Intake Registration

Today’s Date:

Name:

Date of Birth:

Age:

Gender:
MaleFemale

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

May I have permission to mail to this address?
YesNo

Email Address:

Marital Status:
Never MarriedDomestic PartnerSeparatedDivorcedMarriedWidowed

If Married – How many years?

If Widowed – How many years?

Education (List highest level of education attained):

Employer:

Occupation:

How long have you worked there?

How long in this occupation?

Primary Insurance:

Phone Number:

Group Number:

Policy Number:

Subscriber’s Name:

Social Security Number:

Date of Birth:

Employer:

Client’s Relationship to Subscriber:
SelfSpouseChildOther

If Other, please specify:

Secondary Insurance:

Phone Number:

Group Number:

Policy Number:

Subscriber’s Name:

Social Security Number:

Date of Birth:

Employer:

Client’s Relationship to Subscriber:
SelfSpouseChildOther

If Other, please specify:

Parent/Guardian Information

(Please complete if the client is under 18 years of age)

Parent/Guardian Name:

Date of Birth:

Phone Number:

Spouse/Partner Information

Name:

Date of Birth:

Age:

Gender:
MaleFemale

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Employer:

Occupation:

Education (List highest level of education attained):

Emergency Contact

Name of Local Friend or Relative (Not living at the same address):

Relationship to Client:

Phone Number:

Physician Information

Primary Physician:

Phone Number:

List any significant health problems:

Mental Health History

Referred By

Medical Provider:

Insurance Provider:

My Website:
www.evolvingreflections.com

Friend/Family Member:

Other:

I am interested in the following type(s) of counseling: (check all that apply)
IndividualCouplesFamilyGroup

What would you like to accomplish out of your time in therapy?

What issues or concerns bring you to counseling today?

When did your problem first start?
Within the last 30 Days6 – 12 Months2 YearsDuring AdolescenceDuring Childhood

Have you previously received any type of mental health services?
YesNo

If yes, which of the following:
PsychotherapyMedicationOutpatient HospitalizationInpatient Hospitalization

Name of Provider or Facility:

Location:

Dates of Treatment:

Reason for Treatment:

Is there any other information that you feel is important for me to know before we begin our work together?

Family History

Please list your siblings (brothers and sisters) in order of their birth, including yourself.

Where were you born?

Where did you grow up?

Area Type:
CitySuburbsCountry

Who did you live with while growing up?

Mother’s Name:

Father’s Name:

Mother’s Occupation:

Father’s Occupation:

Lien/Lawsuit

Understanding the Therapeutic Process

Therapy is most effective when both the client and the therapist make a commitment to the therapeutic process and relationship. Through mutual commitment, the therapist and the client create a relationship in which there is trust, respect, safety and an open exploration of the client’s thoughts, feelings and experiences. Within the safety of the therapeutic relationship, change becomes possible.

As with any effort to create lasting change, psychotherapy requires time, energy and commitment. Our first few sessions will involve an evaluation of your needs, from which I will provide impressions of what our work will include and an initial treatment plan. Psychotherapy can feel frustrating because we often cannot control the pace of change. On the path toward healing, you may experience an increase in painful feelings; this is a normal part of the process. Psychotherapy has both risks and benefits. Usually people find psychotherapy helpful, although it can cause disappointing or unexpected outcomes.

If you have concerns about your progress or any aspects of treatment, I invite you to discuss this with me in person or in writing. You are free to terminate at any time; however, I hope you will discuss this prior to stopping. I can give you a referral to other providers if you choose to discontinue our work together

Informed Consent

Welcome to Evolving Reflections! We appreciate that you are entrusting us with your mental health needs and look forward to assisting you in achieving your mental health goals.

This document will provide you with important information about Evolving Reflections and our business policies. It is important that you read these documents carefully so that you can make an informed decision in regard to our services.

Services Provided

Evolving Reflections offers a variety of mental health services that include, but are not limited to, the following:

• ∗ Individual Psychotherapy

• ∗ Assessments

• ∗ Consultation

• ∗ Referrals for Alternative Healthcare Providers

Typically, the first sessions will involve a comprehensive assessment of your needs and goals. You and your therapist will decide which service(s) best match your needs and create a treatment plan. It is important to provide accurate and complete information so that we can make the most appropriate recommendation for services for you. We encourage you to ask questions and talk openly with your therapist about any concerns requests, or needs you may have. Your therapist is always willing to discuss your treatment with you and to look at alternatives that might work better. Although during the course of the therapy relationship, you may be disclosing vulnerable or personal information, the therapy relationship is professional in nature. Planned contact outside of the therapeutic relationship or sexual interactions of any kind is prohibited.

Confidentiality Statement

With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone except where disclosure is required by law.

1. I abide by and respect the ethical code of confidentiality. This means that I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me, without your written permission. You may give written consent for me to share information with whomever you choose, and you can change your mind at any time and revoke that permission.

2. The following are the legal exceptions to your right to confidentiality. I will inform you if at any time I feel it is necessary to put these into effect.

A. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also inform the police and ask them to protect that person.

B. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services or Social Services within 72 hours.

C. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and contact the police or crisis team. However, whenever possible, I would explore all other options with you before taking this step.

**In any of these situations, I would reveal only the information necessary to protect you or the person in danger. I would not tell everything you have told me.

D. If you become involved in a court case or proceeding, a judge or court may require that I provide information or testify.

E. I may sometimes consult with another professional about your treatment. All counselors are required by professional ethics to keep your information confidential. These case consultations are helpful to both you and I in determining that I am providing you the best treatment possible. In addition, when I am out of town or unavailable, another therapist will be on hand to assist my clients. I must provide him or her with information about any clients that might be calling.

F. If I treat children under the age of 12, I cannot guarantee confidentiality. Parents of young children have the right to remain informed about treatment. As children grow more able to understand and choose their right to confidentiality increases. Therefore, for children between the ages of 12 and 18, most of the details of our work together will be kept confidential. However, parents and guardians do have the right to general information, such as how their child’s therapy is going. The same legal exceptions to confidentiality also apply.

G. If you and your partner decide to have individual sessions as part of your couples therapy, what we discuss in those individual sessions will most likely be discussed in your joint sessions. I will not be a part of keeping secrets between partners in couple’s therapy. If you do not wish to work on your concerns together, I suggest you see separate counselors for individual therapy.

Initial:

Therapist Communications

Your therapist may need to communicate with you by telephone or other means. Please indicate your preference by checking one of the choices listed below. Please be sure to inform your therapist if you do not wish to be contacted at a particular time or place, or by a particular means.

Records and Your Right to Review Them

I keep very brief session records, noting only that you have been here, what interventions happened in session, and the topics we discussed. Please note that clinically relevant information from emails, texts, and faxes are part of the clinical records. Both the law and the standards of my profession require that I keep treatment records for at least 7 years. I retain clinical records only as long as is mandated by Nevada law.

You have the right to a copy of your file at any time. You have the right to request that I correct any errors in your file. You have the right to request that I make a copy of your file available to any other health care provider with your written consent.

Social Networking:

I do not accept friend requests from current or former clients on social networking sites, such as Facebook. I believe that adding clients as friends on these sites and/or communicating via such sites can compromise their privacy and confidentiality. In addition, accepting friend requests from clients is prohibited by ethical guidelines of the American Counseling Association, by which I am bound. For this same reason, I request that clients not communicate with me via any interactive or social networking web sites.
Initial:

Financial Agreement:

The fee for a 45-minute session is $125.00 payable at the time of treatment. I accept cash, checks and credit cards. Many insurance plans are accepted with prior authorization. If your insurance is not one that I accept, you may be able to utilize your out-of-network benefits. You will need to pay your session fee in full at the time of service, and I can provide you with a HCFA billing form, which you can submit to your insurance company for reimbursement.