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YOU MAY PRINT THESE TWO FORMS, COMPLETE THEM,
AND BRING THEM TO THE OFFICE AT YOUR FIRST VISIT NEW CLIENT FORM 1 Date:_____/______/______ Name _______________________________________________
Birthdate _____/_____/_____ Age_____________ Marital Status:
Single
Married
Separated
Divorced Address ____________________________________________________________________________________________ City/State/Zip _________________________________________ Home Phone _________________________________ Email Address__________________________________________ Cell/Work Phone ____________________________ Education _________________________________________________ Occupation _______________________________________________________________________________________ Employer’s Name _________________________________________________________________________________ Name of your Primary Care Physician
____________________________________________________________________ Referred By:
Physician ______________________________
Therapist _________________________________ (please circle) Yellow Pages
Friend
Internet
Other____________________________ Other people living in the home: Name
Age
Relationship to Client
___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Name ___________________________________________ Birthdate ______/______/______ Age _______________ Address ____________________________________________________________________________________________ City/State/Zip _________________________________________________ Home Phone _________________________ Occupation __________________________________________________ Cell/Work Phone ____________________ Employer’s Name __________________________________________________________________________________ Education _____________________________________ Nearest Relative or Close Friend Not Living With You: Name ________________________________________ Address ____________________________________________ Home Phone __________________________________ Cell/Work Phone ___________________________________ 08/04 NEW CLIENT FORM 2 Business Policy This statement contains information regarding my office policies.
Please read them and if you have any questions, discuss them with me. Your
signature at the bottom of this sheet signifies that you have read, understand and agree to abide by these policies. Each session is approximately 45-50 minutes in length and the rate is $150.00. Extended telephone calls or sessions are prorated according to the per session fee. Fees are to be paid at the time of service. A
statement can be provided upon request for your records or to submit to receive insurance reimbursement. Your appointment time is
reserved for you. If you must cancel, please notify the office as soon as possible. You will be charged in full for the appointment if you do not give 24 hours notice. If you are filing claims for your visits with your insurance company, it is important
that you know that insurance benefits do not extend to missed appointment charges. If you choose to file insurance claims for services, your insurance company may require information
from the office records; please speak to me if you have concerns about this possibility.
Visa and MasterCard payments are accepted for amounts over $50.00.
There is a $10 charge for checks drawn on insufficient funds. Termination (ending therapy) is an important part of the treatment process. It is best this be a joint decision so progress can be reviewed and expectations for the future can be
discussed. If I cannot provide appropriate therapy for your treatment needs,
if treatment goals that are mutually agreeable cannot be developed, if financial commitments are not honored, if you are not
benefiting from therapy or if the therapy environment becomes unsafe, the therapeutic relationship will be terminated. Any nonvoluntary termination will be accompanied by an appropriate referral for mental
health services. A case will be identified as voluntarily closed after mutual
discussion between therapist and client(s) or if there has been no contact for 60 days. I am available to return routine
and urgent calls within 24 hours. If emergency mental health services are needed
and I am not available to contact you immediately, call the emergency mental health number in your county, go directly to the closest emergency room or call 911. I will arrange for coverage by another licensed
clinician in the event I am unavailable for an extended period of time during business hours or after hours. There is always a 24-hour voicemail and answering service seven days a week, so messages can be left at
any time. Confidentiality and the Release of Information Your participation in treatment and all information about you is confidential and will not be disclosed
to anyone without your written consent. The only exceptions are: 1) Cases of
suspected abuse or neglect of a child or elder and 2) Cases where the client presents a clear and imminent danger to him/herself
or to another person. Other common circumstances in which you may waive your right
to confidentiality include a) releasing information to another professional (e.g. physician, agency), b) legal proceedings
which involve information about your mental health, and c) the use of health insurance. My signature indicates that I have read and understand
these policies. Signature of Client (or Guardian)
Date (08/04) |
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