Professional legal forms

General intake questionnaire 2... GENERAL INTAKE QUESTIONNAIRE FAIR EMPLOYMENT PROGRAM CHEYENNE OFFICE CASPER OFFICE Labor Standards 1510 E. Pershing Boulevard West Wing, Room 150 Cheyenne, WY 82002 (307) 777-7261 FAX (307) 777-5633

Acupuncture intake form Union Center For Healing Integral PLLC Confidential HEALTH INTAKE FORM Please take the time to fill out this questionnaire carefully. The information you provide will assist me in formulating a complete

Bookkeeping client intake form... Bookkeeping Client Intake Form Business Type: Specific Category Initial Consultation: First Visit: NL Y Referred by: Thank you sent: N Completed HC Y N Completed BC Y N Completed Business Name Address

Patient intake form acupunctur... PATIENT INTAKE FORM ACUPUNCTURE Patient Name: Sex: Date: / / 2012 DOB: Age: M F 1. Phone: 2. Phone: Email: Address Treatment #: DESCRIBE YOUR CURRENT PROBLEM AND HOW IT BEGAN: PLEASE CIRCLE AREAS

Individual provider contractor... If this printout is not available you must provide the new copy of your SS card before contracting can be completed. HCS / AAA / DDA INDIVIDUAL PROVIDER CONTRACTOR INTAKE DSHS 27-122 REV. HOME AND COMMUNITY SERVICES HCS AREA AGENCY ON AGING AAA DEVELOPMENTAL DISABILITIES ADMINISTRATION DDA HCS / AAA / DDA Individual Provider Contractor Intake Instructions An Individual Provider IP is A person working under contract with the Department of Social and Health Services DSHS who acts at the direction of a DSHS client living in his or her own home and provides that client with personal care and/or DDA respite care. This form is intended for individuals and not business entities. If you are completing this form for a business entity please STOP and request a Contractor Intake from the person who sent you this form. Complete form in its entirety and return to 1. Home and Community Services HCS if you will be working for a client of HCS or 2. Area Agency on Aging AAA if you will be working for a client of an AAA or 3. Development Disabilities Administration DDA if you will be working for a client of DDA. Part A Individual Provider Information Mandatory for all Contractors 1. CONTRACTOR S SIGNATURE DATE without this information. 1. Are you a current Washington State employee or an employee of a State University or Community College State University and Community College employees are considered Washington State employees. School District Employees are not considered State employees in this context. 3. If yes what year did our employment terminate with the State of Washington Date within the last two years you must fill out Part C and return with Part A and B of this intake form. statements are true and correct and that I will notify DSHS of any changes in any statement. cannot be issued without this information. CURRENT STATE OFFICER / STATE EMPLOYEE NAME TITLE OF YOUR STATE JOB CURRENT STATE EMPLOYER I hereby certify that both of the following statements are true I am a current state employee My role as an individual provider is not in conflict with the proper discharge of my official duties as a state And one of the following is also true I will not receive anything of economic value under the contract as defined in RCW 42. This form is intended for individuals and not business entities. If you are completing this form for a business entity please STOP and request a Contractor Intake from the person who sent you this form* Complete form in its entirety and return to 1. Home and Community Services HCS if you will be working for a client of HCS or 2. Area Agency on Aging AAA if you will be working for a client of an AAA or 3. Development Disabilities Administration DDA if you will be working for a client of DDA. Part A Individual Provider Information Mandatory for all Contractors 1. Contractor Information The Contractor Name is your name as it appears on your Social Security card. If you have additional addresses you may submit them on a separate sheet of paper. For any additional addresses please make sure you label the type of address example home mailing etc*.

Intake form in social work Provider Name and Credentials Type of License Office Address City, ST Zip Code Child and Adolescent History Form The information requested in this form is treated as CONFIDENTIAL. The questions are

Massage therapy intake form Massage Therapy Client Health Intake Form Patient Information Name Address City State Zip Home Phone Work/Cell Phone E-mail Occupation Date of Birth Emergency Contact Person Phone Are you currently under a physicians care for an acute or chronic illness Y N If yes please explain If yes who is your health care provider Have you received a massage before Y N If yes when How did you hear about me What are your goals for this session Please list areas of tension stress and/or pain you wish to be addressed Health Information Please mark an X by all current conditions and P for all past conditions Abdominal /digestive problems Allergies Anxiety Arthritis/tendonitis Asthma or lung cond. Athletes foot Blood clots Chronic pain Circulatory/heart Constipation/diarrhea Depression Diabetes Fatigue Headaches migraine Hearing problems Hernia High blood pressure Jaw pain/TMJ pain Low blood pressure Muscle/bone injuries Muscle/joint pain Numbness/tingling Pregnancy Rash/fungus Sinus problems Sleep difficulties Spinal disorders Sprain/strain Tension/stress Vision problems Varicose veins Other Elaborate on noted areas above Please list your stress-reduction activities hobbies exercise and/or sport participation Please use the letters provided in the key to identify the symptoms you are feeling today. Circle the area around each letter representing the size and shape of each symptom location* P pain or tenderness S joint or muscle stiffness N numbness or tingling I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge. I will inform my health care provider and massage therapist if anything changes in my status. I understand that massage/bodywork I receive is for the purpose of stress reduction and the relief from muscular tension spasm or pain and to increase circulation* If I experience any pain or discomfort I will immediately inform my massage therapist so that the pressure and/or methods can be adjusted to my comfort level* I understand that my massage therapist does not diagnose illness or disease nor perform any spinal manipulations and does not prescribe any medications/treatments. I acknowledge that massage is not a substitute for a medical examination or diagnosis and that I should see my health care provider for those services. If I am unable to attend my scheduled appointment I will respect and abide by the set cancellation policies. Sexual advances request for sexual favors and other verbal or physical conduct of a sexual nature will constitute as sexual harassment and will not be tolerated* I understand that I am receiving massage therapy at my own risk. In the event that I become injured either directly or indirectly as a result in whole or in part of the aforesaid massage therapy I hereby hold harmless and indemnify the therapist their principals and agents from all claims and liability whatsoever. Athletes foot Blood clots Chronic pain Circulatory/heart Constipation/diarrhea Depression Diabetes Fatigue Headaches migraine Hearing problems Hernia High blood pressure Jaw pain/TMJ pain Low blood pressure Muscle/bone injuries Muscle/joint pain Numbness/tingling Pregnancy Rash/fungus Sinus problems Sleep difficulties Spinal disorders Sprain/strain Tension/stress Vision problems Varicose veins Other Elaborate on noted areas above Please list your stress-reduction activities hobbies exercise and/or sport participation Please use the letters provided in the key to identify the symptoms you are feeling today. Circle the area around each letter representing the size and shape of each symptom location* P pain or tenderness S joint or muscle stiffness N numbness or tingling I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge.

Psychotherapy online form Disclosure Forms Client Psychotherapy Intake Form Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.

Massage form Massage Intake Form - CONFIDENTIAL INFORMATION WELCOME I would like to make your appointment as pleasant and comfortable as possible. If at any time you have questions regarding your session please let me know. Name Date of birth Address State City Home Phone Work Phone Occupation Have you ever received massage therapy Yes No Type of massage experienced swedish shiatsu deep tissue etc* Are you currently taking any medications If yes please list name and reason for medications Please review this list and check those conditions that have affected your health either recently or in the past. Place a check mark next to the condition* arthritis diabetes blood clots broken/dislocated bones bruise easily cancer chronic pain constipation/diarrhea auto-immune condition hepatitis A B C other skin conditions stroke surgery TMJ disorder depression panic disorder other psych condition diverticulitis headaches heart conditions back problems high blood pressure insomnia muscle strain/sprain pregnancy scoliosis seizures whiplash chemical dependency alcohol drugs AIDS fibromyalgia chronic fatigue lupus etc* If any of the above needs to be detailed or if there is anything else to share please do so Do you have any of the following today skin rash cold/flu anything contagious open cuts severe pain injuries/bruises Do you have any allergies to medications foods nuts etc* environmental allergens dust pollen fragrances reactions to skin care products Are you wearing contact lenses hearing aid hairpiece Please indicate with an X if any the areas in which you are feeling discomfort What are your goals/expectations for this therapy session The following sometimes occurs during massage. They are normal responses to relaxation* Trust your body to express what it needs to need to move or change position sighing yawning change in breathing stomach gurgling emotional feelings and/or expression movement of intestinal gas energy shifts falling asleep memories Please read the following information and sign below 1. I understand that although massage therapy can be very therapeutic relaxing and reduce muscular tension it is not a substitute for medical examination diagnosis and treatment. 2. This is a therapeutic massage and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment. 3. Being that massage should not be done under certain medical conditions I affirm that I have answered all questions pertaining to medical conditions truthfully. If at any time you have questions regarding your session please let me know. Name Date of birth Address State City Home Phone Work Phone Occupation Have you ever received massage therapy Yes No Type of massage experienced swedish shiatsu deep tissue etc* Are you currently taking any medications If yes please list name and reason for medications Please review this list and check those conditions that have affected your health either recently or in the past. Place a check mark next to the condition* arthritis diabetes blood clots broken/dislocated bones bruise easily cancer chronic pain constipation/diarrhea auto-immune condition hepatitis A B C other skin conditions stroke surgery TMJ disorder depression panic disorder other psych condition diverticulitis headaches heart conditions back problems high blood pressure insomnia muscle strain/sprain pregnancy scoliosis seizures whiplash chemical dependency alcohol drugs AIDS fibromyalgia chronic fatigue lupus etc* If any of the above needs to be detailed or if there is anything else to share please do so Do you have any of the following today skin rash cold/flu anything contagious open cuts severe pain injuries/bruises Do you have any allergies to medications foods nuts etc* environmental allergens dust pollen fragrances reactions to skin care products Are you wearing contact lenses hearing aid hairpiece Please indicate with an X if any the areas in which you are feeling discomfort What are your goals/expectations for this therapy session The following sometimes occurs during massage.

Client intake form massage I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that the american massage therapy association has provided this form as a reference and is not held liable for any services provided. signature assignment of benefits I am responsible for all charges for all service provided. In the unfortunate event that my insurance company denies payment or makes a partial payment contracted with my insurance company at a discount rate for services the amount remaining will be waived and I will not be asked to pay the balance. I authorize and direct payment of medical bene ts to my massage therapist for services billed. signature of parent or legal guardian if client if a minor release of medical records I authorize the release of medical records or other health care information including intake forms chart notes reports correspondence billing statements and other written information to my attorneys healthcare providers and insurance case managers for the purposes of processing my claims. I understand that the american massage therapy association has provided this form as a reference and is not held liable for any services provided. signature assignment of benefits I am responsible for all charges for all service provided. In the unfortunate event that my insurance company denies payment or makes a partial payment contracted with my insurance company at a discount rate for services the amount remaining will be waived and I will not be asked to pay the balance. I authorize and direct payment of medical bene ts to my massage therapist for services billed. signature of parent or legal guardian if client if a minor release of medical records I authorize the release of medical records or other health care information including intake forms chart notes reports correspondence billing statements and other written information to my attorneys healthcare providers and insurance case managers for the purposes of processing my claims. employer s name/school name phone primary insurance plan name group number plan number Please inform your practitioner immediately upon signing any exclusive Release of Medical Records with your attorney that may impact the above release statement. Client intake form client signature date of initial visit personal information current health Do you exercise regularly and/or participate in any sports r Y name rN If yes what kind of exercise/sports address state home phone Do you perform any repetitive movement in your work sports or hobby zip rY Are you experiencing tension sti ness discomfort or pain r Y city cell phone If yes describe Do you sit for long hours at a workstation computer or driving work phone email occupation Do you experience stress in your work family or other aspect of your life marital status referred by emergency contact name physician s name Have you recently had an injury surgery or areas of in ammation Do you have sensitive skin Do you have any allergies to oils lotions or ointments massage experience Have you had a professional massage before r Yes r No If yes what types of massage have you had swedish shiatsu deep tissue etc. How long have you been receiving massage therapy If yes please explain List any medications you are currently taking Frequency of massages What are your goals for treatment List any known allergies health history Musculoskeletal Bone or joint disease Tendonitis/Bursitis Arthritis/Gout Jaw Pain TMJ Lupus Spinal Problems Migraines/Headaches Osteoporosis Circulatory Heart Condition Phlebitis/Varicose Veins Blood Clots High/Low Blood Pressure Lymphedema Thrombosis/Embolism Respiratory Breathing Di culty/Asthma Emphysema Allergies specify Nervous System Shingles Numbness/Tingling Pinched Nerve Chronic Pain Paralysis Multiple Sclerosis Parkinson s Disease Reproductive Pregnant stage Ovarian/Menstrual Problems Prostate Skin Rashes Cosmetic Surgery Athlete s Foot Herpes/Cold Sores Digestive Irritable Bowel Syndrome Bladder/Kidney Ailment Colitis Crohn s Disease Ulcers Other Cancer/Tumors Diabetes Drug/Alcohol/Tobacco Use Contact Lenses Dentures Hearing Aids Any other medical condition s not listed Please explain any of the conditions that you have marked above Psychological Anxiety/Stress Syndrome Depression This form was created as a resource by the american massage therapy association and they are not held liable for any services provided. client agreement health release form insurance information client s full name date ins. ID date of injury Is your condition the result of an auto accident If so in what state did the accident occur r A work injury r A health condition r Other What type of insurance do you have that may cover you for this condition check all that apply r Auto r Workers compensation/state Industrial r Liability r Health Was a police/accident report led Client s relation to insured r Self r Spouse r Partner r Child r Other insured s full name date of birth r Male r Female r Single r Married r Partnered r Other It is my choice to receive massage therapy.

Counseling intake forms sample... CLIENT INTAKE FORM Please provide the following information for our records. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality

Cpca short intake form CLIENT INTAKE FORM Name: Address: Phone: Home #: Work #: Cell #: Email: What time and day is best? Okay to leave a phone message? Yes No Text message/Email? Yes No Age Date of Birth Occupation: Marital

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