you tell the court that you are in therapy, we may then be ordered to show the court my records. Please consult your lawyer about these issues. 3. If you make a serious threat to harm yourself or another person, the law requires the therapist to try to protect you or that other person. 4. If I believe a child, or a dependent adult, has been or will be abused or neglected, we are legally required to report this to the authorities. 5. If you send a health insurance claim form to your insurance for reimbursement, it will have a mental health diagnosis listed and it will become part of your permanent medical record. 6. In order to provide you with the best treatment we may consult with other mental health professionals about your case but would not share with them your name or other identifying information. Late Cancellation/No Show Policy If you are unable to make your scheduled appointment, please cancel at least 24 hrs. in advance so another client can be scheduled during that time. If 24 hrs. notice is not given, you will be charged the full session amount. If Case of Emergency If you have an emotional, behavioral, or medical crisis call the The I understand, and agree to, the policies as stated above, and I give consent for treatment The Client’s Name:_______________________________ Date:_____________________ Client’s (or Responsible Party’s) Signature:______________________________ Relationship to Client:_______________________________ Date:_______________ |
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Sign up today for our next Premarital Seminar scheduled for Saturday, Feb 5th, at 1pm.
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