Preston
Counseling, PLLC
INDIVIDUAL INTAKE
CLIENT’S
FULL NAME:
_______________________________________________________TODAY’S
DATE: _________________
ADDRESS:
__________________________________________________________________________________________________
STREET
OR P.O. BOX
________________________________________________________________________________________________________________________
CITY STATE ZIP
TELEPHONE:
HOME ________________________CELL___________________________WORK
___________________________
AGE:
____________BIRTHDATE: _____________________SSN#:
____________________________________________________
MARITAL
STATUS: __________________________ DRIVER’S
LICENSE#:______________________________________________
EMPLOYER
OR SCHOOL (IF STUDENT):
________________________________________________________________________
Referred
by:
_______________________________________________Phone:________________________________________
PERSON
WHO DOES NOT LIVE WITH YOU TO CONTACT IN AN EMERGENCY:
____________________________________________________________________________________________________________
NAME
RELATIONSHIP
PHONE
INSURANCE
INFORMATION
INSURANCE
COMPANY: ____________________________________NAME
OF INSURED:_________________________________
INSURED’S
SSN#: ________________________________________INSURED’S D.O.
B.: _________________________________
INSURED’S
POLICY #:_____________________________________INSURED’S GROUP
#: ______________________________
INSURED’S
EMPLOYER: __________________________________________________AMOUNT OF
CO PAYS: ______________
AMOUNT
OF DEDUCTIBLE ________________ ANNUAL DEDUCTIBLE MET? YES_________
NO____________
ANNUAL
VISIT MAXIMUM ? YES_______________ NO_______________ # OF
VISITS?____________________
INSURED’S
RELATIONSHIP TO
CLIENT:_________________________________________________________________________
AUTHORIZATION
#:_________________________________________________________________________________________
IF
YOUR COUNSELING IS BEING PAID FOR THROUGH AN EMPLOYEE ASSISTANCE
PROGRAM, PLEASE LIST AUTHORIZATION NUMBER AND HOW MANY SESSIONS ARE
BEING AUTHORIZED.
EAP
COMPANY AUTHORIZATION NUMBER # OF SESSIONS
__________________________________________________________________________________________
To be completed
by therapist:
Primary
diagnosis____________________ Secondary diagnosis_______________
TREATMENT
AGREEMENT:
PLEASE
INITIAL:_______________
Co-payments
and deductible are due at the time of service. you are responsible
for verifying co-payment, deductible and annual visit limits________
I
hereby assign payment of insurance benefits directly to preston
counseling,pllc. While preston counseling, pllc will bill my
insurance company, I will be responsible for any charges incurred if
my insurance company does not pay. _________
It
is my responsibility to contact my insurance company to obtain the
proper authorizations if required. If I fail to do this and charges
are denied I will be responsible for all charges. _________
If
your portion of the bill is not paid within 90 days from the last
date it was incurred a letter will sent giving you 14 days to pay
your account or to arrange for a payment plan. iF YOU DO NOT
RESPOND you will be sent to collections. ______
A
1% INTEREST WILL BE ADDED TO YOUR PORTION OF THE BILL THAT REMAINS
UNPAID AFTER 30 DAYS.____________
FEES
ARE $________ for each session. _______
You
will be charged $80.00 for missing an appointmenT OR NOT GIVING AT
LEAST 24 HOURS PRIOR NOTICE to cancelling an appointment. ________
I
have receIVED the treatment agreement AND Disclosure statement i
understand and agree to abide by my financial responsibilities. I
understand that information will be released to my insurance company,
if necessary, and any charges that my insurance company will not
cover I am responsible for.
CLIENT
SIGNATURE: _________________________________________________DATE:
__________________________
To enable
My Therapist with accurate and confidential services please complete
the following:
Please
be aware that Fax transmissions arrive at preston counseling pllc’s
OFFICE. confidentiality is maintained with these records, as with
all records in our office.
Messages
regarding appointments may be left on my VOICE MAIL. _______YES
_______NO
EMAIL
MAY BE USED TO COMMUNICATE WITH ME. ___YES ___NO EMAIL
ADDRESS______________________________
The
following individuals may schedule and or confirm appointments.
___________________________________________________________________________________________________________
_____________________________________________________________________________
CONCERNS
AND GOALS:
Please
describe why you have come in:
________________________________________________________________
_____________________________________________________________________________
Describe
goals you want to accomplish by coming here:
____________________________________________
__________________________________________________________________________________________________________________________________________________________
Please
CHECK individual items you want to address. Please CIRCLE
the two most important, to address first:
Concentration Fears Bowel
Trouble Self-esteem
Hopelessness Guilt Stomach
Trouble Temper
Depressed Self-control Sexual
Problem Relaxation
Harm
to self Harm to others Drug Use Finances
Suicidal
concerns Impulsivity AlcohoL Use Work
High
energy Hyperactive Headaches Motivation
Low
energy Attention Difficulties Memory Legal Matters
Anger Sleep
Problems Thoughts Career Choices
Temper Dreams Abuse Education
Nervousness Nightmares Trauma Making
Decisions
Anxiety Health
Problems Shyness Meaninglessness
Stress Appetite/Weight Crying
spells Unresolved Grief
Panic Eating/Food
trouble Unhappiness Spiritual Concerns
Please
CHECK relationship items you want to address. Underline
THOSE YOU feel apply to another family member. Please circle
the two most important to address first.
Marriage Parenting Recreation Friendships
Separation Children Infidelity/Affairs Holding
Other Down
Divorce Housing Physical
Fighting Conflicting Schedules
Intimacy Finances Common
Interests Problem Solving
In-laws Sexual
Desire Showing Appreciation Loneliness
Relatives Agreeing
on chores Trusting Each Other Common Goals
Jealousy Sexual
Performance Affection Verbal Fighting
Use
of time Spouse’s Cleanliness Communication Having Fun
Together
HEALTH
INFORMATION:
List
all current medications:
____________________________________________________________________________
_____________________________________________________________________________
List
all current health problems INCLUDING ALLERGIES:
__________________________________________________
_____________________________________________________________________________
List
past significant health problems:
___________________________________________________________________
_____________________________________________________________________________
Have
you been hospitalized OR HAD other psychiatric care related to your
mental health? _________
If
yes please provide dates and treatment outcome for those events:
_________________________________
____________________________________________________________________________________________________________
List
previous professional help, AND DATES you received for personal,
marital, or family concerns:
________________________________________________________________________________________________
_____________________________________________________________________________
Name
of your primary care physician: _______________________May we
contact? ______________________
Phone
number: ________________________ When were you last seen?
______________________________________
I
GIVE MY CONSENT FOR MY THERAPIST TO RELEASE MY RECORD TO MY
PRIMARY PHYICIAN SO THAT THEY CAN DISCUSS MY TREATMENT:
SIGNED_____________________________DATE______________
I
DO NOT GIVE MY CONSENT FOR MY THERAPIST TO RELEASE MY RECORDS TO
MY PRIMARY CARE DOCTOR TO DISCUSS MY TREATMENT:
SIGNED_____________________________DATE_______________
DRUG
AND ALCOHOL ASSESSMENT;
Are
drugs or alcohol used by yourself or someone else a significant
factor in why you are coming to our office? ________yes
________no
If
yes __________self __________other:
Relationship_________________________________________________________
ALCOHOL
ASSESSMENT:
Frequency of
Alcohol use:
_____ Never
______ Less than1 time/month _____ 1-4 times per month _____ 2-3
times per week ______ Daily
Usual Alcohol
Consumption:
______ None
_______ 1-2 drinks per sitting ______3-4 drinks per sitting ________
5 or more drinks per sitting
Frequency of use
to levels of intoxication:
______ Never
______ less than 1 time/month ______ 1-4 times per month ______ 2-3
times per week ______ Daily
Please
describe any alcohol-related problems (e.g. legal, job, physical, or
social):_____________________________
____________________________________________________________________________________________________________
|
Self-perception
of alcohol use: (check all that apply)
___
Occasional or social ___ Problem use
___ Psychological dependence
___
Addicted-cannot stop ___ Does not want to stop
___ Motivated to stop
|
|
History
of treatment attempts: (check all that apply)
___
None ___ Stopped on own
___ Attended AA/ other 12 step program
___
Attended outpatient program ___ Attended inpatient program ___
Attended community-based program
|
OTHER
SUBSTANCE USE ASSESSMENT: (Check
Frequency and Duration for each drug used in the last 6
months)
Frequency
Duration
Daily Weekly Monthly Less
than More than
Or
less one year one Year
Marijuana _____ _____ _____ _______ ________
Sedative _____ _____ _____ _______ ________
Stimulant _____ _____ _____ _______ ________
Cocaine _____ _____ _____ _______ ________
Opiates _____ _____ _____ _______ ________
Inhalants _____ _____ _____ _______ ________
Hallucinogens _____ _____ _____ _______ ________
Prescription
Drugs _____ _____ _____ _______ ________
Caffeine
_____ Number of cups per day ______ Tobacco____ if cigarettes-number
per day _______
Please
describe any drug-related problems (e.g. legal, job, physical, or
social) ________________________________
____________________________________________________________________________________________________________
|
Self-perception
of Drug Use: (check all that apply)
___
Occasional or social ___ Problem use
___ Psychological dependence
___
Addicted-cannot stop ___ Does not want to stop
___ Motivated to stop
|
|
History
of treatment attempts: (check all that apply)
___
None ___ Stopped on own
___ Attended NA/ other program
___
Attended outpatient program ___ Attended inpatient program ___
Attended community-based program
|
LEGAL
INFORMATION:
Do
you have any legal issues? If yes, please
explain:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
MARITAL
INFORMATION:
Married:
______ Divorced: _______ Living together: _____ SEPARATED: _______
Single: _______ Other: ______
If
you checked “Other” please explain:
__________________________________________________________________
LIst
dates and lengths of any previous marriages:
_____________________________________________________
_____________________________________________________________________________
FAMILY
HISTORY:
List
the names, ages, and relationship, of all persons living in your
home:
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List
the names, and ages of any immediate family members that are not
listed above
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
RELIGOUS
INFORMATION:
ARE
SPIRITUAL ISSUES OF CONCERN TO YOU ___________YES __________NO
What
is your religious affiliation, if any?
______________________________________________________________
Revised
10/28/2005
