Confidential Intake Information

CONFIDENTIAL INTAKE INFORMATION
Client Name*
Age*
Gender*
- Male
- Female
Date*
MM slash DD slash YYYY
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Home Phone*
Cell Phone*
Employer*
Email*
Address of Residence*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County of Residence*
Emergency Contact (name)*
Relationship*
Emergency Contact Phone Number*
Is Client the Responsible Party?*
- Yes
- No
Relationship to Client*
Name of Responsible Party (if different than client)*
Client/Responsible Party Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Insurance Info
Provider Name*
Member Name*
Subscriber ID*
Group #*
Payment Card Info
Type (e.g., Visa, Mastercard, American Express)*
Card #*
Zip Code*
Security Code*
Expiration Date #*
MM slash DD slash YYYY
Marital Status*
- Single
- Married
- Cohabitating
- Divorced
- Re-Married
Client Initial*
Name of Spouse or Partner*
Date*
MM slash DD slash YYYY
Spouse or Partner’s Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Occupation*
SS#*
DOB*
MM slash DD slash YYYY
Names of Children*
DOB*
MM slash DD slash YYYY
Living in the Home?*
Employer Name*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone Number*
*
PLEASE COMPLETE THIS PAGE IF CLIENT IS UNDER 18
Father’s Name*
DOB*
MM slash DD slash YYYY
SSN#*
Father’s Address (If different than client):*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mother’s Name*
DOB*
MM slash DD slash YYYY
SSN#*
Mother’s Address (If different than client):*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parents Relationship*
- Married
- Divorced
- Separated
- Never Married
Client’s Legal Guardian(s)*
*
Provide contact information here if not listed elsewhere on form
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SSN#*
DOB*
MM slash DD slash YYYY
Phone*
Client Initial*
Date*
MM slash DD slash YYYY
If parents are not together or child is currently in foster care or adopted, who has the right to make medical decisions?*
Please provide therapist with custody and other legal paperwork needed to ensure therapist has permission by guardians to see client. Without necessary paperwork, therapist may be unable to see the client
*
PAYMENT AGREEMENT (Initial each line item and sign below) ____________ Payment is due at the time of your appointment. Cash and check are acceptable forms of payment. ____________ A credit or debit card is required to be kept on file. The card will be charged upon services rendered unless other arrangements have been made. ___________ The standard fee for services is $150 per 53 minute individual, couple or family session (on the phone or in the office). Services may be offered at reduced fees based on total household income. (Note: If you’d like to request a reduced fee for services, please request and complete the Sliding Scale Application). __________ The standard fee for the initial evaluation is $200 per 53-minute session. __________ A fee of $30 will be assessed for a returned check and future payments must be made in cash. __________ Cancellations require 24 hours notice prior to the time of the appointment. You will be charged the full agreed upon fee (noted above) for cancelling appointments with less than 24 hours notice or for missing appointments without prior notice. _________ The initial intake session will be dedicated to understanding the client’s background and current situation, assessing for immediate risks, evaluating readiness for requested therapy, providing referrals if needed, and establishing treatment goals. There may be no therapeutic counseling or intervention during the initial intake session. _________ Phone calls in excess of 10 minutes will be billed to the client’s account in accordance with the standard session fee ($25 per 10 minutes). This fee is NOT covered by insurance and will be billed directly to the client. _________ Treatment may be interrupted or terminated after three (3) unpaid no shows, due to three (3) consecutive cancellations, or after unresolved debt of three (3) or more sessions. _________ Accounts become delinquent after thirty (30) days. Accounts ninety (90) days in arrears will be terminated. At this point counseling speaks reserves the right to enlist a collection agency to facilitate collection of monies owed.
Client Initial*
Date*
MM slash DD slash YYYY