New Venture Christian Fellowship Therapy Introduction to Individual Counseling
|
|
|
- Jason Waters
- 8 years ago
- Views:
Transcription
1 New Venture Christian Fellowship Therapy Introduction to Individual Counseling Welcome to counseling. We look forward to meeting with you and getting started. People and their situations are often very complex your therapist will need to understand as much of the context as possible in order to help with a solution. The following paperwork (though extensive) is designed to give your therapist the context quickly. Please complete it and bring it to your initial appointment. The informed consent is your formal agreement to enter therapy please be sure that you understand all the items, if not, ask your therapist about them before you sign the form. The questionnaire follows please fill it out completely as your therapist will need all of this information. Thank you for completing these forms. Sincerely, New Venture Christian Fellowship Therapy Department Intake
2 New Venture Christian Fellowship Informed Consent Your signature at the bottom of this page means that you understand and consent to the following policies and procedures: Counseling is a collaborative process between therapist and patient(s) who work together on mutually agreed upon goals. Participation is voluntary and is only effective when both patient(s) and therapist are actively striving for the patient s growth and change. Patients realize that participation in therapy can involve discussing issues that may be distressing however, therapy is designed to help patients personally and in their relationships. When minors are involved, it may be necessary that parent(s)/guardian(s) participate in the counseling process with their child(ren) at the discretion of the therapist. Some problems may be best resolved with the participation of other family members or close relations. Christian Worldview I understand that New Venture Christian Fellowship is a Christian Church and all therapists operate and practice therapy with a Christian worldview. Therapists use their spiritual orientation in the counseling process anyone uncomfortable with this should discuss the matter immediately with the therapist. Appointments are made in advance and start and end on time a session lasts 50 minutes. If a patient is late, the session will still cost full price and end at the pre-arranged time. 24-hour advance notice is expected for cancellation or rescheduling. Any patient who fails to cancel, cancels at the last minute, or doesn t attend a regularly scheduled session will be held responsible for full payment of the missed session. Lateness, or cancellations made by the therapist will be rescheduled. Emergencies: in the event of an emergency dial 911 or The therapist will discuss emergencies with you and may provide emergency contact information at their discretion. As a rule, most telephone calls will be returned during normal business hours on weekdays. Payment is expected at the time of service and will be collected at the beginning of the session. Any check that is returned for insufficient funds will be assessed a $25 fee. Premises are owned by New Venture Christian Fellowship. Confidentiality is vital to trust - all sessions are confidential. This means the therapist will not discuss any aspect of the session or case with anyone outside of therapy without prior written consent of patient(s). It is important that a patient (especially children) has a confidential relationship with their therapist. Interns are pre-licensed counselors who are registered with the state of California and work under the clinical supervision of a licensed therapist. Intern will discuss the course of therapy with the supervisor as mandated by the professional and ethical codes of the profession. Secrets within relationships sometimes can be destructive or counter-productive to the goals of therapy. If a patient divulges such a secret to the therapist, the therapist will use his discretion about revealing it. Generally, the therapist will ask the patient to divulge the secret if the therapist believes the secret is destructive or counter-productive to the counseling process, he may refuse to continue working with the patient until the patient reveals the secret. In cases of danger, the therapist may reveal the secret to maintain safety. Limits of confidentiality: The following are exceptions to confidentiality and MUST BE REPORTED to the appropriate service and/or police. Please note these reports are mandated by law and may be made without your consent or written permission. 1. If a patient (s) become a danger to himself/herself, steps will be taken to keep the person safe. 2. If the patient should become a danger to another identifiable person(s), the potential victim(s) will be warned and the police will be notified. 3. Any suspicion of child abuse (including physical, sexual, and/or emotional abuse as well as child neglect or endangerment) whether past or present, previously reported or not, will be reported. 4. Any suspicion of abuse or neglect of an elder or dependent adult will be reported to Adult Protective Services. I authorize New Venture staff/ therapist to leave voice messages at my home or with a family member or friend regarding appointments, billing issues, or other pertinent information regarding my Behavioral Health Care. YES / NO (choose one) Signature I agreed to the above policies: Signature Date
3 New Venture Christian Fellowship Therapy AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION I understand that New Venture Christian Fellowship uses administrative staff to perform basic clerical functions that are ordinary and typical to run a therapy department. New Venture Christian Fellowship staff will ONLY have access to the following types of information about those attending therapy: 1. Demographic information (names, addresses, telephone numbers, dates of birth, etc.) taken from client intake questionnaire. 2. Billing information (names, dates, charges, payments, payment methods, diagnostic codes, etc.). 3. Emergency contacts in the unlikely event that your therapist becomes so ill or incapacitated that he/she is unable to contact me/us, staff may contact me/us regarding logistical issues (for example, staff may call to cancel an appointment when my therapist is sick). Staff will hold any such information confidential. Staff will not have access to information about the content of counseling and therapy sessions. Staff will not have access to information about any communications (such as telephone or mail) that pertain to counseling and therapy matters. By signing below, I understand and agree to the contents of this form. Name: date:
4 Adult Questionnaire Today s Date First Name Last Name M. Current Age Place of Birth Primary address of patient - Street Address City State/Zip Other Address (if applicable) City State/Zip OK to OK to OK to Home Phone leave message? Work phone leave messages? Cell Phone leave messages? Gender male / female please circle only one single / married / cohabiting / separated / divorced / widowed how long since how long since ever been how partner ever been how married/cohabiting? separated,/divorced/widowed? married before? many times? married before? many times? yes / no yes / no race / ethnicity religion / denomination date of birth sexual orientation names & ages of children conceived with current spouse/ partner names & ages of children conceived with previous spouse(s)/ partner(s) highest level school completed current occupation current employer / school hours worked each week how long worked here? second jobs how long at this job? hours worked each week any problems at work / school? unemployed? why? how long unemployed? yourself your spouse / partner
5 last physical exam date yourself your spouse / partner results of exam? current physical problems any head injuries / seizures? when? any major illness past or present? what & when? any operations? what & when? any prior hospitalizations? for what & when? any family history of alcoholism? any family history of depression? any family history of mental illness? list personal strengths list personal weaknesses list personal hobbies Please list everyone who lives in the household at least two days / week - please list from oldest to youngest Full name Date of Birth Age School / occupation Who can I call in case of an emergency? Phone City Relationship to patient Why are you coming to counseling at this time?
6 Are you being pressured to come to counseling? By whom and why? Have you been referred? Yes / No by whom? May I have your permission to thank the person/agency who referred you? Yes / No signature authorization What problems are you wanting to address in counseling?: How long have these problems existed? What makes these problems worse? What makes these problems improve? Overall, how motivated are you to Very motivated not motivated change these problems? Circle one: What do you expect from therapy? Is anyone currently getting counseling? Yes / No Who? why? for how long? With whom? telephone Any hospitalizations for mental health reasons? Yes / No who? When? Why? Where? Has anyone received help for any drug / alcohol use? Yes / No who? what for? when? who? what for? when? Is anyone currently under the care of a physician for physical problems? Yes / No who? For what? With whom? telephone: Name of patient s primary physician Telephone Has anyone ever been arrested and/or committed a crime? Yes / No who? When For what? Outcome of situation If need be, would other relatives be willing to come into therapy sessions? Yes / No If not why?
7 Problems and Other Symptoms Please check any of the following which may apply to anyone in the household. Please check issues even if they do not relate to the primary reasons you are coming to counseling. problem who has problem? problem who has problem? alcohol use inability to relax angry outbursts legal matters anorexia or bulimia (past / present) loneliness anxiety loss of interest in things bad dreams boredom can't get motivated to do things they usually enjoy career choices crying easily depression difficulty concentrating difficulty falling asleep or staying asleep difficulty getting up in the morning difficulty making decisions difficulty parenting divorce drug use easily annoyed or irritated energy problems extreme fear of places or events faintness or dizziness fatigue feeling fearful feeling inferior to others feeling tense or nervous financial problems friendship problems gambling guilt impulsiveness loss of sexual interest or desire marriage problems memory problems nervousness overeating parent - child conflict poor appetite poor or decreased ambition pornography use preoccupation with death school problems self-confidence self-mutilation sexual problems shyness stuttering suicidal attempts suicidal thoughts thoughts hard to get rid of trouble remembering things uncontrollable outbursts of temper unhappiness violent behavior violent thoughts work problems worrying about things
8 person taking medicine Medication Survey Current Non-Psychiatric Medications medicine dose purpose how long on this medicine? person taking medicine Current Psychiatric medications medicine dose purpose how long on this medicine? Previous Psychiatric Medications person taking medicine Please list each drug chronologically, starting with the first medication ever given for an emotional problem medicine dose purpose how long on this medicine?
9 Summary of Prior Counseling / Psychotherapy Please begin with the FIRST therapist you ever had and move forward to the most recent therapist if you need more room, use back side. name of therapist and degree (MD, PhD, MFT, etc.) start & end dates - - how often did you meet? (weekly?) reasons for seeking treatment -- reasons for stopping treatment what type of therapy? was it helpful? did you have any negative reactions? THANK YOU FOR FILLING OUT ALL THESE FORMS!
10 Substance use Checklist I consume alcohol. never 1time/ month 2-4 times / month 2-4 times / week daily When I drink, I usually drink. none 1-2 drinks or beers 2-3 drinks or beers 3-4 drinks or beers 5+ drinks or beers I get drunk. never 1x/ month 1-4x/month 2-4x / week daily I've been drinking like this for the... last month 2-6 months 6-12 months more than a year more than 3 years My drinking has resulted in one or more of the following... passing out sleep disturbances can't stop once I start blackouts relationship problems binges work/school problems seizures Assaults &/or arrests physical withdrawal legal problems medical complications The following apply to me (check all that apply) I rarely or never drink not even socially I'm an occasional/ social drinker I'm not sure if I have a problem I probably have a problem I have a problem, and I want to stop I have a problem, but I don't want to stop I've tried to control my drinking with... Nothing! I stopped on my own I ve attended AA / other 12-step program a few times I ve attended AA / other 12-step program a regularly I attended day or outpatient treatment I attended inpatient / residential treatment I attended a community-based program (e.g., church program, etc.) I was forced to attend treatment of some kind I currently use / I once used / I only ever tried. only used age tried regularly started none pot sedative stimulant cocaine meth inhalants Heroin/ opium prescription drugs LSD, mushrooms other The following apply to me (check all that apply) I don't gamble I gamble occasionally I like to gamble Gambling has caused me problems I have gambled until all my money was gone I have gambled more than I planned to I like to gamble to escape worry or trouble I have borrowed money in order to gamble At times I've felt remorse after gambling I've lost time from work or school due to gambling age stopped
11
Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #:
Intake Form PATIENT INFORMATION Patient Last Name: First Name: Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Gender: Employer:
Client Intake Information. Client Name: Home Phone: OK to leave message? Yes No. Office Phone: OK to leave message? Yes No
: Chris Groff, JD, MA, Licensed Pastor Certified Sex Addiction Therapist Candidate 550 Bailey, Suite 235 Fort Worth, Texas 76107 Client Intake Information Client Name: Street Address: City: State: ZIP:
Declaration of Practices and Procedures
LOGAN MCILWAIN, LCSW Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: (225) 387-2287 Fax: (225) 383-2722 Declaration of Practices and Procedures I am pleased
Date of Current Marriage/Separation: Highest Level of Education:
ADULT INTAKE FORM Name: Date: Social Security: Home Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: May we call you and leave messages at home? Yes No May we call you and leave messages
Santa Fe Sage Counseling Center
Couple/Family Client Intake Date: Names: Partner/Parent/Child (circle one) Partner/Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Parent/Child (circle one) Insurance ID #:
General Information. Age: Date of Birth: Gender (circle one) Male Female. Address: City: State: Zip Code: Telephone Numbers: (day) (evening)
Kelly Bernstein, MS, LCDC, LPC Medical Center Psychological Services 7272 Wurzbach Road, Suite 1504 San Antonio, Texas 78240 Office: (210) 522-1187 Fax: (210) 647-7805 Functional Assessment Tool The purpose
8 Wakeman Rd Fairfield, CT 06824 (203) 255-5078
Southern Connecticut Christian Counseling Center, Inc. dba R E N E W C O U N S E L I N G A S S O C I A T E S Christian therapists committed to serving you, your family, and your community 8 Wakeman Rd
Arrive 15 minutes before your scheduled appointment time.
Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist
Client Initial Interview Form. Address: City: State: Zip: Phone: (h) (C) May I leave messages at these phone numbers? yes no
Nancy Thomas, M.A., LPC-Intern Supervised by Jennifer Perla, LPC-S The Vale Counseling and Therapeutic Center 2862 N. Belt Line Road, Sunnyvale, TX 75182 www.nancythomascounseling.com Office: (972) 698-8478
Associates for Life Enhancement, Inc. 505 New Road ~ PO Box 83 ~ Northfield, NJ 08225 Phone (609) 569-1144 ~ Fax (609) 569-1510 ~ 1-800-356-2909
Parents Names (If Client is a Minor) Client Information Sheet Client s Last Name First M.I.. Social Security No. Date of Birth: Age Sex M / F Home Phone No.( ) Education Level: Marital Status: Home Address:
Suzanne Burger, Psy.D. 24 Patterson Road Pound Ridge, NY 10576 (914) 764-5582 Fax (914) 234-2398
Suzanne Burger, Psy.D. 24 Patterson Road Pound Ridge, NY 10576 (914) 764-5582 Fax (914) 234-2398 Thank you for filling out this form. All information will be kept in strict confidence. Name Date Address
The Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM
The Global Relief Association for Crises & Emergencies G.R.A.C.E. COUNSELING INTAKE FORM Personal Information Date: Name: Phone #: Cell #: May we leave a message on these numbers?: Best time to reach me
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete. Child s Name: DOB: Age:
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete Child s Name: DOB: Age: School: Grade: Race/Ethnic Origin: Religious Preference: Family Members and Other Persons
Michael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION
Michael Simpson, Ph.D. - Clinical Psychologist 954-217-3966 PATIENT INFORMATION PLEASE PRINT CLEARLY DATE NAME ADDRESS DX (OFFICE USE ONLY) CITY STATE ZIP OCCUPATION HOME PHONE EMAIL WORK PHONE CELLULAR
Declaration of Practices and Procedures
Peggy S. Arcement, MS, MA, LDN, LPC, NCC Licensed Professional Counselor Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722
OK to leave Messages?
Jami Howell, Psy.D., LLC Licensed Clinical Psychologist 1215 SW 18 th Avenue, Portland OR 97205 p (503) 504-5222 f (503) 224-2134 jami@doctorjamihowell.com Client Information Name: Preferred Name: Date
INITIAL INTAKE FOR MEGAN POLLOCK THERAPY (PLEASE COMPLETE PAGES 1 5 AND RETURN TO THERAPIST)
INITIAL INTAKE FOR MEGAN POLLOCK THERAPY (PLEASE COMPLETE PAGES 1 5 AND RETURN TO THERAPIST) Last Name: Dr. Mr. Mrs. Ms. First Name: Middle Initial: Date of Birth: Home Address: City: Zip Code: Social
Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328
Atlanta Center For Positive Change Karen Kallis, M.Ed., LAPC, NCC 333 Sandy Springs Circle, Atlanta, GA 30328 An important part of the helping relationship is understanding the expectations of the relationship.
Declaration of Practices and Procedures
Kyndal C. Jacoby, MSW, LCSW Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722 Declaration of Practices and Procedures I am
Ellyn L. Turer, PsyD, PLLC 1320 19 th Street, NW Suite 202 Washington, DC 20036 Tel: 202-293-6463, ellyn-turer@hushmail.com
Date CLIENT INFORMATION Client Name Address City State Zip Code Primary Contact Ph # Cell Home Work Secondary Ph # Cell Home Work Email Address Do you text? Yes No Birth date Social Security Number Occupation
SPOUSE / PARTNER ONE TO COMPLETE THIS SECTION SEPARATELY. Name: (Last) (First) (Middle Initial)
Katherine E. Walker, PhD, LPC, NCC, BCIA-C Licensed Professional Counselor 8300 Health Park, Suite 201 Raleigh, NC 27615 Mobile: 919-760-3068 Fax: 919-676-9946 Email: walker@carolinaperformance.net Couples
CLIENT QUESTIONNAIRE
Leland E. McHatton, MFT Marriage Family Therapist 1430 East Avenue, Suite 4C 530.566.1212 Chico, California 95926 CLIENT QUESTIONNAIRE Client s Name: Spouse s or Parent s Name: Date of Birth: Date of Birth:
Intake Form for Testing Services. Last Name First Name Date of Birth. Address City State/ZIP Sex (M/F)
Intake Form for Testing Services Date Last Name First Name Date of Birth Address City State/ZIP Sex (M/F) Email Address: @ CAN I EMAIL YOU FOR: (CIRCLE ALL THAT APPLY) SCHEDULING SERVICES UPDATES AVAILABLE
The Counseling Center at
Dear Client, Thank you for choosing Winston Salem First. Please read all of this important information. Ke e p this one s he e t for your information. 1- Please complete all forms in full and bring all
41. Name and address of your physician:
Providence Biblical Counseling Ministry - Personal Data Inventory Identification Data: 1. Name: 2. Phone: 3. Date: 4. Address/City/Zip: 5. Occupation: 6. Business Phone: 7. Cell Phone: 8. Email: 9. Birth
Discipleship Counseling
Discipleship Counseling www.gbcn.org 239.513.0044 1610 Trade Center Way Suite 3, Naples, FL 34109 info@gbcn.org Personal Identification Mr. Mrs. Miss Name Address City Zip Home Phone ( ) Other Phone (
Comprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms,
Comprehensive,Behavioral,Healthcare,of,Central,Florida,,LLC, Lawrence,B.,Erlich,,M.D., New,Patient,Intake,Forms, PATIENT INFORMATION Last Name/ First Name/ M.I. Social Security Number: Date of Birth (MM/DD/YY):
Biblical Counseling General Intake Form Personal History and Problem Evaluation
Biblical Counseling General Intake Form Personal History and Problem Evaluation Identification Data Name: Phone: Date: Address: Occupation: Business Phone: Gender: Date Of Birth: Age: Education: Last Grade
Mosaic Arlington Counseling Center 817 W. Park Row Arlington, Texas 76013 Phone: (817) 929-3408 NEW CLIENT INFORMATION
NEW CLIENT INFORMATION (Please Print) / / Client Name M/ F of Birth Address City/State Zip Home ( ) Work ( ) Cell ( ) Email Address: (Circle One) Minor Single Married Divorced Separated Widow Living Together
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete
NEW PATIENT INFORMATION
NEW PATIENT INFORMATION Date Patient Name Sex Age DOB / / Address City State Zip Phone Email Emergency Contact: Relationship to patient: Phone #(s) How did you hear about my practice? RESPONSIBLE PARTY
Sterman Counseling and Assessment
Information for Clients Welcome to Sterman Counseling and Assessment. We appreciate the opportunity to be of assistance to you. This packet answers some questions about therapy services. It is important
Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name. Nicknames: Social Security #: - - Current address: Apt #:
Parent Questionnaire Child s Legal Name: Date of Birth: Age: First, Middle, and Last Name Nicknames: Social Security #: - - Current address: Apt #: City: State: Zip Code: Home Phone: Cell/Other #: Parent
James A. Purvis, Ph.D. Psychotherapy Services Agreement
James A. Purvis, Ph.D. Psychotherapy Services Agreement PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist
James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc.
James H. Bramson, Psy.D., LCSW Licensed Clinical Psychologist (PSY-19459) Psychological & Organizational Solutions, Inc. 89 Moraga Way, Suite B Tel: 925-285-2429 Orinda, CA 94563 Fax: 925-429-9259 Name
ANDREA LEIMAN, PH.D. 8536 WEST HOWELL ROAD BETHESDA, MD 20817 PH: 301-469-7793 FAX: 301-469-0586 DRAJLPHD@VERIZON.NET
ANDREA LEIMAN, PH.D. 8536 WEST HOWELL ROAD BETHESDA, MD 20817 PH: 301-469-7793 FAX: 301-469-0586 DRAJLPHD@VERIZON.NET COLLABORATIVE DIVORCE ENGAGEMENT AGREEMENT DIVORCE COACH This document contains important
INTAKE FORM. General Information Name DOB Date Address: Phone: Cell Phone: Email:
INTAKE FORM General Information Name DOB Date Address: Phone: Cell Phone: Email: Marital Status (Circle One) Single Engaged Married Separated Divorced Widowed If married how long? Number of previous marriages
Warner Family Counseling
Warner Family Counseling General Policies Insurance: I will file claims on your behalf, provided that I am an in-network contracted provider with your individual plan. Prior to our first meeting contact
ADULT INTAKE QUESTIONNAIRE. Today s Date: Home phone: Ok to leave message? Yes No. Work phone: Ok to leave message? Yes No
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Ok to leave message? Yes No Work phone: Ok to leave message? Yes No Cell phone: Ok to leave message? Yes No Email:
Wake Forest Mind and Health, PLLC 501 North Main Street Wake Forest, NC 27587
Wake Forest Mind and Health, PLLC 501 rth Main Street Wake Forest, NC 27587 Katherine E. Walker, PhD, LPC, NCC, BCIA-C Jennifer Endries, MEd, LPC Licensed Professional Counselor Licensed Professional Counselor
Marci Danielson, M.S., LMFT COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES
COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES The mission of the counselors at Synchronicity Counseling is to offer a holistic, nonjudgmental approach to therapy with an understanding that all human
GENESIS COUNSELING GROUP, S.C.
PSYCHOLOGY SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions
CAGE. AUDIT-C and the Full AUDIT
CAGE In the past have you ever: C tried to Cut down or Change your pattern of drinking or drug use? A been Annoyed or Angry because of others concern about your drinking or drug use? G felt Guilty about
Behavioral Health Consulting Services, LLC
www.bhcsct.org infohealth@bhcsct.org 46 West Avon Road 322 Main St. 530 Middlebury Road Suite 202 Suite 1-G Suite 103 B Avon, CT 06001 Willimantic, CT 06226 Middlebury, CT 06762 Office phone- 1-860-673-0145
Relational Connections
INFORMED CONSENT Relational consists of individual, couples, and therapy services provided in Minneapolis with the objective to promote growth in individuals, couples and families. These services are provided
WMBC Counseling Ministry Personal Data Inventory
WMBC Counseling Ministry Personal Data Inventory Please complete this inventory carefully (Question marks have been eliminated.) Personal Identification Name: Birth Date: Physical Address: Mailing Address
Anna Hiatt Nicholaides, PSY.D. 2200 Arch Street, Suite 200, Philadelphia, PA 19103 (267) 702-6623 anna.nicholaides@gmail.com
Demographic Information 1. Contact Information Date: Last Name: First Name: Middle Initial: Date of Birth: Age: Home Address: City: State: Zip: Home Phone: Wohone: Cell Phone: Email: How and when do you
PATIENT / PSYCHOTHERAPIST SERVICE AGREEMENT INFORMED CONSENT. Welcome!
Jeremy Frank, PhD CADC Licensed Psychologist and Certified Alcohol and Drug Counselor Presidential City Madison Building 2 Bala Plaza, Suite Plaza 13 (Pl-13) Bala Cynwyd, Pennsylvania 19004 215-356-8061
DECLARATION OF PRACTICES AND PROCEDURES
DEE JONES ADAMS, PhD, LPC, LMFT Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, LA 70802 225-387-2287 (FAX 225-383-2722) Email: Dee@brchristiancounseling.com DECLARATION OF PRACTICES
Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC
Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Patient Name (please print): Welcome to the therapy services
5421 Riverbluff Parkway North Charleston, SC 29420 (843) 300-0440 counseling@riverbluff.org
Minor Child 5-12 years Client Information Packet Please take a moment to complete all of the following information. This information will assist us in getting to know you and what prompted you to seek
TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452
TIVERTON PSYCHOLOGICAL SERVICES 2128 MAIN ROAD TIVERTON, RI 02878 www.tivertonpsych.com Phone: 401-624-9972; Fax: 401-624-1452 Dorothy B. Brown, Ph.D. Anne Davidge, Ph.D. Dennis J. Rog, Ed.D. Licensed
TRI-CITIES CENTER FOR CHRISTIAN COUNSELING 1111 N. Eastman Road Kingsport, TN 37664 Phone: 423-246-5111 Fax: 423-246-5288 www.tricitiescounseling.
TRI-CITIES CENTER FOR CHRISTIAN COUNSELING 1111 N. Eastman Road Kingsport, TN 37664 Phone: 423-246-5111 Fax: 423-246-5288 www.tricitiescounseling.org EDWARD H. MARTIN, M.A., LPC.. MARLA S. FREEMAN, M.A.
Columbia Addictions Center
Columbia Addictions Center Eileen Dewey, L.C.S.W.-C Director Date: Client Name: Date of Birth: Address: City: State: Zip: Home #: Cell #: E-mail: Preferred contact (circle one): home # cell # e-mail Emergency
TIDELANDS COUNSELING STACY GUISSE, PSY.D., MFT LICENSE #48134 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401
TIDELANDS COUNSELING STACY GUISSE, PSY.D., MFT LICENSE #48134 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 Adult Consent for Treatment and Service Agreement Welcome to Tidelands Counseling! Tidelands
Declaration of Practices and Procedures
Peggy S. Arcement, MS, MA, LDN, LPC, NCC Licensed Professional Counselor Baton Rouge Christian Counseling Center 763 North Boulevard, Baton Rouge, Louisiana 70802 Phone: 225-387-2287 Fax: 225-383-2722
Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA 94566 (925) 963-8835
Lisa C. Tang, Ph.D. Licensed Clinical Psychologist 91 W Neal St. Pleasanton, CA 94566 (925) 963-8835 Professional Policies and Consent to Treatment Welcome to my practice. I appreciate your giving me the
Megan Ogle, PsyD Clinical Psychologist 1215 SW 18 th Avenue, Portland, OR 97205 971.313.4518 dr.meganogle@gmail.com
Megan Ogle, PsyD Clinical Psychologist 1215 SW 18 th Avenue, Portland, OR 97205 971.313.4518 dr.meganogle@gmail.com Client Information Date: Name: Preferred First Name: Date of Birth: / / SSN: - - Address:
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
Adult Intake Information
Adult Intake Information Welcome to Eagle s Landing Christian Counseling Center! We know that you have many options for behavioral health care, and we appreciate your choosing our team to assist you. On
CATC Exam Practice Questions: 2015
CATC Exam Practice Questions: 2015 These practice questions are included within the Certified Addictions Treatment Counselor (CATC) Examination Candidate Handbook, presented by California Association for
Grace Biblical Counseling Ministry
Grace Biblical Counseling Ministry Personal Data Inventory Name Address Sex: Age: Date of Birth: Phone Number: Highest Education: High School GED College Graduate Post Graduate Other Education or Training
UWM Counseling and Consultation Services Intake Form
UWM Counseling and Consultation Services Intake Form Dear Student, Date Affix Label Here (Office Use Only) Thank you for giving us the opportunity to better serve you. Please help us by taking a few minutes
Therapist: RT AL SR DV LB CL NP INT. Name of Child s School: Is child seeing a guidance counselor? YES NO If yes, name of counselor:
224 East Main Street Lexington, SC 29072 (803) 808-5222 E-mail LCC@LexingtonChristianCounseling.org Date: I. Client Information Primary Client Name Birthdate SSN Hm. Phone # Wk Phone # Cell Phone # Messages
Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900
PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip
Colorado Springs Office 3210 E. Woodmen Rd., #100 Colorado Springs, CO, 80920. Denver Office 837 Sherman St. Denver, CO 80203
Colorado Springs Office 3210 E. Woodmen Rd., #100 Colorado Springs, CO, 80920 Denver Office 837 Sherman St. Denver, CO 80203 Welcome to my practice. I am honored that you are giving me the opportunity
Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677
Kathleen Long, Ph.D. 510 A Pollock Street New Bern, NC 28562 Phone: (252) 636-2286 Fax: (252) 636-5677 Welcome! Please take a minute to complete the following information. Your name: Phone Number: Address:
Marian R. Zimmerman, Ph.D.
Marian R. Zimmerman, Ph.D. Clinical Health Psychology www.mzpsychology.com 3550 Parkwood Blvd., 306 (214)618-1451 Phone Frisco, TX 75034 (214)618-2102 Fax Pre-Surgical Evaluation Patient Name: Age: Date
PROFESSIONAL DISCLOSURE STATEMENT Information and Consent
Molly Casebere, M.S., LPC, NCC Licensed Professional Counselor, North Carolina (License # 8518) Nationally Certified Counselor (Certification # 239857) PROFESSIONAL DISCLOSURE STATEMENT Information and
ADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code
ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from
Drug Abuse and Addiction
Drug Abuse and Addiction Introduction A drug is a chemical substance that can change how your body and mind work. People may abuse drugs to get high or change how they feel. Addiction is when a drug user
LISA R. HERRICK, PH.D. Ph. 703-847-5793 Fx. 703-847-5791 www.lisaherrick.com
LISA R. HERRICK, PH.D. Ph. 703-847-5793 Fx. 703-847-5791 www.lisaherrick.com COLLABORATIVE DIVORCE MENTAL HEALTH PROFESSIONAL CLIENT AGREEMENT AND INFORMED CONSENT The Collaborative Divorce Process is
PATIENT INTAKE FORM PATIENT INFORMATION. Name Soc. Sec. # Last Name First Name Initial Address. City State Zip. Home Phone Work/Mobile Phone
PATIENT INTAKE FORM PATIENT INFORMATION Name Soc. Sec. # Last Name First Name Initial Address City State Zip Home Phone Work/Mobile Phone Sex M F Age Birth date Single Married Widowed Separated Divorced
Counseling Intake Form (Each person attending therapy should complete a form)
Counseling Intake Form (Each person attending therapy should complete a form) Name Male Female Mailing Address Date of Birth Home Phone Work Email How would you like to be contacted? Home Work Email Okay
ARTICLE #1 PLEASE RETURN AT THE END OF THE HOUR
ARTICLE #1 PLEASE RETURN AT THE END OF THE HOUR Alcoholism By Mayo Clinic staff Original Article: http://www.mayoclinic.com/health/alcoholism/ds00340 Definition Alcoholism is a chronic and often progressive
Informed Consent for Psychological Services Policies & Procedures (Sample Only)
Jeffrey Schreiber Kline, Ph.D. CLINICAL PSYCHOLOGY License No. PSY10811 825 Oak Grove Avenue, Suite D-201 Menlo Park, CA 94025 (650) 329-8904 Fax 329-8914 for Psychological Services Policies & Procedures
Assignment of Benefits Financial Agreement
Cornerstone Family Health Clinic Patient Registration Information Please PRINT AND complete ALL sections below Thank You. PERSONAL INFORMATION Marital Status: Single Married Divorced Widowed Sex: Male
Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187
Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 F(808) 748-0778 OUTPATIENT SERVICES CONTRACT This document
How To Protect Your Health Care Information From Disclosure
Thank you for choosing North Valley Christian Counseling. We look forward to working with you. Please take a few minutes to fill out the following forms. We will also take a few moments at the beginning
PSYCHOTHERAPY CONTRACT
Aaron J. Dodini, Ph.D. Licensed Clinical Psychologist Licensed Marriage & Family Therapist PSYCHOTHERAPY CONTRACT Welcome to my practice. This document contains important information about my professional
Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT
Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT Thank you for choosing Family Life Resource Center (FLRC) as your mental health provider. This document contains important
Garland s Christian Counseling Center
Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave
OFFICE POLICIES AND SERVICE AGREEMENT
Thomas Cicciarelli, Psy.D. PSY17298 350 Parnassus Avenue, Suite 601. San Francisco, CA 94117. 415-767-5199 OFFICE POLICIES AND SERVICE AGREEMENT Introduction Welcome to my practice. This document contains
Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606
Beth Cerrito, Ph.D. Licensed Clinical Psychologist 1357 Monroe Avenue Phone: (585) 442-9601 Rochester, NY 14618 Fax: (585) 442-9606 CONSENT FOR EVALUATION AND TREATMENT Welcome to my practice. This document
Lifeway Information Form
Lifeway Information Form Patient Name: First MI Last Date of Birth: / / Gender: M F Marital Status: M S D Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone: Please circle home cell
Jane Beresford, Psy.D. Licensed Psychologist PSY 16618 (310) 551-8535 Info@DrBeresford.com 15300 Ventura Boulevard, Suite 301
Patient Information (PLEASE PRINT) Patient Name: _ Today s Date: Patient s SSN: - - DOB: / / Age: Sex: Marital Status (circle): Single Married Separated Divorced Other: Home Address: Email: OK to leave
Adult Intake Information
Focus for Living, PLLC 308 East Renfro, Suite 202 Burleson, Texas 76028 817 295 8708 Office Use Only ID# Intake Date: Therapist: Hourly Fee: Previous Client: Y/ N Previous Date of FFL Service: PW Signed
What are some of the signs that alcohol is a problem?
Problems with Alcohol How can I tell if alcohol is a problem for me? Alcohol is a problem if it affects any part of your life, including your health, your work and your life at home. You may have a problem
Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:
Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name
Jason S Berman, PhD, PLLC; Licensed Psychologist; 12830 Hillcrest, Suite 111 Dallas, Texas 75230; (214) 929-9244 PROFESSIONAL SERVICES CONTRACT
PROFESSIONAL SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions
PATIENT INFORMATION I. IDENTIFYING INFORMATION DATE: Name: Date of Birth: Age: Street: City: State: Zip: Email: Phones: Home Work Cell
PATIENT INFORMATION I. IDENTIFYING INFORMATION DATE: Name: Date of Birth: Age: Street: City: State: Zip: Email: Phones: Home Work Cell Occupation / Grade in school: Place of Employment / School: Can we
TIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401
TIDELANDS COUNSELING CINDY STRICKLEN, M.S., I.M.F. LICENSE #61293 1411 Marsh Street Suite 105, San Luis Obispo, CA 93401 Minor Consent for Treatment and Service Agreement Welcome to Tidelands Counseling!
PSYCHIATRIC MENTAL HEALTH NURSE PRACTITIONER SERVICES
Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Sandra Mote, MS, CS, ARNP Patient Name (please print): Welcome to the psychotherapy and psychiatric
Client Brochure, Disclosure Statement, and Consent for Services
DENVER THERAPY & ASSESSMENT Alexandra McDermott, PsyD Licensed Psychologist 600 South Cherry Street, Suite 230, Denver, CO 80246 Alex@DenverTherapyAssessment.com (720) 485-4194 Client Brochure, Disclosure
Informed Consent for Counselling at the University of Lethbridge 1
Informed Consent for Counselling at the University of Lethbridge 1 Purpose: For you to understand the process and nature of counselling as well as the associated risks and benefits, in order for you to
Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889
Southern Counseling and Psychological Services LLC 104B E. Linda Vista, Roswell, NM 88201 (575) 420-1853 Fax (575) 624-8889 PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT Welcome to my practice. This document
Macalester Health & Wellness Center Counseling Services Page 1 Intake Data Sheet
Macalester Health & Wellness Center Counseling Services Page 1 Intake Data Sheet Date: Student s Name: Student s ID: Local Address: Residence Hall & Room Number or Local Street Address Personal Phone:
Connections Counseling, L.L.C. Couple/Family s Personal Information
Name (s): SS#(indicate name): Home Address: Connections Counseling, L.L.C. Couple/Family s Personal Information DOBs/Ages: How were you referred? Specify names of which client for all questions below:
NEW PATIENT INFORMATION CONSENT AND AGREEMENT
NEW PATIENT INFORMATION CONSENT AND AGREEMENT PSYCHOLOGICAL SERVICES. Psychological services vary depending on the reason for referral. In all cases, the initial appointment is set up with the parents/guardians
WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work together and providing you with assistance.
Lorie Jenddryka, MS, LCPC, CH 800 E. Northwest Highway, Suite 500 Palatine, IL 60074 (847) 794-8836 WELCOME TO MY PRACTICE Thank you for choosing me as your therapist. I am looking forward to our work