Adult Therapy Intake FormClient InformationFirst NameLast NameDate of BirthPreferred Name: Pronouns: AddressAddress Line 1CityStateZip CodePhone Number: Email Address: Preferred Method of Contact: Phone Text Email Patient PortalEmergency ContactName: Relationship: Phone Number: Insurance InformationPrimary Insurance Company: Member ID Number: Group Number: Policy Holder Name: Policy Holder Date of Birth: Relationship to Policy Holder: Self Spouse Parent Other: Secondary Insurance (if applicable):Insurance Company: Member ID Number: Group Number: Policy Holder Name: Relationship to Policy Holder:Financial Responsibility & Payment InformationPayment Method on File: Credit Card Debit Card HSA/FSA OtherOther:Financial Agreement Please initial each statement: I understand that I am responsible for all copays, coinsurance, deductibles, and any non-covered services. I understand that insurance verification is not a guarantee of payment. I understand that I am responsible for payment of services denied by my insurance carrier. I authorize my therapist to bill my insurance company on my behalf. I authorize payment of insurance benefits directly to the provider. I understand that balances not covered by insurance are my responsibility I understand that payment is due at the time services are rendered unless other arrangements have been made.Appointment PoliciesCancellation & No-Show Policy Please initial: I understand that appointments canceled with less than 24 hours notice may be subject to a cancellation fee of $ 75.00. I understand that missed appointments (no-shows) may be charged a fee of $100.00. I understand that insurance companies generally do not cover missed appointment fees.Presenting ConcernsWhat brings you to therapy at this time?How long have you been experiencing these concerns?What are your goals for therapy?Mental Health HistoryHave you previously participated in therapy? Yes NoProvider Name: Dates of Treatment: Reason for Treatment:Have you ever been hospitalized for mental health concerns? Yes NoIf yes, please explain:Current SymptomsPlease check any symptoms you have experienced recently: Anxiety Excessive Worry Panic Attacks Depression Sadness Irritability Mood Swings Difficulty Sleeping Fatigue Difficulty Concentrating Racing Thoughts Low Motivation Grief/Loss Relationship Problems Work/School Stress Trauma History Anger Social Withdrawal OtherOtherMedical HistoryPrimary Care Physician: Date of Last Physical Exam: Current Medical Conditions:Current Medications:Medication Dosage Prescribing ProviderAllergies:Substance Use Do you currently use any of the following?Alcohol Never Occasionally Weekly DailyTobacco/Nicotine Never Occasionally DailyMarijuana Never Occasionally Weekly DailyOther Substances Yes NoIf Yes (Please explain)Family & Social HistoryRelationship Status: Single Married Divorced Separated Partnered WidowedDo you have children? Yes NoIf yes, ages: Who lives in your household?Describe your support system:Employment & EducationCurrent Employment Status: Full-Time Part-Time Self-Employed Unemployed Student RetiredOccupation:Highest Level of Education: High School Some College Associate Degree Bachelor's Degree Master's Degree Doctorate OtherOther:Risk AssessmentHave you ever had thoughts of harming yourself? Yes NoIf yes, please explain:Have you ever attempted suicide? Yes NoIf yes, please explain:Do you currently have thoughts of harming yourself? Yes NoDo you currently have thoughts of harming someone else? Yes NoIf yes to either question, please explain:Telehealth Consent I understand the benefits and risks associated with telehealth services. I understand that confidentiality protections remain in place during telehealth sessions. I understand that technical difficulties may interrupt services.Consent for Treatment I voluntarily consent to participate in psychotherapy services. I understand the nature and purpose of treatment, confidentiality limitations, and my rights as a client.Client Signature: Sign Here Date: Therapist Signature: Sign Here Date: HIPAA Acknowledgment I acknowledge that I have received and/or been offered a copy of the Notice of Privacy Practices.Client Signature: Sign Here Date:Availability for Therapy Services Please indicate your preferred days and times for scheduling appointments.Days Available Monday Tuesday Wednesday Thursday Friday Saturday (if available) Sunday (if available)Preferred Appointment Times Morning (8 Afternoon (12 Evening (5Specific Availability Please list the days and times you are generally available for appointments: Specific Availability Day Time Frequency Preference Weekly Bi-Weekly Monthly Unsure / Discuss with TherapistBest Way to Confirm Appointments Phone Call Text Message Email Patient PortalScheduling Notes Please include any information that may affect scheduling (work schedule, childcare needs, rotating shifts, travel, etc.):Schedule Now
