Confidential Client Intake Step 1 of 2 50% Name* First Last Age*Date of Birth* MM slash DD slash YYYY Gender*FemaleMaleTransgender M to FTransgender F to MAddress* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Mailing Address Same as previous Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email* Best Contact Phone Number*May we email you? (no advertising)*YesNoMay we leave voicemail messages?*YesNoMay we text you? (No advertising)*YesNoEmergency Contact Name* Relationship* Phone*PRESENTING PROBLEMBriefly describe the problem you most wish help with right now:*How would you rate the intensity of the problem or concern that brought you in?* 1 (not intense) 2 3 4 5 (extremely intense) How much has your current problem interfered with your life in general? Not at all A little Somewhat Moderately To a great extenent How have you attempted to cope with this problem thus far?How often would you like to meet with your therapist to address this problem? Once a week Once every two weeks Once a month How motivated are you to resolve this problem? Not at all A little Somewhat Moderately Extremely Why have you decided that now is the time in your life to take action to resolve this problem?How hopeful are you that this problem can be resolved? Not at all A little Somewhat Moderately Extremely List the strengths and qualities you admire about yourself:When our work together has been successful, what differences will you notice in yourself?THE FOLLOWING INFORMATION IS VERY IMPORTANT WHEN DESIGNING AN APPROPRIATE TREATMENT PLAN. THE MORE ANSWERS YOU PROVIDE PRIOR TO SESSION, THE MORE TIME WILL BE AVAILABLE DURING SESSION TO ADDRESS YOUR PRESENTING PROBLEM.SOCIAL CULTURAL BACKGROUNDWhat Race/Ethnic Background do you identify with? How much do you identify with your ethnic heritage? Not at all A little Somewhat Moderately Strongly Do you identify yourself in other ways that are meaningful to you (e.g., cultural background, sexual orientation, socioeconomic status, physical ability, etc) Please list: Religious preference: Are you currently active in your religion? Yes Somewhat No Would you like to incorporate your religious/spiritual values and/or rituals into the counseling process? Yes No I don't know ACADEMIC / WORK BACKGROUNDType of employment / position: Hours worked per week: Years with current employer:Are you satisfied with your job?YesNoI Don't knowHighest degree earned and Major: Are you currently a student?YesNoIf yes, where are you studying: RELATIONAL / SUPPORT HISTORYPlease indicate your current relationship status:* Single In a Committed Relationship Living with a Partner Married Separated Divorced Widowed Approximately how many significant romantic relationships have you had? Are you satisfied with your current romantic relationship?YesNoI Don't KnowHow would you rate the quality of your friendships?*Very PoorUnsatisfactoryAbout AverageExcellentDo you feel supported by your partner / spouse?*YesNoI Don't KnowBesides family, how many people can you count on right now for friendship / emotional support?* FAMILY BACKGROUNDWho lives with you currently (include ages): What is your family's religious / spiritual background: How much conflict do you currently experience with your family (whether living with you or not): None Very little Some Moderate Strong extreme Who in your family do you currently feel closest? Most distant from? In most conflict with? PHYSICAL HEALTHHow is your physical health at present?* Poor Unsatisfactory Satisfactory Good Very good When was your last physical examination? Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc):* Do you have a disability? (If yes, specify) Are you presently taking any prescribed medication?* Yes No Are any of these medications for mental health related issues (e.g. depression, anxiety, bipolar, etc)?* Yes No Are you having any problems with your sleep habits? Yes No Are you having any difficulty with appetite or eating habits? Yes No Have you had a significant weight change in the last 2 months? Yes No Do you have any problems or worries about sexual functioning? Yes No How many times per week do you exercise? For how long each time? MENTAL HEALTH HISTORYHave you ever been a victim of: (if you do not feel comfortable completing this section, you may leave it blank for now) Emotional abuse as a child Physical abuse as a child Sexual molestation / abuse as a child Emotional abuse by a partner / spouse Physical assault / abuse by a partner / spouse Sexual abuse / assault as an adult Other Trauma: Have you received counseling here or elsewhere before? Yes No If yes, where: When Duration: What was the focus of the the previous counseling? Are you currently seeing a psychiatrist or have you seen a psychiatrist in the past?* Yes No If yes, where: When: Duration: What was the focus of the psychiatric treatment? How often are you having suicidal thoughts presently? Frequently Sometimes Rarely Never How often have you had suicidal thoughts in the past?* Frequently Sometimes Rarely Never When: How often have you had thoughts of harming others presently* Frequently Sometimes Rarely Never How often have you had thoughts of harming others in the past?* Frequently Sometimes Rarely Never When: Have you ever intentionally inflicted harm upon yourself?* Yes No Unsure When Have you ever attempted suicide?* Yes No If yes, Date(s): Have you ever been hospitalized for psychological reasons?* Yes No If yes, Date(s): ALCOHOL AND OTHER DRUG USEHow often do you drink alcohol?* Daily 3 or more times per week 1-2 times per week Once a month Once or twice a year Never In a typical week, on how many days do you have 4 or more drinks? How often do you use other drugs (marijuana, cocaine, ecstasty, oxycotin, etc)* Daily 3 or more times per week 1-2 times per week Once a month Once or twice a year Never Do you or someone you know think that you may need to cut down or stop drinking/using drugs?* Yes No Maybe Informed ConsentTHERAPIST-CLIENT SERVICE AGREEMENT Welcome to The Brave Ones Therapy Center, LLC. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign or at any time in the future. The Brave Ones Therapy Center is an association of independently practicing mental health professionals who share certain expenses and administrative functions. While the members share a name and office space, each clinician is completely independent in providing his/her clinical services and each is fully responsible for those services. He/she practices according to his/her own background, training, and expertise. Based on the information provided by you, he/she will determine the appropriate scope, means, manner, and method of your treatment. Clinical records are separately maintained by each clinician and no member of the group can have access to them without your specific, written permission. THERAPEUTIC SERVICESTherapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. Your therapist will also have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to continue to work outside of session on things discussed with your therapist during session. APPOINTMENTSAppointments will ordinarily be 50 minutes in duration, once per week at an agreed upon time, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide your therapist with 24 hours’ notice by phone or email. If you miss a session without canceling, or cancel with less than 24 hour notice, our policy is to collect 50% of the agreed upon session fee prior to scheduling another session. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. PROFESSIONAL FEESYour therapist follows a sliding scale fee schedule based on household income. Your fee will be set with your therapist during your free phone consultation. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment can be made by cash, check, or credit cards to your therapist. Any checks returned to your therapist are subject to an additional fee of up to $25.00 to cover the bank fee that incurred. In addition to weekly appointments, your therapist will charge your fee amount for other professional services you may request. Other services include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized and requested, preparation of records or treatment summaries, and the time spent performing any other service you may request of your therapist. If you become involved in legal proceedings that require your therapist’s participation, you will be expected to pay for their professional time even if he/she is called to testify by another party. Because of the difficulty of legal involvement, your therapist will charge $350 per hour for preparation and attendance at any legal proceeding. PROFESSIONAL RECORDSYour therapist is required to keep appropriate records of the therapeutic services provided. Your records are maintained in a secure location. Records include brief notes that you were here, your reasons for seeking therapy, the goals and progress set for treatment, your diagnosis, topics discussed, your medical, social, and treatment history, records received from other providers, copies of records sent to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, it is recommend that you initially review them with your therapist, or have them forwarded to another mental health professional to discuss the contents. If your therapist refuses your request for access to your records, you have a right to have his or her decision reviewed by another mental health professional, which will be discussed with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request. CONFIDENTIALITYOur policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together. PARENTS & MINORSWhile privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is our policy not to provide treatment to a child under age 13 unless s/he agrees that his/her therapist can share whatever information considered necessary with a parent. For children 14 and older, we request an agreement between the client and the parents allowing the therapist to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child’s agreement, unless the therapist feels there is a safety concern (see also above section on Confidentiality for exceptions), in which case the therapist will make every effort to notify the child of his or her intention to disclose information ahead of time and make every effort to handle any objections that are raised. COUPLES In order for couples counseling to be effective, it is important for the therapist to remain a neutral and objective party. For this reason, we strictly adhere to the following policies: It is our strict policy to not keep secrets for individuals in couple’s therapy. If one partner chooses to disclose information in an individual session that is important to the health of the relationship, the therapist will require disclosure of this information to the other party.If individual sessions are conducted as a part of the therapy process, each partner will have the same number of individual sessions to promote fairness in the process.If a couple’s session has been scheduled but only one partner shows up to the session, the session will be canceled and full payment for the session will be expected.The therapist will adhere to the ethical and legal requirements of confidentiality as stated in this informed consent. However, the therapist cannot ensure that both partners will maintain confidentiality about the therapeutic experience including content discussed within the couples’ counseling session.It the coupe decides to discontinue couples counseling and one partner wishes to continue with individual counseling, the therapist will not be able to return to providing couples counseling at a later date and will have to refer the couple to a different therapist.Consent* If you are receiving couples counseling, please check here to indicate that you have read and agree to the above termsCourt/Legal Proceedings and Custody Evaluations Your therapist is not acting in the capacity of a custody evaluator and, therefore, is not available to testify for any reason throughout your divorce process. Should your therapist be subpoenaed in to court, a retainer of $1,000 will be charged to you, the client, as well as an hourly rate of $350 for any time spent both preparing for and appearing in court. Such time includes all phone calls, fax, emails, face-to-face meetings, transportation time and any additional costs involved in court preparation. If your therapist is called to court for any reason for your case, you assume full responsibility for these court related costs for your therapist.Consent* I/we agree that The Brave Ones Therapy Center therapist is not acting in the capacity of a custody evaluator and, therefore, will not be called in to court to testify for any reason throughout our divorce proceedings process. I/we understand that we are responsible for any court costs related to involving my The Brave Ones Therapy Center therapist.CONTACTING YOUR THERAPISTYour therapist will often not be immediately available by telephone. Your therapist does not answer his or her phone when he/she is with clients or otherwise unavailable. At these times, you may leave a message on his or her voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from your therapist or your therapist is unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) contact the National 24-hour Suicide Hotline at 1-800-273-TALK (8255). 2) go to your Local Hospital Emergency Room, or 3) call 911 and ask to speak to the mental health worker on call. The Brave Ones Therapy Center is not a 24 hour mental health facility and your therapist will not be available 24 hours for crises. Therefore, it is your responsibility to take advantage of the above options if you are experiencing a crisis. Your therapist will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering his or her practice.To ensure your intake form is routed correctly, please select the therapist you are working with:* Mandy Persaud Cathy Pinnock Angie Rivera Arielle Saunders Cierra Collum Stephanie Preston-Hughes Jetlexis Carlos I don't remember CONSENT TO PSYCHOTHERAPYIn submitting this form, I agree to the information being used for the purposes of private therapy. The information will only be accessed by your individual therapist. I understand my data will be held and submitted securely and will not be distributed to third parties. I have a right to change or access my information.Date MM slash DD slash YYYY Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.
THERAPIST-CLIENT SERVICE AGREEMENT
Welcome to The Brave Ones Therapy Center, LLC. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign or at any time in the future.
The Brave Ones Therapy Center is an association of independently practicing mental health professionals who share certain expenses and administrative functions. While the members share a name and office space, each clinician is completely independent in providing his/her clinical services and each is fully responsible for those services. He/she practices according to his/her own background, training, and expertise. Based on the information provided by you, he/she will determine the appropriate scope, means, manner, and method of your treatment. Clinical records are separately maintained by each clinician and no member of the group can have access to them without your specific, written permission.
THERAPEUTIC SERVICESTherapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. Your therapist will also have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to continue to work outside of session on things discussed with your therapist during session.
APPOINTMENTSAppointments will ordinarily be 50 minutes in duration, once per week at an agreed upon time, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide your therapist with 24 hours’ notice by phone or email. If you miss a session without canceling, or cancel with less than 24 hour notice, our policy is to collect 50% of the agreed upon session fee prior to scheduling another session. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.
PROFESSIONAL FEESYour therapist follows a sliding scale fee schedule based on household income. Your fee will be set with your therapist during your free phone consultation. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment can be made by cash, check, or credit cards to your therapist. Any checks returned to your therapist are subject to an additional fee of up to $25.00 to cover the bank fee that incurred.
In addition to weekly appointments, your therapist will charge your fee amount for other professional services you may request. Other services include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized and requested, preparation of records or treatment summaries, and the time spent performing any other service you may request of your therapist. If you become involved in legal proceedings that require your therapist’s participation, you will be expected to pay for their professional time even if he/she is called to testify by another party. Because of the difficulty of legal involvement, your therapist will charge $350 per hour for preparation and attendance at any legal proceeding.
PROFESSIONAL RECORDSYour therapist is required to keep appropriate records of the therapeutic services provided. Your records are maintained in a secure location. Records include brief notes that you were here, your reasons for seeking therapy, the goals and progress set for treatment, your diagnosis, topics discussed, your medical, social, and treatment history, records received from other providers, copies of records sent to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, it is recommend that you initially review them with your therapist, or have them forwarded to another mental health professional to discuss the contents. If your therapist refuses your request for access to your records, you have a right to have his or her decision reviewed by another mental health professional, which will be discussed with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.
CONFIDENTIALITYOur policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.
PARENTS & MINORSWhile privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is our policy not to provide treatment to a child under age 13 unless s/he agrees that his/her therapist can share whatever information considered necessary with a parent. For children 14 and older, we request an agreement between the client and the parents allowing the therapist to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child’s agreement, unless the therapist feels there is a safety concern (see also above section on Confidentiality for exceptions), in which case the therapist will make every effort to notify the child of his or her intention to disclose information ahead of time and make every effort to handle any objections that are raised.
COUPLES
In order for couples counseling to be effective, it is important for the therapist to remain a neutral and objective party. For this reason, we strictly adhere to the following policies:
Court/Legal Proceedings and Custody Evaluations
Your therapist is not acting in the capacity of a custody evaluator and, therefore, is not available to testify for any reason throughout your divorce process. Should your therapist be subpoenaed in to court, a retainer of $1,000 will be charged to you, the client, as well as an hourly rate of $350 for any time spent both preparing for and appearing in court. Such time includes all phone calls, fax, emails, face-to-face meetings, transportation time and any additional costs involved in court preparation. If your therapist is called to court for any reason for your case, you assume full responsibility for these court related costs for your therapist.
CONTACTING YOUR THERAPISTYour therapist will often not be immediately available by telephone. Your therapist does not answer his or her phone when he/she is with clients or otherwise unavailable. At these times, you may leave a message on his or her voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from your therapist or your therapist is unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) contact the National 24-hour Suicide Hotline at 1-800-273-TALK (8255). 2) go to your Local Hospital Emergency Room, or 3) call 911 and ask to speak to the mental health worker on call. The Brave Ones Therapy Center is not a 24 hour mental health facility and your therapist will not be available 24 hours for crises. Therefore, it is your responsibility to take advantage of the above options if you are experiencing a crisis. Your therapist will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering his or her practice.
