NAME:     ______________________ (Last)           ___________________  (First)               ______   (Middle)    

Today's Date __________

BIRTH DATE: __ __   / __ __    __  

MARITAL STATUS:

q  Single

q  Married

q  Widow

q  Divorced

SOCIAL SECURITY #    _  _  _     _  _     _  _  _  _

HOME ADDRESS:

Street:        ______________________________

City:             ______________________________

State:             ________________ Zip: __________

Country:        __________________

E-mail  address:   __________________________

Contact Numbers:

Home:(         ) ____________

Work: (         ) ____________

Pager: (        ) ____________

Cell:    (        ) ____________

Fax:     (        ) ____________

OCCUPATION: _____________________________

EMPLOYER:    ______________________________

Whom can we thank for referring you?

PERSON TO CONTACT IN AN EMERGENCY:

NAME: _________________ (last) __________________ (first

ADDRESS:  ____________________________________________________

                     City: ________ State: _____ Zip: ____

PHONE:  (         ) ______________      RELATIONSHIP TO YOU: ____________

What is the primary purpose of your visit here today?

Are you taking any medications?

q  No

q  Yes (list )___________________

Have you had any serious medical/psychiatric illnesses?

q  No

q  Yes (list)________________________________

Is chemical dependency a concern for you?

q  No

q  Yes

 What substances ?

Are you under the care of a physician or therapist at this time? 

q  No

q  Yes   Whom? _________________________  Tel: ________________________________

Right to Confidentiality:

q  You have a right to complete confidentiality and privacy. The only exceptions to this are legal reporting requirements governing the intention to harm self or others, and in cases involving abuse, neglect of minor children and disabled adults. 

q  No information will be ever released to any third party without your written and informed consent.  

q  While I am required by law to keep therapeutic records, I record our sessions using checklist forms to document sessions. This helps protect your privacy.

q  *****For some sessions, I use a digital recorder in sessions for the purpose of my reviewing the session for the purpose of continuing education in maintaining my certification in rapid trauma resolution.    _________ (initial here to agree to being recorded)

Philosophy & Style of Psychotherapy: 

I am skilled in helping individuals, couples, families, and organizations change. Although trained in both traditional and non-traditional approaches to psychotherapy, I favor the newer, brief therapy methods.  Brief therapies reflect a significantly different approach to treatment from more traditional styles and can focus on rapid resolution approaches.  

Financial Policies:

q  Fees are due at time of service. (Checks may be made out to More Choices Now, Inc).

q  I require 4 hours advance notice for cancellation except in case of emergency.  Otherwise you will be held responsible for missed appointments.

q  I am not on any HMO plans and do not take insurance. You are responsible for direct payment.  I can provide a form for you to submit to your insurance company for possible reimbursement..

I understand the above policies and agree to honor them.

Client Signature: ______________________________________  Date:___________