Personal Intake Form

PERSONAL INTAKE FORM

Client Identification

Client Name:

Date of Birth:    Gender:

Pronouns:

Emergency Contact

Presenting Concerns

Please indicate current concerns (check all that apply):

Medical & Medication History

Mental Health & Substance Use History

Previous therapy or counseling: Yes No

Hospitalizations for mental health issues: Yes No

Social & Legal

Living situation:

Employment status:

Current legal involvement (probation, pending charges, custody issues):

Consent, Confidentiality & Administrative Terms

Confidentiality: All information provided in sessions is confidential and will not be released without written authorization except where disclosure is required by law. Exceptions include: (1) reasonable belief that you present an imminent risk of serious harm to yourself or others; (2) suspected abuse or neglect of a minor, elder, or dependent adult; (3) disclosure ordered by a court of competent jurisdiction; and (4) instances of fraud, threat to public safety, or other legal requirements. By signing below you acknowledge you have read and understand these exceptions.

Consent for Treatment and Communications: I voluntarily consent to receive assessment and therapeutic services. I understand that electronic communications (email, text, voicemail) may not be secure. I authorize the provider to leave messages regarding appointments and basic administrative matters at the phone numbers or email addresses I have provided unless I have informed the provider otherwise in writing.

Fees and Cancellation: I accept responsibility for payment of services. Standard fee for an initial intake session and subsequent sessions will be discussed and recorded in the administrative record. Cancellation policy: clients are asked to provide at least 24 hours notice for cancellations. Late cancellations or missed appointments may incur a fee payable by the client unless waived by the provider for emergency circumstances.

Insurance and Billing: If insurance claims are submitted on your behalf, accuracy of the insurance information and authorization for billing is required. You remain financially responsible for all charges if a claim is denied or if services are not covered.

Authorization to Release Information: I authorize the provider to release or obtain information to/from other health professionals or agencies as necessary for coordination of care, payment, or legal requirements. I understand that a separate signed release is required for most disclosures not related to treatment, payment, or healthcare operations.

Acknowledgement: I acknowledge I have read and understand the above statements and agree to the terms of services and confidentiality exceptions.

Additional Notes

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