Fillable Client Intake Form

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Client Intake Form

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Client Intake Form
Date: _________________
Name: _________________________________________________________________
SSN: Date of Birth: _________________________ ____________________________
Address: _______________________________________________________________
EmailPhone#_____________________________ ______________________________
Gender Race/Cultural/Ethnic Identity ___________________________ ____________
Relationship Status: __Sexual Orientation: ______________ ______________________
Emergency Contact Information
Phone:
Relationship to Patient: Contact Name: ________________________ ____________________
________________________
***In a medical emergency, occurring while at this office, I give permission to receive medical care:
Yes No Signature: __________________________________________________
What is the reason for your seeking services at this time?
Stressors Checklist: (Please check all that apply)
Lifestyle Change
Sleep Problems
Substance Use: (food, caffeine, drugs, alcohol, prescriptions)
Credit Card Debt
Sexual Functioning
Sexual Identity
Too Busy
Isolation
Work School Functioning
Clutter
Relationship Problems
Children Issues
Significant Loss
Other
Preferred Pronoun:_______
Mood Concerns: (Please check all that apply)
Other Concerns: (Please check all that apply)
Excessive Worry
Depression
Fear/Panic
Compulsive Behaviors
Memory Problems
Physical Discomfort
Problematic Thoughts
How Were You Referred? ______________________________________________________
Name of Current Treatment Providers:
___________________________________________________________________________
Phone Numbers of Current Providers:
___________________________________________________________________________
Current Medications Including Dosage:
Treatment History: (Past experiences with medications, therapy/counseling, hospitalization, etc.
What was useful what was not?)
What Outcomes Would You Like to See as a Result of Your Treatment?
Fees:
Individual, Family and Couples Counseling:
Assessment: $140; Therapy $125 - 45 mins.; $100 30-mins.; No Show or Late Cancel at Least $50
Payment Types Accepted: Cash, Charge or Check
Hopelessness
Anger
Other
If Other, please list:
Self-Harm
Suicidal Idealizations
Have you ever been hospitalized for mental health?
Consent For Treatment
Mindful Mind & Body Associates for a mental health and/or substance abuse condition. For insurance purposes, a
diagnosis may be necessary and provided by my therapist. All Services are Out-Of-Network however.
(DOB) hereby request and consent to receive treatment from (client name),I, __________________________________ ___
_______
Crisis counseling is not a guaranteed service at this practice. All efforts will be made to assist as soon as possible, however
emergency situations are to be handled by my treating physician or emergency services (Holly Hill Respond Line for instance).
I permit contact via email address and phone number provided; with due protection of confidential information and
discretion, as needed for communication, scheduling and practice updates.
I understand that my information is confidential unless I am in danger of hurting myself or someone else, or if my records are
subpoenaed by the court or I have given my written consent for release of my information. However, in the case of couples
counseling the information gained in sessions is not to be made available for divorce or civil litigations. Also, my insurance
company may access my records. If therapeutic consultation is required, every effort will be made to protect my identity and
privacy. In the case of abuse or neglect of a child or dependent adult, confidentiality is not guaranteed.
I understand that I am responsible for the cost of services and that payment is payable each time I come for treatment.
Sessions are typically 45-50 minutes long and the rate of $100; this rate may vary depending on length, frequency and other
arrangements. I will be charged a fee of $50, if I do not show for an appointment or if I cancel without 24 hours notice.
I can expect my therapist to provide services based on ethical guidelines and professional expertise. If a concern develops
regarding boundaries, confidentiality, effectiveness or any other limitations to the psychotherapy process these will be
addressed as soon as possible. I may address any concerns with my therapist, my insurance company or the professional
association regulating my therapist’s practice.
I understand that entering into treatment does not guarantee success, I am free to discontinue services at any time and that
there are alternatives to outpatient psychotherapy to address my condition(s). Treatment is based on client-therapist
agreement and assessment of my history and current symptoms. Psychotherapy involves exploring past and present issues
with an emphasis on increased understanding and awareness to promote improved functioning and mood. At times, painful
experiences are part of the process of creating overall positive change. Homework and other adjunct resources may be used to
support the process.
It is distinctly understood that the practitioner is hereby fully released from any claims and demands, which might arise from
treatment provided with ordinary care and professional responsibility.
_________________________________________ ______________
Signature of Patient Date
Consent for Treatment of a Minor:
We, I, the parent(s)/guardian(s) of _
proceed with clinical evaluation and treatment as recommended and provided by Mindful Mind & Body Associates. Though as the
parents we may have access to our child’s records, we accept that our child’s privacy is part of the clinical process and will support
efforts to protect his/her confidentiality.
(client), give full and unconditional authority to _________________________________
_________________________________________ _____________
Date
______________________________________
Signature(s) of Parent(s)/Guardian(s)
__________________________________________ ______________
Witness Date
If you have not
made an appointment in over 4 weeks, you will be considered discontinued from treatment.
HIPAA NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used; please review it carefully.
I. PROTECTED HEALTH INFORMATION (PHI)
-PHI is information that is created in the process of assessment and treatment and contains identifying information. It contains data about health
conditions, past and present, services provided and payment information.
-Law requires that this information is protected, and Notice is provided as to WHEN, HOW, and WHY PHI may be used within the practice and/or
disclosed to a third party. Only necessary information is used or disclosed. If these policies change, this Notice will be updated and posted; changes
will be retroactive to beginning date of service.
II. WHEN, HOW and WHY PHI MAY BE USED/DISCLOSED
A. Prior Written Consent Is NOT Needed for Disclosure or Use Related to Treatment, Payment or Health Care Operations
1. Treatment. Sharing information with health care providers involved in your care does not require written consent.
2. Health Care Operations. PHI may be used to facilitate correct operation of the practice (i.e. accounting, legal and consulting services
used by the practice).
3. Payment. Billing and Collection services that require use and/or disclosure of PHI, such as billing the insurance company do not
require prior consent.
4. Other Disclosures.
a. Emergencies.
1. Incapacitated. Disclosure of PHI to coordinate treatment (i.e. you are unconscious).
2. Dangerousness. Mental status indicates danger to self, others or property of others.
b. Contact client for appointment reminders, benefits and services of interest.
c. Legally required by subpoena or court-order to release PHI
d. Abuse/Neglect suspected of Child, Disabled or Elderly.
B. Prior Written Consent Is Required For Use And Disclosure Of PHI In Other Circumstances.
1. Family, Friends or Others – PHI may be shared in coordinating treatment or payment unless you object in part or in whole. You may
revoke consent at any time. Emergencies may cover use of information as listed in I-A.4
2. Other Situations – In any other situation not described in previous sections, written authorization will be required before using or
disclosing your PHI. You may revoke consent at any time and limit information to be released.
III. YOUR RIGHTS.
A. The Right To See And Get Copies Of Your PHI.
Must be requested in writing and response given within 30 days of receipt of request. If denied a written explanation will be provided and can be
appealed. There will be a charge of $.25 per page. Summaries and Reports requested will also require a charge to be determined upon request.
B. The Right to Request Limits on Uses and Disclosures of Your PHI.
Request may not be granted as determined by HIPPA permitted use and disclosure. Limits will be included in your record in writing.
C. The Right to Choose How PHI is Sent to You.
Alternate address or method of sending will be granted if permissible without undue inconvenience.
D. The Right to Get a List of Disclosures Made.
Accounting of Disclosures Log is available at no cost (one copy/year), but will not include disclosures for treatment, payment or operations. Neither
will it include disclosures made for national security purposes, to corrections or law enforcement nor those made before April 15, 2003.
E. The Right to Amend Your PHI.
-If you believe an error or omission of importance exists in your PHI, requests made in writing will be addressed within 60 days of receipt.
-Denials will be made in writing with an explanation as to why and how you can challenge the denial. And your request may be included in the PHI.
-Denials would occur if the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written by someone else.
F. The Right to a Copy of This Notice.
IV. HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES.
If you feel your rights have been violated or you have an objection, you may file a complaint with me or you may send a written complaint to the
Secretary of the Dept. of Health and Human Services at 200 Independence Ave. SW, Washington DC 20201. If you file a complaint, no retaliatory
action will be taken against you.
V. EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on April 14, 2003.
I have read the above information regarding release and disclosure of my private health information and agree to the terms listed above.
Patient Signature: _______________________________________________________ Date: ____________________
Witness: ____________________________________________________Date: _________________________
Authorization For Release of Information
I, _____________________________(client name), ___________ (DOB) hereby give my consent to
the following persons or agencies:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
to exchange information regarding my mental health, substance abuse, medical (inc. HIV/AIDs
status), educational or vocational status, history and recommendations with:
Mindful Mind And Body
for the purpose of:
Emergencies
Coordinating my treatment
Legal, educational or vocational needs
I consent to receive information regarding appointments, follow-up contact and service delivery
through electronic communication (email, text, skype, webinar, fax, etc)
____________________________________ ________________
Client Signature Date
Parental Consent for Minor:
_____________________________________ _________________
Date
______________________________________
Signature(s) of Parent(s)/Guardian(s)
______________________________________ __________________
Witness Date
Revocation of Consent to Release:
To:_____________________ Client Signature: _____________________Date: _____
To:_____________________ Client Signature: _____________________Date: _____
To:_____________________ Client Signature: _____________________Date: _____
Date: Name: _________________________ _________________________
Self-Defeating Behaviors Risk Assessment:
What are your self-defeating thoughts and behaviors you want to decrease or eliminate?
What are situations, thoughts or moods typically lead you to do any self-defeating behavior,
self-destructive habit?
What do you do on your own to help yourself feel better or distract yourself when you feel
yourself headed toward a crisis?
Who are people you can contact when you are upset to improve your mood and distract
yourself?
List the most important things to you that make you want to stay alive and healthy:
** If you answer yes to any of the following please complete Page 2
no yes
Is there anything in your environment that you have thought about or have used as a means of
harming yourself? _ ______ ___
If yes, please describe how you will make your environment safer:
no yes Do you have current thoughts of harming yourself or anyone else? _ _____
Risk Assessment Form
Have you ever considered or attempted suicide? ___yes ___no
If yes, when and what happened?
Safety Plan:
Support System:
Who are people you can contact for help when you do not feel safe on your own?
(Names & Phone #s)
Professionals to Assist in Crisis:
Clinician Name: _______________________Phone #:_______________________
Clinician Name: _______________________Phone #: _______________________
*Your therapist at Mindful Mind and Body is not available for immediate crisis. Contact your
providers with 24-hr availability for assistance in emergencies.
Local Urgent Care Services:
Alliance Behavioral Healthcare Hotline: 800-510-9132
Mobile Crisis Unit 877-626-1772 NAMI Mental Health Crisis Line 844-549-4266
Hopeline 919-231-4525 Mental Healthline 888-537-6606
Wakebrook Crisis Center: 107 Sunnybrook Rd. Raleigh; Ph #: 984-974-4800
Holly Hill Hospital: 3019 Falstaff Rd. Raleigh; Ph #: 919-250-7000
Suicide Prevention Lifeline: 1-800-273-TALK (8255) http://suicidepreventionlifeline.org/ Safety
Plan:
Comfort/Distract; Reach Out for Support: Contact Medical/Mental Health Professionals; Make
Environment Safe; Go Somewhere Safe;
Avoid Drugs and Alcohol; Take Time Off to Take Care of Your Mental Health; Intensive Out-
Patient Treatment (ie Cary Behavioral; Pasadena Villa, Holly Hill)
Stay Alive and Safe; Hospital or Crisis Center; Call 911
Are you willing and able to commit to following the safety plan here to protect yourself now
or in the case of a crisis in the future? ______yes ______no
Client Name: _____________________________ Date: _________________
Signature: _____________________________Client given copy _________(Initial)
BCBS Insurance Information:
At this time, BCBS is our only contracted insurance company and some plans are not included in that
contract; therefore, full payment will be required until reimbursement rates are confirmed. When we
are in network with your insurance, your rate will be determined by the contract; and Trolenberg and
Company, PA will bill your insurance. By signing below, you authorize us to bill your insurance and
receive payment. You will be responsible for the full payment if services are not covered.
Insurance Company Name: ________________________________________
ID Number: _______________________________________________
Policy Holder’s Name: ___________________________________
Social Security Number: ___________________________________
Date of Birth: __________________________________________
Address: ___________________________________________________
Patient’s Relationship to Insured: ____________________________________
If Not Self, please complete the following
Patient Name: ______________________________
Patient DOB: _______________________
Patient SSN: __________________________________________
Patient Address: ___________________________________________________
Date: Client Signature: ____________________________________________ _____________________
Credit Card Authorization Form
Please complete all fields.
You may cancel this authorization at any time by contacting us.
This authorization will remain in effect until cancelled.
Credit Card Information Card Type: ☐ MasterCard ☐ VISA ☐ Discover ☐ AMEX
☐ Other ___________________________________________
Cardholder Name (as shown on card): ___________________________________
Card Number: ___________________________________________
Expiration Date (mm/yy): __________________________3-digit Code _________
Cardholder ZIP Code (from credit card billing address): ____________________
I, _______________________________, authorize _________________________
to charge my credit card above for agreed upon purchases. I understand that my
information will be saved to file for future transactions on my account.
Signature _____________________________________ Date: _______________
Mindful Mind & Body Associates
Consent for Telehealth Consultation:
I, ______________________________ (name) agree to the use of telehealth as part of my work
with my therapist. And I understand that telehealth is not the same as direct contact with my
provider.
______ (init) I have been given the opportunity to work directly in the office with my therapist
and use telehealth as well. My questions have and will be asked as needed regarding the use of
telehealth.
______ (init) I understand that there are risks to this technology, including interruptions,
unauthorized access and technical difficulties. And I will discontinue the use of telehealth if I or
my provider determine it is ineffective or inadequate.
_____ (init) I understand that telehealth is not an emergency service, and in the event of an
emergency I will call 911 or other 24-hour crisis line.
Signature ______________________________________
Date _______________________________
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Client Intake Form

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Completed 10 June 2022

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