New Client Paperwork

Paperwork that clients can fill out at home, or at the office before their first session.  There are three forms that must be completed. Our fax number is (215) 922-6302. If you have any questions, please feel free to call Alex (267) 324-9564. 

 

 

FORM 1: New Client Form

Therapist Name: ________________________________________________________

Identified Client’s Name: _________________________________________________

Type of Service Requested: __ Individual __ Couples ___ Family ___ Group __ Unsure

Social Security Number: _____________________________  DOB _____________

Address: ______________________________________________________________
                 (street address)
                _______________________________________________________________
               (city)                                     (state)                                      (zip code)

Phone Number: _______________________________________________________(H)

                           _______________________________________________________(W)

                           _______________________________________________________(C)
                           (only include numbers that TCFG have permission to use)

Do you want to be on TCFG mailing list?      Yes  ___________      No ____________

Date of Initial Session:______________________   Fee: ________________________

 

Name of others who might be attending session to support client _________________________________________

Address _______________________________________________________________________________________

Social Security # ________________________________________________________________________________

Phone Numbers given to use if needing to change an appointment time. ___________________________________

 

_______________________________________________________________________________________________________________________________

 

FORM 2 : PERSONAL DATA INVENTORY

_______________________________________________________________________________________________________________________________

 

Assessment Date:________

Please fill out this sheet as thoroughly as possible. All information is confidential and for The Center for Growth, Inc. records only. Note: If you have been a client here before, please fill in only the information that has changed.

 

Name: __________________________________________________________________

Nickname:_________________________________SS#:__________________________

Date of Birth:______________________________ Age:__________________________

Race:__________________________________ Gender: _________________________

Address: ________________________________________________________________

City: _________________________State: __________________Zip Code: __________

Home Phone: ____________________________________________________________

Work Phone: ____________________________________________________________

Cell Phone: _____________________________________________________________

Email:_________________________________________________________________

Occupation:_____________________________________________________________

Marital Status: Single____ Living Together__________ Married______ Separated_________ Divorced______ Widowed__________

Education: (Last year completed) ____________________________________________

Other training: List type and years____________________________________________

 

Referral: Who referred you to me?

Name: _______________________________________________________________

Address:______________________________________________________________

Web Site:_____________________________________________________________

If you got my name from a person (as opposed to the Internet) may I have your permission to thank this person for the referral? Yes________ No________

 

Relational Information

Sexual Orientation: _____________________________

Marital Status: Single____ Living Together__________ Married______

Separated_________ Divorced______ Widowed__________

Name of partner: _______________________ Partners age: ____________

Relationship to you: Spouse___ Partner___ Friend ___ Other (describe) _____________

Address:_____________________________

Phone: ______________________________

Occupation: ______________________________

Is your partner willing to come for counseling? Yes _______  No ______Not Sure_____

Have you ever been separated? Yes __No ___ When______

Have either of you ever filed for divorce? Yes ___ No___ When_____

Date of Marriage________ Any previous marriages? No ___ Yes____ When_____

List children and ages ____________________________________________________

 

 

Religious background

Religious preference? ____________________________________________________

What are your parent’s religious preferences? _________________________________

Is faith an important part of your life?________________________________________

 

Health History

Height: ________________________  Weight: ________________________________

List all important present or past illnesses, injuries or handicaps ____________________

_______________________________________________________________________________________________________________________________________________

Date of last medical exam _________________________________________________

Primary care doctor _______________________Phone __________________________

Address _______________________________________________________________

Urologist / Gynecologist ___________________Phone _________________________

Address _______________________________________________________________

If you enter treatment with me for psychological problems, may I tell your primary care doctor and urologist/gynecologist so that he or she can be fully informed and we can coordinate your medical treatment?

Primary Care Doctor:  Yes___________ No_______________

Urologist: Yes_____________________ No________________

Gynecologist: Yes___________________ No_________________

 

Current Medications:

Condition

Medication

Dosage

Frequency

Start Date

 

Allergies / Reactions to medications: _________________________________________

_______________________________________________________________________

 

Have you ever received psychological or psychiatric treatment or counseling services before?  Yes_________ No__________ If yes, please indicate

 

When?

From Whom?

For What?

With What Results?

 

 

Cigarette Use History

 

Do you smoke cigarettes or have you smoked cigarettes in the past?  Yes _____  No________

If Yes, how many cigarettes do you smoke in a day? ______________and for how many years have you smoked? ________________________ If you have quit smoking, how many years did you smoke for? ________________________________________________________________

 

 

 

 

Chemical Use History

Have you ever used drugs for purposes other than medical? Yes ____ No________

If yes, please explain ___________________________________________________

____________________________________________________________________

 

When is the last time you got drunk?  _________________________________________

How frequently do you drink alcohol? ________________________________________

How much alcohol do you drink in a week? ____________________________________

How long ago was your most recent period of abstinence?_________________________

 

When is the last time you used marijuana________________________

How frequently do you get high?_______________________________
How much do you use in a week? ___________________________________

How long ago was your most recent period of abstinence? _________________

What other types of drugs do you use, and how much? ___________________

_______________________________________________________________

_____________________________________________________________

Does a recovering addict live in the house? Yes___________ No__________

Does an active addict live in the house? Yes ____________ No_______________

 

Have you ever received drug or alcohol treatment / services before?  Yes____No___ If yes, please indicate.

When?__________________________________________________

From Whom? __________________________________________________

For What?__________________________________________________

With What Results? __________________________________________________

 

Suicidal & Homicidal Ideation

Are you currently having thoughts about hurting yourself? Or have you ever had thoughts about harming yourself?  ____________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

Have you ever attempted suicide? __________________________________________________

_____________________________________________________________________________________________________________________________________

Have you ever been hospitalized for suicidal ideations? ________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Are you currently having thoughts about hurting others?________________________________ ______________________________________________________________________________  _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever hurt someone else?  Please include all childhood fights where someone else might have ended up with a black eye, broken bone, smashed hand etc.________________________________________________________________________________________________________________________________________________

Have you ever been hospitalized for homicidal thoughts? ____________________________________________________________________________________________________________

Family Environmental

In your family, is there any history of a mental health disorder (anorexia, anxiety, bulimia, depression, panic attacks, schizophrenia, sexual addiction, etc)?

Yes ______ No ______ Unknown________

                           Diagnosis

Mother __________________________________________________

Father __________________________________________________

Sibling __________________________________________________

Child __________________________________________________

Spouse __________________________________________________

Uncle __________________________________________________
Aunt__________________________________________________

Grdparent__________________________________________________

Other __________________________________________________

 

Legal History

 

Are you presently suing anyone or thinking of suing anyone? No ____ Yes _____ If yes, please explain _________________________________________________________

_______________________________________________________________________________________________________________________

 

Is your reason for coming to see me related to an accident or injury?  No ____ Yes _____ If yes, please explain _____________________________________________________

_______________________________________________________________________________________________________________________

 

Are you required by a court, the police, or a probation/parole officer to have this appointment? No ____ Yes _____ If yes, please explain _______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

 

List all the contacts with the police, courts, and jails/prisons you have had.  Include all open charges and pending ones. Under “Jurisdiction,” write in a letter: F = federal, S = state, Co = county, Ci = city. Under “Sentence,” write in the time and the type of sentence you served or have to serve (AR = accelerated or alternate resolution, CS= community service, F = fine, I = incarceration, Pr = probation, Po = parole, O = other, R=restitution).

 

Date__________________________________________________

Charge     __________________________________________________

Jurisdiction(F,S,C,Ci)__________________________________________________

Sentence (AR,I,Pr,Pa) __________________________________________________

Probation/parole__________________________________________________

Officer’s name__________________________________________________

Your attorney’s name__________________________________________________

Your current attorney’s name: _______________________Phone:__________________

Are there any other legal involvements about which I should be aware? ______________

________________________________________________________________________

________________________________________________________________________

Referral Source: ______________________________________________________

 

 

_____________________________________________________________________________________________________________

FORM 3: THE AGREEMENT / CONTRACT BETWEEN THERAPIST & CLIENT

_____________________________________________________________________________________________________________

 

Client Agreement / Contract

 

This document is designed to ensure that you understand our professional relationship.

 

At The Center for Growth our desire is to help you meet your goals. To do so, may require one session, several months, or even years of counseling.  As a client, you have the right to end your counseling relationship at any point.  If counseling is successful, you should feel that you are able to face your immediate challenges.

 

Although your sessions may be psychologically intimate, it is important for you to realize that your relationship with your therapist is a professional rather than a social one. Please do not invite your therapist to social gatherings, offer gifts, or ask your therapist to relate to you in any way other than in the professional context of your counseling sessions. Your therapist will keep confidential the contents of a counseling, intake, or assessment session.  Both verbal and written records about a client can not be shared with another party without the written consent of the client or the client’s legal guardian.  It is the policy of The Center for Growth not to release any information about a client without a signed release of information.

 

Limits of Confidentiality

Duty to warn and protect: Your therapist is required by law to contact the police and your family if you disclose intentions and/or a plan to harm yourself or others.
Abuse of children and vulnerable adult: if a client states / suggests that he or she is abusing a child / vulnerable adult, or has recently abused a child or vulnerable adult, or a child / vulnerable adult is in danger of abuse, your therapist is required by law to report this information to the appropriate social service / legal authorities.
Prenatal exposure to controlled substances: As a health care professional, your therapist is required by law to report admitted prenatal exposure to controlled substances that are potentially harmful.
In the event of a client’s death: In the event of a client’s death, the spouse or parents of a deceased client have a right to access their child’s or spouse’s therapy records.
Professional misconduct: Professional misconduct by a health care professional must be reported by other health care professionals. In cases in which a professional or legal disciplinary meeting is being held regarding the health care professional’s actions, related records may be released in order to substantiate disciplinary concerns.
Court orders: Health care professionals are required to release records of clients when a court order has been placed.
Minors/Guardianship: Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.

 

Other provisions:

1)When fees for services are not paid in a timely manner, collection agencies may be utilized in collecting unpaid debts. The specific content of the services (e.g. diagnosis, treatment plan, case notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the client’s credit report may state the amount owed, time frame, and the name of the clinic.

2)Information about clients may be disclosed in consultations with other professionals in order to provide the best treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed.

3)When couples or families are receiving services, a joint file is kept. Therapists at the Center for Growth do NOT hold secrets between the people receiving services together. If you wish to keep some things confidential, then you are advised to seek services as an individual, not as a couple or a family.  As an individual, you could have your partner (or family) attend some of the sessions.  In session, you might notice that the primary difference between individual counseling and couples/family counseling is that the therapist will be focused on meeting your needs, as opposed to the collective needs of the family unit.   From a confidentiality perspective, as an individual whose partner sometimes attends session, the partner will not have access to the records, unless a release of information form is signed by you.         

4)In the event that someone from The Center for Growth must telephone you, such as an appointment cancellation, reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please list where we may reach you by telephone and how you would like us to identify ourselves.  If this information is not provided to us (below), we will adhere to the following procedure when making phone calls: First we will ask to speak to the client (or guardian) without identifying the name of this organization. If the person answering the phone asks for more identifying information we will say that it is a personal phone call. To protect confidentiality, we will not identify the name of this organization. If we reach an answering machine or voice mail we will follow the same guidelines.

 

            Please check where you may be reached by phone. Include phone numbers and how you would like us to identify ourselves when telephoning you.

 

___Home    Phone Number: ______________________________________

                    How should we identify ourselves? __________________________

                    May we mention The Center for Growth _______________

___Work    Phone Number: ______________________________________

                    How should we identify ourselves? __________________________

                    May we mention The Center for Growth _______________

___Other     Phone Number: ______________________________________

                    How should we identify ourselves? __________________________

                    May we mention The Center for Growth _______________

 

 

 

______  I authorize the therapist assigned to my case to keep the above contact information with her when out of the office in the event that she needs to call me regarding a scheduling change or some other issue regarding my therapy. 

 

_____  I do NOT authorize the therapist assigned to my case to keep the above contact information with her when out of the office in the event that she needs to call me regarding a scheduling change or some other issue regarding my therapy. 

 

 

Client Signature: _____________________________________   Date _______________

 

Therapist Signature: ___________________________________ Date _______________

 

 

Client’s Rights and Responsibilities

 

Clients have the right to know their therapist’s experience and training.
Clients have the right to know about treatment choices and what their therapist can offer.
Clients have the right to receive treatment that is helpful to them.
Clients have the right to receive fair treatment, regardless of race, gender, disability or religion.
Clients have the right to a safe treatment environment, free from sexual, physical and emotional abuse.
Clients have the right not to answer any question, or provide information that, for any reason they do not want to provide.
Clients have the right to refuse audio or video recordings of their session (but you may ask for it if you wish).
Clients have the right to ask their therapist about their treatment progress.
Clients have the right to terminate treatment at any point for any reason. If you are court ordered to receive treatment then you still have the right to terminate treatment with your therapist, but there may be legal problems. Thus, it is best if you speak with your lawyer who can advise you further.
Clients have the right to file a complaint with the government or their therapist’s professional group(s).
Clients have the responsibility to treat their therapist with dignity and respect.
Clients have the responsibility to give the therapist accurate information so that she can deliver the best care possible.
Clients have the responsibility to ask questions if they do not understand the therapy process.
Clients have the responsibility to follow the agreed upon treatment plan.
Clients have the responsibility to keep their appointments, and if they can’t, to call as soon as possible to cancel.
Clients have the responsibility to openly talk about their concerns with the quality of care they are receiving and to report abuse/fraud.
Clients are responsible for payment of services received.

 

Legal Issues

 

If you are in the midst of any type of legal issues such as litigation, a dispute with your employer, separation or divorce, please inform your therapist immediately.  Please be aware that in custody cases, therapists typically need signed permission from both parents, and that medical records are frequently subpoenaed when litigation is involved.

 

Fee Information & Payment Policy

 

Your therapist agrees to provide counseling services for you in return for a fee.  Each session, otherwise known as a clinical unit, defined as a 53 minute hour for assessment, and individual, family and relationship counseling, will cost ___________.  My fee for consultation is ___________ per 50 minute session.  Under most circumstances, it is inappropriate for a psychotherapist to become involved in a treatment client’s legal case.  However, should this become necessary, the fee for any time your therapist must spend in a forensic situation is _________ per 1 hour unit. 

 

Payment is expected at the time of service.  Cash and checks are acceptable for payment.  There is a $35 service charge for all returned checks.  You will be given a receipt for all fees paid if you would like.  Check with your insurance company to determine if your coverage honors outpatient counseling provided by The Center for Growth.  Please note that many insurance companies require surveys that request information about symptoms, diagnosis, and treatment. By using your insurance plan you are granting permission for your therapist to communicate personal information to your insurance company.  Please remember that The Center for Growth has no control of, or responsibility, for how information is handled once it is released to third parties. 

 

Cancellation / Office Hours

 

In the event that you will not be able to keep an appointment, you must notify your therapist 48 hours in advance. If such advanced notice is not received, you will be responsible for paying the appointment fee in full.  If for any reason you need to contact your therapist, please call (215) 922-5683 and leave a message on her voice mail 24 hours a day, seven days a week.  All messages will be returned within 72 hours. Phone messages are checked Mondays through Fridays.

 

Emergencies

 

The Center for Growth is a small organization.  Private practice clinicians cannot assume responsibility for client’s day to day functioning, as some more intensive treatment programs are designed to do.  It is the responsibility of the client to discuss expectations of after-hours care with their therapist upon intake so that, if necessary, an appropriate referral can be made.  

 

Should you feel that your situation requires immediate attention, your therapist will return all calls within 72 hours.  You may leave a message on your therapist’s voice mail at (215) 922-5683.  If you do speak with the therapist, you will be billed at the therapist’s current hourly rate for individual therapy for the time she spends with you on the telephone.  You should be advised that your insurance company may not reimburse you for the telephone.   If you wish to speak with someone immediately and a phone call back from your therapist within 72 hours is not fast enough, please contact your local suicide/crisis hotline.  One such number, which is available (24 hours a day /7 days a week) is (215) 686 – 4420. 

 

In the case of an emergency, when a client fears harm to himself/herself or another, please go to your closest Emergency Room and ask to speak with a psychiatrist. 

 

As the client, your signature below indicates that you understand the limits of confidentiality and understand their meanings and ramifications and grant consent for The Center for Growth to provide psychological services and counseling to you and or minor members of your family. Lastly, your signature acknowledges that you have received a copy of this form, including the Client’s Rights and Responsibilities and Crisis/Emergency Procedures.

 

Client / Guardian Signature ______________________  Date __________________

Client / Guardian Signature ______________________  Date __________________

Therapist ____________________________________  Date___________________

 

To Parents of Teenagers

 

As the client, your signature below indicates that you understand the need for confidentiality between your teenager and their therapist, and that confidentiality will be maintained unless this therapist determines that your teenager is a danger to self or others.

 

Parent / Guardian Signature ________________________ Date _________________

 

_____________________________________________________________________________________________________________

FORM 4: Electronic Communication Consent Form

_____________________________________________________________________________________________________________

This form grants permission for the utilization of electronic communication in circumstance in which the continuity of psychological services would be interrupted.  These services are defined as psychotherapy and consultation. As technology progresses there is an increased reliance and utilization of telecommunication services such as Facetime,  Skype, and cell phones. Although these telecommunication services allow for newer, easier, and innovative ways to provide psychological services, they also come with risks and benefits that should be considered before utilizing.

 

Some of the benefits include:

 

  • Access to care and psychological services to those who may be in areas in which these resources are not available (e.g. rural communities)
  • It allows for the continuance of care despite a geological disruption in services. For example, if a client goes on an extended vacation.
  • Some research has shown that electronic forms of therapy are comparable to therapy that is provided face-to-face.
  • Due to the lack of commute time, Skype, Facetime and cell phones allow for more convenient therapist-client interactions.

 

By signing this form, you are agreeing that you ____________________

The Client

will not hold the Center for Growth liable for any breaches of confidentiality due to your usage of electronic forms of communication with The Center for Growth.  The Center for Growth CANNOT guarantee confidentiality. Every effort will be made to ensure that electronic communication is kept confidential.  To ensure full confidentiality, we encourage face-to-face sessions in our office located at 233 S. 6th Street, Suite C33.   
 

Lastly the utilization of electronic communication can be revoked by either of us at any time through written means.

 

By signing below you agree and understand the requirements and provisions of this form:

 

Client Name (printed):_____________________________________________

Client Signature: _______________________________Date:______________

Skype (screenname)________________________________________________

 

Therapist (signature): _____________________________________________

by


Printed from http://www.therapyinphiladelphia.com/tips/new-client-paperwork

Need an Appointment? Call (267) 324-9564