NAME___________________________  BIRTHDATE___________ AGE_______

ADDRESS___________________________________________________________      

CITY_____________________________ZIP_______________________________

HOME PHONE___________________BUSINESS PHONE___________________

CELL PHONE____________________E-MAIL_____________________________

EMPLOYER_____________________POSITION___________________________

DRIVER LIC.#_________________ _______

NAME OF SPOUSE___________YEARS MARRIED____  #OF CHILD_________

NAME OF SPOUSE___________YEARS MARRIED____#OF CHILD__________

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_____________________  

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 50 Minutes in length.

FEES:   Individual/Marital/Family Sessions of 50 Minutes are $170.00.  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 50 minutes, same fee applies.

I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION.

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