ADULT/ADOLESCENT/CHILD
INTAKE COUNSELING
FORM
Office Policies: .
Each client will have the opportunity to meet with the counselor for an initial session in order to get an idea of the personality, expertise, and style of the counselor. It is imperative for you to feel at ease with your counselor. For this reason, you are encouraged to ask me about my education, techniques, supervision, professional experience, and therapeutic orientation. Sometimes it takes clients a few counseling experiences to find the ideal therapist, please do not settle for anything less. It is my passion to help you; if I cannot, please let me know that and let’s work together to help you find the right therapist. For other counseling referrals I encourage you to visit www.PsychologyToday.com. They have a therapy locator whereby you can filter therapists on whether or not they accept insurance, religion, therapeutic orientation, and location. I am in my office Wednesday-Friday and every other Saturday. I do offer phone/skype sessions if need be (on a case by case basis) the other days during the week that I am not in office.
It is of my professional belief that “therapy” and “counseling” are way too narrow and because of this narrow scope, often times were not helping our clients and consequently were causing more harm. My job as your therapist is to help you get your life back on track. I will do whatever I need to do to make sure that happens. (within reason) For example, if I have a client that comes into my office and there struggling with Depression and there not working and they have never had a job. In addition to treating their Depression, I will also help them find work, because it is my belief that Depression cannot be healed unless the client goes back to work. Honestly, no type of therapy will alleviate Depression, unless I work together with you to help you find a job that utilizing your skills’ and gifts. So, if you do not know how to find a job, with your permission I will help you with job seeking tasks, such as helping you with your resume, cover letter, and submitting applications.
With my half time schedule I do send emails and return phone calls at odd times. (weekends and later evenings) If this is a bother to you, please tell me and I will stop. I want to hear your feedback regarding your counseling experience, please let me know what you like or dislike about your counseling experience. You can give me this feedback after each session or at a frequency that you deem necessary. Please bring it up at the next session or email me at and I will bring up your feedback at your next session.
Scheduling/Sessions .
For scheduling purposes, I will schedule your follow up session at your previous session. If you would like to meet the same time & day each week, let me know that and I will set up a recurring appointment. You may call (720) 204-8747 concerning any questions you may have and you will be contacted as soon as I am able. In urgent matters, you may call my work cell phone at 720-771-3144. Please note, The Aurora Center for Healing and Change is not a 24-hour counseling center. In an emergency, please go to your nearest mental health center or call 911. I typically meet with my clients for 50 min sessions 1x each week, some clients I see clients less or more. (once each quarter, once a year, or 2x a week), ultimately you decide how often you would like to come in. I offer 70 & 90 minute counseling intensives for individuals, couples and families that can only come in 1x a month or quarterly. Because this time slot is reserved solely for you, you will be subject to a $45 for appointments that are not canceled at least 48 hours in advance. No Calls/No Shows will be subject to a fee of $110. In the event of an emergency, special consideration may be given regarding the cancellation policy.
Fees/Counseling Costs
The standard rate for counseling sessions is $110 per 50-minute session, $150 per 70 minute session, and $180 per 90 minute session. The sliding scale rate is reserved solely for clients who have demonstrated financial need and/or have no assistance to help pay for therapy and therefore cannot afford the standard rate. To qualify for the sliding scale please provide the 1040 tax return form from the previous year at your first session per person receiving therapy. If you are a dependent who is 18+ and are living at home with your parents, the cost of therapy would be an agreed upon adjusted rate.The initial intake session is $110 for all clients because the intake session is typically longer.
If you do not qualify for the sliding scale, however you are not able to afford the standard rate and/or you have no assistance to help pay for therapy, you can also buy a pre-payment package which consists of 10 sessions at $80 per session and there is no expiration date for these sessions. When you do find the right counselor, I recommend that everybody can benefit from receive counseling for 1-2 sessions each year for optimal emotional, relational, and professional growth. (Kind of like the dentistJ) If you would like me to schedule you for sessions 2x each year let me know that and I will do so.
Counseling Fees and Sliding Scale Counseling Fees Combined Gross Family Income Fee Per 50, 70 min, 90 min session
$100,000 and above$110, $150, $180
$90,001-99,999 $100, $140, $170
$80,001-90,000 $90, $130, $160
$70,001-80,000 $80, $120, $150
$60,001-70,000$70, $110, $140
$50,001-60,000 $60, $100, $130
$30,001-50,000 $50, $90, $120
$20, 001-30,000 $40, $80, $110
$20,000 & Under Free-$40*
*I will take on 1 pro-bono client each month and provide them with 6 free counseling sessions. After the 6 sessions, the client will go up to the $40 per session fee. If you qualify for this, please let me know. I am offering this sliding scale so I can provide services for all people regardless of their income level. If you are dishonest about your personal finances, than I may not be able to provide services for someone else who may really need it.
Payment is due at the time of each session. Cash, checks, and credit card payments are all acceptable forms of payment. I’m trying to streamline my business practices, for this reason, when you come into the waiting room, if you are paying with cash or check, please slide your payment under the door before your counseling session begins.
If you have a health insurance plan, your visits may be partially paid for by your insurance company. Billing statements will be available in office only on a request basis, I am no longer sending billing statements electronically. Statements will contain all pertinent information required by the insurance company for reimbursement.
I have read and understood the above information. I agree to the session fees and understand that I am responsible for full payment at the time of service.
Client Signature (parent or guardian for minor) Date
Personal Information .
Date: ____/____/____ Who can we thank for the Referral?:______
First Name ______Last Name ______
Soc. Sec. # ______Date of Birth______
Address ______Apt # ______
City ______State ______Zip ______Primary Phone ______Work Phone ______Ext. Cell Phone ______Email Address______
Employer ______Physician: ______
Is there a day and time each week that you would like to meet consistently? If so please list here:______
Primary reasons for seeking our services: Please circle all areas that you identify with, most people will probably identify with a handful. J I am wanting help in therapy with:
Depression, Self Esteem, Relationships, Abuse/Trauma, Anxiety, Insecurity, Social Anxiety, Narcissism, Pride, Anger Problems, Family of Origin Wounds, Parenting Issues, Job Placement, Career Issues, Procrastination, Laziness, Perfectionism, Ego Wounds, Family Therapy, Weight Issues, Organization, Violence, Addictions, People Pleasing, Lying, (people-pleasing is a form of lying.)
What are your top 5 Strengths? What are your top 3 Weaknesses?
Have you had any previous counseling experience? oYes oNo
ADULT INTAKE QUESTIONS: (If you are seeking out relationship therapy, please each fill out the adult intake section of the intake form.)
(If you are a parent of an adolescent/child who is receiving therapy please skip this section and go to the Adolescent or child intake section.)
Are you currently (or recently) taking any prescription or over the counter medications? oYes oNo
If yes, please give details:
Has you or a family member been diagnosed with a mental illness? oYes oNo
If yes, please give details:
Do you drink alcohol? oYes oNo
If yes, please give details (how much, how often, etc.):
Do you use any other recreational drugs? oYes oNo
If yes, please give details (what drugs, how often, last use etc.):
Have you ever suffered from any type of eating disorder? oYes oNo
If yes, please give details:
Have you ever been charged with a crime, arrested or convicted? oYes oNo
If yes, please give details:
Do you have any work-related problems or difficulties in school? oYes oNo
If yes, please give details
Do you have a history of trauma (i.e. abuse, neglect, victim of natural or other disaster)? oYes oNo
If yes, please give details:
Goals for therapy:
Please circle appropriate responses:
Symptoms Checklist .
Please circle appropriate responses
Star appropriate responses ( *) that you would like to address in counseling
Sleep: No problems Not enough Trouble getting to sleep Nightmares
Too much sleep Trouble getting up Tired upon waking up
Appetite: No problems Decreased Increased
Exercise: None Infrequently Often Frequency: ______x per month / week
Energy: Normal Increased Low Up and down
Interest in sex: Normal Increased Low
Concentration: Normal Difficult Poor Terrible
Memory: Good Some difficulty remembering Poor
Depressed or sad: All the time Most days Some days Not at all
Suicidal thoughts: All the time Most days Some days Not at all
Past suicidal attempts: No Yes
If yes, please give details:
Homicidal Thoughts: All the time Most Days Some Days Not at all
Anxiety: Panic attacks All the time Most days Some days Not at all
Anger / Irritation: All the time Most days Some days Not at all
Are you religious or spiritual? No Yes
If yes, please give details:
Are you having spiritual problems? No Yes
Are you angry at God? Do you think God is a disappointment? Tell me more.
ADOLESCENT INTAKE QUESTIONS:
(To be filled out by the adolescent receiving therapy)
Please Rate the Following Issues with a Number: Be honest, there is no judgment at all. J
1 = Yes, this is a problem 2 = Maybe, sometimes a problem 3 = No, not a problem
______Feeling accepted by my peers
______Making and keeping friends/Social life
______Getting along with my parents or other family members
______Worrying about issues in my life
______Making decisions
______Dealing with alcohol or drug use/abuse
______Dealing with problems at school
______Dealing with how I feel about myself
______Self-Harm/Cutting
______Not Eating/Eating too much/Bingeing and Purging
______My Parents do not discipline me enough, I think I need more structure at home.
______I can manipulate my parents a lot, they think I can do no wrong. (Or little wrong)
______My parents do not notice me, I feel invincible a lot when I’m at home.
______My parents yell at me a lot & I feel like I’m walking on egg shells in my home.
Who are you currently living with?______
Who are the 3 people in your life you trust the most?______
Are you currently on any medications? If so, what?______
What is your goal for therapy? ______
Are you wanting your parents to participate in family therapy or parenting therapy? Do you feel like family therapy or parenting therapy would be helpful in your situation? ______
Parent of Adolescent/Teenager: Would you be willing to meet individually upon request of your child to provide parenting therapy/coaching? ______
CHILD INTAKE COUNSELING QUESTIONS:
(Please fill out these questions with your child)
What is the primary reason for seeking our services? ______
Is your child currently on medications? If so, what? ______
Are you willing to participate in parenting counseling/coaching where I can help you in your parenting practices?______
What is your goal for therapy? ______
It is of my belief that child therapy is NOT effective unless the parent is willing to fully participate and receive help in their parenting practices as well. The best parents are the parents that are humble and are willing to get help and change their parenting ways when their failing/struggling. One of my favorite quotes is “FAIL YOUR WAY TO SUCCESS”. When we are honest about our parenting failures, only then can we improve as a parent. J
Please indicate which of the following are current problems for your child:
□ Crying Spells □ Hyperactivity
□ Excessive Fear/Anxiety □ Refusal to Respond to Parent (authority issues)
□ Bullying/Picking Fights □ Acts Spoiled A lot/Sometimes
□ Scared of parents* □ Separation Anxiety
□ Teacher Complaints □ Tantrums
□ Decreased/Increased Appetite □ Lack of Self-Confidence
□ Difficulty Making or Keeping Friends □ Loss of Interest in Usual Activities
□ Obsessions/Compulsions □ Insomnia/Hypersomnia/Nightmares
□ Picky Eater
*Does your child feel like he/she is walking on egg shells around you? If you do not know the answer to this question, ask your child. When they share with you, just listen. ______
Does your child do chores? If yes, how often? 1x a day, 1x a week, etc. Is your child expected to pick up after him or herself?______
What are your child’s responsibilities each day? E.g, brush teeth, do homework, chore, pick up messes? If your child does not have any responsibilities, no big deal, just say that.______.
Do you yell at your children and then feel bad afterwards?______
What do you think of yourself as a parent? What are your strengths and weaknesses as parent?______
DISCLOSURE STATEMENT