CLIENT INTAKE INFORMATION  2/2002
Please PRINT All Information clearly
(if two of you are being seen - please complete 2 intakes)
YOUR FULL NAME: __________________________________________________________
Address: ____________________________________________________________________
City: _______________________ State: _____________ Zip: _________
Date of Birth: ____/____/____    Age: _____   Sex: (M)____ (F)____
Home Phone #(______)________________  Work Phone #(______)__________________ ext:____
Cell Phone #(______)__________________    S.S. # ______-____-______
Church Affiliation: __________________________________
Relationship Status:
1. Single                                         5. Separated
2. Cohabitation                               6. Divorced
3. Engaged                                     7. Widowed (how long:______________)
4. Married: (How Long: _________) How many times have you been married? ______
                          How many times has your spouse (or fiancé') been married? ______
Family Members: (if married - include spouse)
Name Age D.O.B. Relationship Living at home with you
          /      /    
          /      /    
          /      /    
          /      /    
How were you referred to the Counseling Center: ____________________________________
In Case of Emergency, the Therapist may contact: __________________________________
     Phone #: (______)_________________ Relationship to Client: _________________________
Responsible party for this account / bill: ___________________________________________
       Relationship to client:  Self.   Spouse,   Parent,   Priest,   EAP Service
       If other than client or EAP - Please ask for release of Information to sign
Do you have health insurance to cover your mental health counseling? _____ YES   _____ NO
       Do you want us to file insurance for you? _______ (not necessary if using EAP services)
Insurance Company _______________________________ Phone #(_____)________________
Insured Person: ___________________________ SS# _____-_____-_____
Employers Name: _____________________________________________
Client's job experience / Skills: Current Employer __________________________________________
Occupation ______________________________________________
Company Address: ________________________________________
City, State, Zip: ___________________________________________
Working:  Full Time,   Part Time,   Student,   Laid Off,   Not Employed at this time
                Retired,   Disability/WC Leave,   Medical Leave
 
Description of the problem(s): The following is a list of areas in which you may be experiencing some difficulty. Please check (√) any of the symptoms that apply to you or help describe a problem you are having.
A. PHYSICAL CONCERNS:
1. CHANGE IN: [  ] Sleep [  ] General Health [  ] Appetite [  ] Weight
 [  ] Interest in Activity [  ] Physical Energy      
2. INCREASED USE OF: [  ] Diet pills [  ] Alcohol [  ] Drugs [  ] Laxatives

 [  ] Antacids

 [  ] Sleeping pills [  ] Pain relievers [  ] Other:
3. RECENT HISTORY OF: [  ] Infection [  ] Delirium Tremors [  ] Flashbacks [  ] Miscarriage
 [  ]  Nausea & Vomiting [  ] Illness [  ] Fever, Chills, Sweats [  ] Bleeding [  ]  Severe headache
 [  ]  Shortness of breath [  ] Dizziness [  ] Cheat Pains [  ]  Rapid breathing [  ] Head injury
 [  ] Difficulty in speech [  ] Abortion [  ] Loss of balance [  ] Swollen joints [  ] Skin Rash
 [  ] Diarrhea [  ]  Paralysis [  ] Loss of memory [  ] Seizure(s) [  ] Numbness
 [  ] Hospitalization [  ] Blackouts [  ] Change in vision [  ]  Loss of consciousness
 [  ] Palpitations (pounding heart) [  ] Other:    
B. PSYCHOLOGICAL CONCERNS
1. THOUGHTS OF:   [  ] Suicide [  ] Harming self [  ] Harming others
2. EXPERIENCE OF: [  ] Seeing visions [  ] Thought control [  ] Racing thoughts [  ] Being out of body
 [  ] Vivid dreams or nightmares [  ] Decreased need for sleep [  ] Hearing voices  
3. FEELINGS OF: [  ] Dread [  ] Anxiety [  ] Depression [  ] Guilt
 [  ] High Energy [  ] Boredom [  ] Loneliness [  ] Low self worth [  ] Tension
 [  ] Despair/ hopelessness [  ] Persecution [  ]  Jealousy [  ] Rage
4. FEAR OF: [  ] Animals [  ] Cancer [  ] AIDS [  ] Death
 [  ] Being insane [  ] Objects [  ] Loss of control [  ] Places [  ] Being possessed
 [  ] Being alone [  ] Situations [  ] Punishment [  ] Exposure [  ] Other:
C. SOCIAL/ OCCUPATIONAL CONCERNS
1. CONCERNS WITH: [  ] Child [  ] Spouse [  ] Family member [  ] Friend / peer
 [  ] Work supervisor        
2. PROBLEM WITH: [  ] Job [  ] Legal authorities [  ] School [  ] Finances
 [  ] Other:        
3. VICTIM OF: [  ] Rape [  ] Persecution [  ] War injury [  ] Bad accident
 [  ] Emotional abuse [  ] Slander [  ] Discrimination [  ] Natural disaster [  ] Violent crime
 [  ] Malpractice [  ] Vandalism [  ] Disfigurement [  ] Sexual abuse [  ] Harassment
 [  ] Spouse or child abuse [  ] Physical abuse [  ] Verbal abuse  
 [  ] Witness to violence / death [  ] Cult group / practice [  ] Other:  


 

On the scale below, please estimate the severity of your problems:
Mild        Moderate        Severe        Extreme        Incapacitating
In your own words, state the nature of your problem(s)? What has been tried that has helped or tried and made things worse? (use the back if more space is needed).
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Job satisfaction:  Very High,  High,  OK,  Low,  None,  Minus
Job Status:  Secure,  In jeopardy,  Unemployed,  Retired,  Disabled,  Worker's comp., 
Social security,  Working more than one job,  Other: ____________
Other kinds of work I am qualified to do: _____________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Highest level of completed education: Elementary,  Junior/Middle School,  High School
College,  Graduate School
Past Psychological Treatment: Have you ever had a previous therapy or been hospitalized for a nervous or mental disorder? Yes      No
When? ________________ For How Long? ___________________________
Where? ________________________________________________________
Who was your Doctor? ____________________________________________
Have you ever attempted suicide?   No      Yes
When: ______________________________  How: ___________________________
General Health: How would you rate your overall health: Excellent,  Good,  Average,  Poor
Primary Care Physicians Name: _______________________________________________________
Address: ___________________________________________________________________________
City: ____________________________________ State: ____________ Zip: _____________________
Phone #: (_______)______________________________ Date of last physical: ____________________
List ALL Medication being taken at this time and its purpose (use back if needed)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Medical History (List problems, allergies & dates including surgeries):
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

 

 


 

EPISCOPAL COUNSELING CENTER POLICY STATEMENT
I understand that I am consenting to treatment or testing, have read the policy letter, and that my records will remain with the Episcopal Counseling Center.

I authorize the Episcopal Counseling Center to release any necessary information to expedite insurance claims if they are being filed on my behalf. I understand that it is customary to pay for professional services when they are rendered, that I am responsible for all charges, regardless of insurance coverage, and that my account may be turned over to a collection agency if payment is not made.

I also understand that unless I give 24 hour notice to cancel an appointment, I will be financially responsible for a charge of $50 for a missed appointment (regardless of insurance coverage). There is an answering service (or machine) available to leave a message if the office is closed, and emergency situations can be discussed with my therapist.

We understand that personal problems are very difficult to talk about. That is why confidentiality is extremely important to us. We take every precaution in protecting the confidentiality of your visit with us. WE DO NOT DISCUSS YOUR SITUATION WITH ANYONE EXCEPT FOR THE REASONS CITED BELOW, UNLESS YOU GIVE US WRITTEN PERMISSION TO DO SO. The State of Florida requires that the Episcopal Counseling Center inform you that under the following three (3) circumstances, confidentiality will be breached:

  1. If we learn about child, adolescent or elder abuse or abuse of disabled adults, we are required by law to report it to the proper authorities
  2. If, in our judgment, a client is dangerous to himself or others (suicidal or homicidal), we will disclose information in order to help protect persons from harm
  3. If we are required to present records or witness testimony, to comply with a court order, it is our legal responsibility to comply.

This provides a safe and secure opportunity for you to discuss personal problems with us. If supervision is required by your therapist, client information will be released only to the supervisor.

I have read and understand all of the above and I have received a copy of the HIPAA Notice of Privacy Practices.

Please let us know if you would like a copy of this page
     

 (Client Signature)

 (Spouse or Parent Signature (If Needed))
     

 (Client PRINTED Name)

 (Date)