Fresh Perspective Psychotherapy, LLC

Intake Form

Client Name (First, MI, Last):_____________________________________________________

Mailing Address:________________________________________________________________

Primary Phone#:________________________

Alternate Phone#:_______________________

Work Phone#:_____________________ Ok to contact you at work if needed? Y or N

Email address:__________________________________________________________________

Is it ok to leave messages (circle Y or N):

· Via Phone? Y or N

· Via Text? Y or N

· Via Email? Y or N

DOB:____________

SS#:_____________

Marital Status (circle one): Married Divorced Separated Single Widow(er)

Employment (where, job title):_____________________________________________________

Highest level of education:________________________________________________________

(Please include school name and grade if currently enrolled)

Emergency Contact:

· Name:________________________________

· Phone number:_________________________

· Relationship to you:______________________

Spouse/significant other information (if applicable, please include name, employment, and age):__________________________________________________________________________

Children (names, ages, please include stepchildren, adopted children, and foster children):____________________________________________________________________________________________________________________________________________________

Persons currently living in your household (names and relationship to you):_________________

____________________________________________________________________________________________________________________________________________________________

Siblings (names and ages; include biological, step, and adoptive):_________________________

____________________________________________________________________________________________________________________________________________________________

Parent information (names, ages, employment, and whether living or deceased; please include biological parents, stepparents, and/or adoptive parents):________________________________

____________________________________________________________________________________________________________________________________________________________

Please list any significant medical/health problems that you have experienced, or are currently experiencing:___________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________

Please list any surgeries and/or hospitalizations:_______________________________________

______________________________________________________________________________

Please list any childhood illnesses or accidents you have experienced:______________________

____________________________________________________________________________________________________________________________________________________________

Please list any previous counseling, or outpatient mental health treatment, that you have received (please include dates and locations):_________________________________________________

____________________________________________________________________________________________________________________________________________________________

Please list any psychiatric inpatient treatment that you have received (please include dates, location, and whether voluntary or involuntary admission):______________________________

____________________________________________________________________________________________________________________________________________________________

Please list any prior mental health diagnoses that you have received and by whom:___________

____________________________________________________________________________________________________________________________________________________________

Please list any current, or previous, drug and/or alcohol use (please include ages of use, years sober/clean, and any previous substance abuse treatments):______________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please list all medications that you are currently taking (please include dosage, prescribing physician, and reason for prescription):______________________________________________

____________________________________________________________________________________________________________________________________________________________

Please list the name(s) and location(s) of your primary care physician and/or psychiatrist:__________________________________________________________________________________________________________________________________________________

If you have ever been convicted of a crime, please explain (charge, age when convicted, jail time, outcome, etc.):_____________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Please list any recent, major life changes (marriage, divorce, childbirth, moves, loss/death of loved one, etc.):_________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Have you experienced any “traumatic event” in your life? (circle one): Y or N

(if yes, please provide a brief description)____________________________________________

____________________________________________________________________________________________________________________________________________________________

Billing Sheet

Client Name:_____________________________ DOB:_________________________

Address:_______________________________________________________________

Phone:______________________________ SS#:______________________________

Insurance:

Insurance company:_____________________________________________________

Phone# (on back of card):_________________________________________________

Name of insured:______________________________ DOB:_____________________

ID# or SS#:____________________________________________________________

Place of employment:____________________________________________________

I hereby instruct and direct my insurance company to pay by check or direct deposit to:

Fresh Perspective Psychotherapy, LLC

1120 Sandy Creek Rd.

Thornton, WV 26440

OR

If my current policy prohibits direct payment to clinician, I hereby also instruct and direct you to make the check payable to me and mail it to the above listed address. This check will be for the professional expense benefits allowable and otherwise payable to me under my current insurance policy, as payment toward the total charges for the professional services rendered. This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above mentioned assignees. I have agreed to pay, in a current manner, any balance of said professional service charges over and above the insurance payment.

A photocopy of this assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. I authorize clinician to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

I understand that I am responsible for my insurance information being correct and current. I also understand that regardless of what the insurance pays, I am responsible for all charges. Any monies received by the clinician from the above insurance companies over and above my indebtedness will be refunded to me when my bill is paid in full. I authorize the release of any medical/behavioral health benefits to this provider for services rendered. Your signature below indicates that you have read this agreement and accept the terms. This also serves as acknowledgment that we have discussed HIPPA and the confidentiality policy.

Client Signature:___________________________________________ Date:________

Spouse Signature:__________________________________________ Date:________

Parent/Guardian Signature:___________________________________ Date:________

Clinician Use Only:

Diagnosis:__________________________________ Initial date of service:__________

Clinician Signature:_________________________________________ Date:________

Consent for Treatment

and Limits of Liability

Limits of Services and Assumptions of Risks:

Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to many variables that affect these therapy sessions, as well as the individual’s ability to utilize skills learned in these sessions. Experiencing uncomfortable feelings and discussing unpleasant situations and/or aspects of your life are considered risks of participating in psychotherapy sessions.

Limits of Confidentiality:

What you discuss during your therapy sessions will remain confidential. No contents of these sessions, whether verbal or written, may be shared with another party without your written consent, or the written consent of your legal guardian. The following is a list of exceptions to this confidentiality policy:

Duty to Warn and Protect

If you disclose a plan or threat to harm yourself, the clinician must attempt to

notify your family/emergency contact, as well as legal authorities. In addition, if

you disclose a plan or threat to harm another person, the clinician is required to

warn the possible victim, as well as the legal authorities.

Abuse of Children and Vulnerable Adults

If you disclose, or it is suspected, that there is abuse or harmful neglect of

children or vulnerable adults (i.e. the elderly, disabled/incompetent), the clinician

must report this information to the appropriate state agency, as well as the legal

authorities.

Prenatal Exposure to Controlled Substances

The clinician is required to report any admitted prenatal exposure to controlled

substances that could be harmful to the mother or unborn child.

Minors/Guardianship

Parents, or legal guardians, of non-emancipated minor clients have the right to

access the client’s records.

Insurance Providers

Insurance companies and other third-party payers are given information that they

request regarding services provided to the clients.

The type of information that may be requested includes: types of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc.

By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.

_________________________________________ ________________

Client Signature (Parent/Guardian if client under 18)Date

Collaborative Confidentiality Disclaimer

A collaborative confidentiality agreement exists between the owners of Fresh Perspective Psychotherapy, LLC (Sheena Nicholson), Beacon Barn Therapeutic Farm, LLC (Molly McCartney), and Creative Connections Psychotherapy, LLC (Sarah Long). This agreement permits the owners of each practice to share and discuss confidential client information with each other in order to maximize the benefits of the therapeutic process. Confidential case information will be discussed with each client’s best interest in mind, and also while adhering to HIPPA regulations and the NASW Code of Ethics. This agreement also allows each clinician to have access to all client information of all named practices, in the event that the primary clinician becomes incapacitated for any reason. This collaborative agreement also grants permission to each clinician to receive and/or reply to any crisis calls, or provide crisis services, to clients of all named practices in the event that the client’s primary therapist is unavailable.

I understand that my confidential information will not be discussed with anyone outside of this collaborative agreement, unless another exception to confidentiality has been met (danger to self/others, abuse/neglect, etc). I also understand that I have the right to request that my information not be discussed with anyone named in this agreement, and will discuss reasoning with the clinician.

*Initial here if you prefer your case NOT be discussed with the other clinicians named in this agreement: _______________Date:____________________

By signing below, I agree to the terms of the collaborative confidentiality agreement. I also understand that in the event of a crisis, my call may be returned by one of the above named clinicians if my primary clinician is unavailable:

__________________________________________________________

Client Signature (over the age of 12)Date

__________________________________________________________

Parent/Guardian Signature (if client under age of 18)Date

Fresh Perspective Psychotherapy, LLC

1120 Sandy Creek Rd.

Thornton, WV 26440

(304) 900-2002

Court Policy

Due to the confidential nature of the relationship between the therapist and client, it is this practice’s policy not to appear in court for any reason. We feel this breach in confidentiality would limit the expected benefits from therapy and place the client in a more vulnerable state, leading to more guarded behavior during sessions. Your signature below indicates that you have been made aware of this policy, and are in agreement.

Summary Statement Policy

In the case of a request for a written summary statement (in cases of divorces/parenting plans, disability cases, legal reasons, or other medical professionals/treatment facilities) there will be a $50.00 fee charged to the requestor. A release of information, signed by the client or the parent/guardian of clients under the age of 18, is also required.

Cancellation/Payment Policy

Due to limited appointment availability, I understand that I must provide 24 hours notice if I need to cancel or reschedule my appointment. In the event of a late cancellation, or a missed appointment I understand that I will be charged a $75 fee. This fee will be the sole responsibility of the client, and not billed to the insurance. I also understand that I must pay this fee before, or at the time of, my next appointment.

I have read and understand the above policies, and agree to all terms.

______________________________________________________________

Printed name of Client or Parent/Guardian if under 18Date

__________________________________________________

Signature of Client or Parent/Guardian

Fresh Perspective Psychotherapy, LLC

1120 Sandy Creek Rd.

Thornton, WV 26440

(304) 900-2002

Therapy Animal Policy

There are a variety of animals, used for therapeutic purposes, on the premises. These animals are all friendly and handled on a daily basis. However, please keep in mind that some of these animals are still fairly young and in the process of being trained as therapy animals. It is also important to remember to remain calm and non-threatening when interacting with the animals, and approach them in a gentle manner. Please also remember that even the most tame animals are still animals, and can be somewhat unpredictable at times. Therefore, remember to always listen to how the therapist instructs you to interact with any animals that you may encounter. The animals are meant to add to the therapeutic experience in a positive way. Please be respectful of the animals and follow the therapist’s instructions in order to keep it a safe and positive experience for both you and the animals.

I have been made aware of this policy, have discussed any risks involved with interacting with the animals, as well as the behavior that is expected from me towards the animals, and I agree to the terms of the policy.

*Please note that you are also NOT REQUIRED to interact with the animals as part of your therapeutic process.

_____________________________________________ __________________

Name of Client or Parent/Guardian if under 18Date

_______________________________________________________________

Signature of Client or Parent/Guardian if under 18Date

Diagnostic Impression Sheet

(Clinician use only)

Axis I:________________________________________________________________________

Axis II:_______________________________________________________________________

Axis III:______________________________________________________________________

Axis IV:______________________________________________________________________

Axis V (GAF):_________________________________________________________________

Treatment Goals

1.____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

4.____________________________________________________________________________