INTAKE FORM

Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.
Once you are finished, please hit the Submit button at the end.

Date: Name:
Birth Date: / / Age: Gender:
Contact Phone: May we leave a message:
Text?
Email: May we email you?
Address:
 
(Street and Number)
(City)
(State)
(Zip)
Referred by:
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Last visit to therapist - why you ended?
Medication(s) your are taking and dosage:
Emergency Contact:
 
(Name)
(Number)
(Relationship)
GENERAL HEALTH AND MENTAL HEALTH INFORMATION
1. What is your main reason for seeking therapy at this time:
2. How would you rate your current physical health?
Please list any specific health problems you are currently experiencing:
3. How many times per week do you generally exercise?
What types of exercise do you participate in?
4. Please list any difficulties you experience with your appetite or eating patterns:
5. Are you currently experiencing sadness, grief, depression?

If so, for approximately how long?
6. Are you currently experiencing anxiety, panic attacks or have any phobias:

If yes, when did you begin experiencing this?
7. Are you currently experiencing any chronic pain?

If yes, please describe
8. Do you drink alcohol more than once a week?
9. How frequently do you engage in recreational drug use:
10. Are you currently in a romantic relationship:
If yes, how long:
On a scale of 1-10, how would you rate your relationship?
11. What significant life changes or stressful events have you experienced recently:
FAMILY MENTAL HEALTH HISTORY
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family members relationship to you in the space provided.
  Please Circle Family Member - this can include you.
Alcohol/Substance Abuse  
Anxiety  
Depression  
Domestic Violence  
Eating Disorders  
Obesity  
Obsessive Compulsive Behavior  
Schizophrenia  
Suicide Attempts  
Bi-Polar  
Borderline  
ADDITIONAL INFORMATION
1. Are you currently employed?
If yes, what is your current employment situation:
Do you enjoy your work? Is there anything stressful about your current work?
2. Do you consider yourself to be spiritual or religious?
If yes, describe your faith or belief:
3. What do you consider to be some of your strengths:
4. What do you consider to be some of your weaknesses?
5. What would you like to accomplish out of your time in therapy?
COUNSELING AGREEMENT/INFORMED CONSENT

This agreement has been created for the purpose of outlining the terms and conditions of services to be provided by Jessica George, MA, Marriage and Family Therapist Intern for the following individual: (herein Client) And is intended to provide client with important information regarding practices, policies and procedures of Jessica George, MA, Marriage and Family Therapist Intern (herein Counselor), and to clarify the terms of the therapeutic relationship between Counselor and Client.

I UNDERSTAND AND AGREE TO THE FOLLOWING:

Benefits and Risks of Therapy: Since therapy often involves discussing unpleasant aspects of Clients life, the Client may experience uncomfortable feelings. However, psychotherapy has been shown to have many benefits. Therapy often leads to better relationships, solutions to problems, and significant reductions in feelings of distress. There is no guarantee that you as the Client will experience any or all of these benefits. Please feel free to address any concerns you have about your treatment with me.

Confidentiality: The information disclosed by Client is generally confidential and will not be released to any third party without written authorization from Client, except where required or permitted by law.

EXCEPTIONS TO CONFIDENTIALITY, include, but are not limited to: Reporting child, elder, and dependent adult abuse.
When a Client makes a serious threat of violence towards a reasonably identifiable victim.
When a Client is dangerous to him/herself or to the person or property of another.

PREMISES: Please be advised, this unit does have stairs and does not have an elevator. RELEASE: In consideration of services of property provided, I, do hereby release Andrew Abrams, MFT and Jessica George, MA, MFTI., its principal directors, , and each and every landowner, upon whose property and activity is conducted, from all liability and waive any claim for damage arising from any cause whatsoever. I have read and understood this foregoing acknowledgement of risk, assumptions of risk and responsibility, and release of liability.

Therapist Availability: I have a voice mail that allows Clients to leave a message anytime. I will make every effort to return calls by the next business day, but cannot guarantee the calls will be returned immediately. If you feel that you are unsafe, or require immediate psychiatric assistance, call 911 or go to the nearest emergency department.

Fee and Arrangement: As the Client, you are held responsible for fee pay of all appointments. Counselor reserves the right to periodically adjust fee. Clients will be notified of any fee adjustment in advance. Payment is due each session and Counselor accepts cash, and credit cards. No checks. Your fee is . Please put the amount that you can afford based on your initial phone conversation. This fee must be agreed upon by TRLA prior to your first session.

Cancellation Policy: If you are unable to keep an appointment, you must cancel no less than 24 hours in advance. You are responsible for full payment of the agreed upon session fee for any missed session(s). Cancellations may be left on my voicemail or text 24 hours a day. Cancelling with less than a 24 hour notice will be considered a forfeiture of your appointment. By initialing here, you authorize TRLA to charge your credit card for the missed appointment .

Written Letters: We will not write letters for you of any kind. It is with utmost concern to not break confidentiality.

Legal Cases: Please be advised that we will not enter any legal battle you currently have tied up in court. If you are currently in a court/legal case, please be advised that we have the right to decline service and will do our best to refer you out.

Termination of Therapy: You, as the Client, or I as the Counselor, can terminate treatment at any time. Treatment may be terminated due to, but not limited to the following: excessive no shows or cancellations, lack of payment, or if adequate progress is not being made. Upon either partys decision to terminate therapy, I will generally recommend that Client participate in at least one, or possibly more, termination sessions intended to facilitate a positive termination experience. I will make reasonable attempts to provide you with referrals to other providers should it become necessary to terminate your treatment.

Phone Counseling: You may call therapist at anytime to discuss immediate issues or therapy. Couples must call together (no exceptions). If it is determined that you need a counseling session and cannot wait until an in-person meeting, you will be charged your normal session fee. If you need to have a consult in between sessions, please call. Be advised that anything after 10 minutes will be charged a pro-rated fee based on your session fee.

Texting: Texting may be used to inform therapist that you have arrived or are running late. Therapy discussion via text must not be done. You may call and leave messages on voicemail anytime.

Right to Refer Out: We have the right to decline services to anyone. We follow all ethical standards suggesting referrals for you but cannot guarantee that you will find the most appropriate counselor.

Addiction(s): If therapist determines that severe substance abuse or addiction exists, You, as the Client, will be referred out to an Addiction Support Group. In order to continue individual counseling with Therapist, you will need to be actively enrolled in alternate support group specializing in specific addiction. The therapist has the right to terminate sessions if concurrent plan is not in effect.

Pamphlet: Therapy Never Includes Sex: A 26 page pamphlet is available for you at the office.

Counselor Status: My Counselors status is Marriage and Family Therapist Intern. Counselor has earned Masters Degree in Counseling Psychology, qualifying her for licensure and is registered with the Board of Behavioral Sciences. Counselor has completed all years/hours necessary for licensing. Counselor is supervised by a licensed professional Psychotherapist. All or parts of my counseling sessions may be discussed with supervisor.

ACKNOWLEDGEMENT
Your signature below indicates that you have read and fully understand this Agreement, agree to its terms, and consent to receive psychotherapy with Counselor. Client agrees to hold Counselor/Supervisor free and harmless from any claims, demands, or suits for damages from any injury, complications whatsoever, save negligence, that may result from such treatment. Please type in your name. A final signature will be given at time of session.

 
Signature(s) Date




California Notice Form HIPAA

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

NOTICE OF PRIVACY PRACTICES
Privacy is a very important concern for all those who come to this office. It is also complicated because of the many federal and state laws and my professional ethics. Because the rules are so complicated some parts of this notice are very detailed and you probably will have to read them several times to understand them. If you have any questions I will be happy to help you understand my procedures and your rights.

A. Introduction - To my clients
This Notice will tell you how I handle your medical information. It tells how I use this information here in this office,how I share it with other professionals and organizations, and how you can see it. I want you to know all of this sothat you can make the best decisions for yourself and your family. Because the laws of this state and the laws offederal government are very complicated and I dont want to make you read a lot that may not apply to you, I have removed a few small parts. If you have any questions or want to know more about anything in this Notice, please ask me for more explanations or more details.

B. What I mean by your medical information
Each time you visit me or any doctors office, hospital, clinic, or any other of what are called healthcare providers, information is collected about you and your physical and mental health. It may be information about your past, present or future health or conditions, or the tests and treatment you got from me or from others, or about payment for healthcare. The information I collect from you is called, in the law, PHI, which stands for Protected Health Information. This information goes into your medical or healthcare record or file at my office.

In this office this PHI is likely to include these kinds of information:
o Your history. As a child, in school and at work, marriage and personal history.
o Reasons you came for treatment. Your problems, complaints, symptoms, or needs.
o Diagnoses. Diagnoses are the medical terms for your problems or symptoms.
o A treatment plan. A list of the treatments and any other services that I think will be best to help you.
o Routine progress notes. Each time you come in I write down some things about how you are doing, what I notice about you, and what you tell me.
o Records I get from others who treated you or evaluated you.
o Psychological test scores, school records, and other reports.
o Information about medications you took or are taking.
o Legal matters
o Billing and insurance information

This list is just to give you an idea. There may be other kinds of information that go into your healthcare record here.
I use this information for many purposes. For example, I may use it:
o To plan your care and treatment.
o To decide how well my treatment is working for you.
o When I talk with other healthcare professionals who are also treating you, such as your family doctor or the professional who referred you to me.
o To show that you actually received the services from me which I billed to you or to your health insurance company.
o To improve the way I do my job by measuring the results of my work.
When you understand what is in your record and what it is used for you can make better decisions about who, when, and why others should have this information.

Although your health record is the physical property of the healthcare practitioner or facility that collected it, the information belongs to you. You can read it and if you want a copy I can make one for you (but may charge you for the costs of copying and mailing, if you want it mailed to you). In some very rare situations you cannot see all of what is in your records. If you find anything in your records that you think is incorrect or believe that something important is missing you can ask me to amend (add information to) your record although in some rare situations I dont have to agree to do that. If you want, I can explain more about this.

C. Privacy and the laws
I am also required to tell you about privacy because of the privacy regulations of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The HIPAA law requires me to keep your Personal Healthcare Information (or PHI) private and to give you this notice of my legal duties and my privacy practices, which is called the Notice of Privacy Practices (or NPP). I will obey the rules of this notice as long as it is in effect.

D. How your protected health information can be used and shared
When your information is read by me or others in this office, and used by me to make decisions about your care, this is called, in the law, use. If the information is shared with or sent to others outside this office, that is called, in the law, disclosure. Except in some special circumstances, when I use your PHI here or disclose it to others I share only the minimum necessary PHI needed for those other people to do their jobs. The law gives you rights to know about your PHI, how it is used and to have a say in how it is disclosed (shared), and so I will tell you more about what I do with your information. I use and disclose PHI for several reasons. Mainly, I will use and disclose it for routine purposes and I will explain more about these below. For other uses I must tell you about them and have a written Authorization from unless the law lets or requires me to make the disclosure without your authorization. However, the law also says that there are some uses and disclosures that dont need your consent or authorization.
1. Uses and disclosures of PHI in healthcare with your consent
After you have read this Notice you will be asked to sign a separate Acknowledgement form to allow me to use and share your PHI. In almost all cases I intend to use your PHI here or share your PHI with other people or organizations to provide treatment to you, arrange for payment for my services, or some other business functions called health care operations. Together these routine purposes are called TPO, and the Acknowledgement form allows me to use and disclose your PHI for TPO. Take a minute to re-read that last sentence until it is clear because it is very important. Next I will tell you more about TPO.
1a. For treatment, payment, or health care operations.
I need information about you and your condition to provide care to you. You have to agree to let me collect the information and to use it and share it to care for you properly. Therefore you must sign the Acknowledgement form before I begin to treat you, because if you do not agree and consent I cannot treat you.
When you come to see us, I may collect information about you and all of it may go into your healthcare records here. Generally, I may use or disclose your PHI for three purposes: treatment, obtaining payment, and what are called healthcare operations. Lets see what these mean.
For treatment. I use your medical information to provide you with psychological treatments or services. These might include individual, family, or group therapy, psychological, educational, or vocational testing, treatment planning, or measuring the benefits of my services. I may share or disclose your PHI to others who provide treatment to you, such as with your personal physician. If you are being treated by a team I can share some of your PHI with them so that the services you receive will be working together. The other professionals treating you will also enter their findings, the actions they took, and their plans into your medical record, so we all can decide what treatments work best for you and make up a Treatment Plan. I may refer you to other professionals or consultants for services I cannot provide. When I do this I need to tell them some things about you and your conditions. I will get back their findings and opinions and those will go into your records here. If you receive treatment in the future from other professionals I can also share your PHI with them. These are some examples so that you can see how I use and disclose your PHI for treatment.
For payment. I may use your information to bill you, your insurance, or others so I can be paid for the treatments I provide to you. I may contact your insurance company to check on exactly what your insurance covers. I may have to tell them about your diagnoses, what treatments you have received, and the changes I expect in your condition. I will need to tell them about when we met, your progress, and other similar things. This is especially true when using managed care insurance.
For health care operations. There are a few other ways I may use or disclose your PHI for what are called health care operations. For example, I may use your PHI to see where I can make improvements in the care and services I provide. I may be required to supply some information to some government health agencies so they can study disorders and treatment and make plans for services that are needed. If I do, your name and personal information will be removed from what I send.
1b. Other uses in healthcare
Appointment Reminders. I may use and disclose medical information to reschedule or remind you of appointments for treatment or other care. If you want me to call or write to you only at your home or your work or prefer some other way to reach you, I usually can arrange that. Just tell us. There is a place to note this on my Agreement for Psychotherapy Services form.
Treatment Alternatives. I may use and disclose your PHI to tell you about or recommend possible treatments or alternatives that may be of help to you.
Other Benefits and Services. I may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.
Business Associates. There are some jobs I hire other businesses to do for me. In the law, they are called my Business Associates. Examples might include a copy service I use to make copies of your health records and a billing service that figures out, prints, and mails my bills. These business associates need to receive some of your PHI to do their jobs properly. To protect your privacy they have agreed in their contract with me to safeguard your information.
2. Uses and disclosures that require your Authorization
If I want to use your information for any purpose besides the TPO or those I described above I need your permission on an Authorization form. I dont expect to need this very often.
If you do authorize me to use or disclose your PHI, you can revoke (cancel) that permission, in writing, at any time. After that time I will not use or disclose your information for the purposes that I agreed to. Of course, I cannot take back any information I had already disclosed with your permission or that I had used in my office.
3. Uses and disclosures of PHI from mental health records that dont require a Consent or Authorization
The law lets me use and disclose some of your PHI without your consent or authorization in some cases. Here are examples of when I might have to share your information.
When required by law
There are some federal, state, or local laws, which require me to disclose PHI.
o I have to report suspected child abuse.
o If you are involved in a lawsuit or legal proceeding and I receive a subpoena, discovery request, or other lawful process I may have to release some of your PHI. I will only do so after trying to tell you about the request, consulting your lawyer, or trying to get a court order to protect the information they requested.
o I have to disclose some information to the government agencies, which check on me to see that I am obeying the privacy laws.
For law enforcement purposes
I may release medical information if asked to do so by a law enforcement official to investigate a crime or criminal.
For specific government functions
I may disclose PHI of military personnel and veterans to government benefit programs relating to eligibility and enrollment. I may disclose your PHI to Workers Compensation and Disability programs, to correctional facilities if you are an inmate, and for national security reasons.
To prevent a serious threat to your health or safety, or that of another. If I come to believe that there is a serious threat to your health or safety or that of another person or the public I can disclose some of your PHI. I will only do this to persons or organizations who can prevent or reduce the threat
4. Uses and disclosures where you to have an opportunity to object
I can share some information about you with your family or close others. I will only share information with those involved in your care and anyone else you choose such as close friends or clergy. I will ask you about who you want me to tell what information about your condition or treatment. You can tell me what you want and I will honor your wishes as long as it is not against the law.
If it is an emergency - so I cannot ask if you disagree - I can share information if I believe that it is what you would have wanted and if I believe it will help you if I do share it. If I do share information in an emergency, I will tell you as soon as I can. If you dont approve I will stop, as long as it is not against the law.
5. An accounting of disclosures
When I disclose your PHI I may keep some records of whom I sent it to, when I sent it, and what I sent. You can get an accounting (a list) of many of these disclosures.

E. Your rights regarding your health information
1. You can ask me to communicate with you about your health and related issues in a particular way or at a certain place that is more private for you. For example, you can ask me to call you at home, and not at work to schedule or cancel an appointment. I will try my best to do as you ask.
2. You have the right to ask me to limit what I tell people involved in your care or the payment for your care, such as family members and friends. While I dont have to agree to your request, if I do agree, I will keep my agreement except if it is against the law, or in an emergency, or when the information is necessary to treat you.
3. You have the right to look at the health information I have about you such as your medical and billing records, but you must make your request in writing. I will respond within 30 days of receiving your written request. In certain situations, I may deny your request. If so, I will tell you, in writing, of the reasons for the denial and your right to have the denial reviewed. You can even get a copy of these records but I may charge you, no more than $ .25 per page. Instead of providing the health information you requested, I may provide you with a summary or explanation of the information as long as you agree to that and to the cost in advance.
4. If you believe the information in your records is incorrect or missing important information, you can ask me to make some kinds of changes (called amending) to your health information. You have to make this request in writing and send it to me. You must tell me the reasons you want to make the changes. I will respond within 60 days of receiving your request. I may deny your request if the health information is a) correct and complete, b) not create by us, c) not allowed to disclosed, or d) not part of my records. My written denial will state the reasons for the denial and explain your right to file a written statement of disagreement with the denial. If you dont file one, you have the right to request that your request and my denial be attached to all future disclosures of you health information.
5. You have the right to a copy of this notice. If I change this NPP I will post the new version in my waiting area and you can always get a copy of the NPP from me, or from my website.
6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with me and with the Secretary of the Department of Health and Human Services at 200 Independence Avenue SW, Washington, DC 20201. All complaints must be in writing. Filing a complaint will not change the health care I provide to you in any way. Also, you may have other rights, which are granted to you by state laws, and these may be the same or different from the rights described above. I will be happy to discuss these situations with you now or as they arise.

F. If you have questions or problems
If you need more information or have questions about the privacy practices described above please speak to me. If you have a problem with how your
PHI has been handled or if you believe your privacy rights have been violated, contact me. You have the right to file a complaint with me and with the Secretary of the federal Department of Health and Human Services. I promise that I will not in any way limit your care here or take any actions against you if you complain.
If you have any questions regarding this Notice or my health information privacy policies, please contact me.
Privacy Officer
Pursuant to 45 CFR 164.530(a)(1)(i), Jessica George is hereby designated as the Privacy Officer for this practice and such individual shall be responsible for developing and implementing this entitys health care privacy policies and procedures, including, but not limited to, receiving and handling patient requests for restrictions on uses and disclosures of protected health information (PHI); patient requests to inspect & receive a copy of their PHI; patient requests to receive accountings of disclosures; and, patient requests to amend their PHI.
Contact Person
Pursuant to 45 CFR 164.530(a)(1)(ii), Jessica George is hereby designated as the Contact Person for this practice and such individual shall be responsible for receiving complaints from patients concerning possible violations of their privacy rights.

 
I have received and read the California Notice Form

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