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Intake form / Policy
Statement
WELCOME - It is important that you as a new client understand the
guidelines of the professional services you have chosen to receive.
Therefore please review and sign this policy statement. Please feel free
to ask any questions at any time. A copy of this statement will be given
to you upon request.
I understand that:
1. The counseling/consultation received will be
conducted by a licensed Marriage and Family Therapist trained to diagnose and
treat
emotional and relational difficulties through individual, couples, family or
group therapy.
2. The therapist has up to three
sessions to diagnose and determine type of treatment for the client. Both
therapist and client will arrive
at mutually determined treatment goals. The therapist has the right to
terminate during these three sessions with appropriate referrals if it
has been
determined clinically necessary.
3. The therapist is a consultant and resource professional whose interventions may be freely accepted or rejected by the client.
FEES
The customary fee is
$150.00 per 50 minute session, and is due and payable at the time of service.
If you need to make other arrangements, please discuss these with your therapist
at the beginning of your session. Our fee policies will be reviewed and
adjusted on an annual basis consistent with the standards of our profession.
Any changes in your fee agreement will be discussed with you at least three
months in advance.
INSURANCE
Your insurance may cover a portion of your
treatment, therefore you should understand that you will be responsible for any
and all fees incurred that are not covered by your insurance carrier, including
your deductible. You may request a Superbill to submit to your insurance
provider for possible reimbursement towards your therapy fees.
SCHEDULING
Our sessions will be 50 minutes in length. In
that time, we will be handling business details, scheduling your next
appointment and collecting fees. So to maximize your time, please have checks
made out and know your schedule for the following week. Telephone sessions over
10 minutes will be charged accordingly. Appointments are made on a regular
basis and your time will be held from session to session. You are responsible
for your scheduled appointment. If you plan on missing an appointment, please
call your therapist at least 48 hours in advanced to reschedule. Note: the full
fee is charged for last minute cancellations, no-shows, or missed appointments.
CONFIDENTIALITY
All information shared will be held in the
strictest confidence with the following exceptions: any information regarding
suspected child abuse, elder abuse, dependent adult abuse or intent to harm
yourself or another must be reported according to law.
EMERGENCY OR AFTER HOURS
My office hours are 10 a.m. to 9 p.m., Monday,
Tuesday, and Thursday. If you have a counseling emergency, please call (760)
669-8212 and I will return your call as soon as possible. In the event of a
life-threatening emergency (including suicidal thoughts/feelings) please call
911, or Orange County E.T.S. at (714) 834-6900, in addition to calling my
office.
TERMINATION
The client can terminate treatment at any time
and the therapist can terminate treatment if fees are not paid or if it is
deemed clinically appropriate. However, a mutually agreed upon termination upon
completion of goals is clinically ideal and in the client’s best interest.
I hereby authorize and consent to treatment for myself and/or my minor for whom I am a legal guardian, and certify by my signature that I have read, understand and agree to the terms and conditions herein described.
____________________________________________ ________________________
Signature of Client (or name of minor) Date
____________________________________________ ________________________
Signature of Client (or signature of parent or guardian) Date
____________________________________________ ________________________
Signature of Client (or signature of parent or guardian) Date
Client Information Form
Dear Prospective Client, Today’s Date _____________
Please complete the following information before your initial session. The information you provide is confidential.
PERSONAL DATA
Client Name ______________________________________(M/F) _____Age _____ Birthdate________________
Spouse/Partner ____________________________________(M/F) _____Age _____ Birthdate________________
Home Address ___________________________________________ City ____________________ Zip ________
Home Phone _____________________________________ Business Phone ________________________
Marital Status ______________ Length of marriage __________ Any previous marriages, specify _______________
Number of Children ____________ Names and Ages __________________________________________________
Referred by __________________________________
MEDICAL AND INSURANCE INFORMATION
Were you referred by a physician for therapy at this time? ________ Name of Physician ______________________
Are you presently under the care of a physician and/or psychiatrist? ________ If yes, please explain _______________
____________________________________________________________________________________________
List current medications/treatments ________________________________________________________________
In an emergency, notify _______________________________________________________ Phone ____________
PRESENTING PROBLEM AND
PREVIOUS THERAPY
Please state in your own words the nature of your current problem _________________________________________
____________________________________________________________________________________________
Have you ever seen a therapist before ? ______ Name of therapist/date ___________________________________
Briefly Explain the nature of previous therapy received __________________________________________________