Intake Form

FacebooktwitterredditpinterestFacebooktwitterredditpinterest

NAME___________________________
BIRTHDATE___________ AGE_______

ADDRESS___________________________________________________________

CITY_____________________________ZIP_______________________________

HOME 
PHONE___________________BUSINESS PHONE___________________

CELL PHONE____________________E-MAIL_____________________________

EMPLOYER_____________________POSITION___________________________

DRIVER LIC.#________________________

NAME 
OF SPOUSE___________YEARS MARRIED____  # OF CHILDREN_________

PREVIOUS 
COUNSELING______________________________________________

HEALTH 
INSURANCE_________________________________________________

FAMILY 
PHYSICIAN_______________________PHONE_____________________

REFERRED
 BY________________________________________________________

I accept responsibility for paying all charges (agreed to
at first session) in full following each session regardless of Insurance
coverage.

 

Signature______________________________________Date___________

 

 

CLIENT INFORMATION

Jolliffe & Associates

 1- 949-631-4990

Because I am interested in providing you the most qualified service, allow me to address several important counseling guidelines.  Please feel free to discuss any of the following in your first session.

CONFIDENTIALITY: 
Legal and ethical responsibilities require that our private sessions
remain confidential.  Therefore, no 
information will be released to another person, professional or agency without
 your written consent.  The only exception is in the case where you actually or
 potentially endanger yourself or others, and/or in the case of child abuse or 
elder abuse.  In these cases the law
 requires your counselor/therapist share certain information with specific 
outside parties.

APPOINTMENTS: 
Upon mutual agreement, time will be reserved for your therapy session.
If you need to cancel or rearrange an appointment time, you are required
 to provide our office with 24 hours advance notice. 
Failure to provide 24 hours advance notice will result in your being
 charged for the full session.

LENGTH
 OF SESSIONS:
Sessions are 60 Minutes in length.

FEES:
 Individual/Marital/Family Sessions of 60 Minutes.
 Payment is required at the end of each appointment. Cash, check or credit cards are accepted for payment.
Psychological testing, if necessary, are additional charges.

INSURANCE: 
Insurance will often cover at least part of the cost of psychotherapy and
psychological testing.  If you wish 
to file an insurance claim with your health insurance carrier, our office will
 provide you with a “super bill” that includes all the necessary information 
to assist you in filing your claim. Remember
 that in most cases, insurance companies will insist that you have a diagnosable 
condition in order to receive reimbursement.

VOICE
MAIL:  I
 am available by telephone on request through our office voice mail service.
Should an urgent situation arise that cannot wait until your next 
scheduled appointment, please leave a message and indicate the urgency.
 All emergency calls will be returned as quickly as possible.
 All other calls will be returned the next business day.

TELEPHONE
 CONSULTS:  As 
a result of my twelve plus years of live radio therapy, I have enlarged my 
practice to include telephone counseling/therapy.  Clients who travel on business, or for reasons of illness, or 
foul weather have the convenient option of scheduling telephone consults. 
These appointments are 60 minutes, same fee applies.

I
 HAVE READ AND UNDERSTAND THE ABOVE INFORMATION.

Signature______________________________________Date___________

 

Print Friendly