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Marian “Micki” O’Brien, L.P.C.

2813 Glenview Ave.

Austin, Tx. 78703

Date______

Client Intake Form

Name______

Address______

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Home Ph# ______Cell # ______WK# ______

Age_____ Date of Birth______Female_____ Male_____

Single____ Married _____ Partnered ____ Number/Names of Children/ages/gender______

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Emergency Contact Person, phone # and Relationship to you______

Insurance Provider Name Your Policy # Group ID # ______/______/______

Insurance Provider’s Mental Health Claims Mailing address and phone # ______

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Pre-Authorization# (if required)______

Please describe your primary reason for seeking therapy at this time.

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Please check any of the following which apply to you at this time.

Mood Substance Use/Abuse

____Anxiety ____Alcohol

____Depression ____Other Drugs

____Loss/Grief ____Over-the Counter

____Suicidal thoughts ____Cigarettes

____Suicidal attempts ____Food

____Mood swings

Relationships Physical Symptoms

____Significant Other/Spouse ____Sleeping

____Parents ____Eating

____Siblings ____Headaches

____Children ____Chronic Condition

____Friends ____Other:______

____Relatives (describe)

____Co-Worker/Supervisor

Self/Interpersonal Issues

____Self-esteem ____Shyness ____Emotional abuse

____Perfectionism ____Trust ____Physical abuse

____Caretaker/hero ____Intimacy ____Sexual abuse

____Fears/worries ____Codependency ____Past abuse

____Anger ____Loneliness ____Career/job

____ACOA ____Addiction ____Identity

____Power/control ____Stress/coping ____Other; explain______

____Assertiveness ____Sexual Concerns ______

____Confidence ____Sexual Identity ______

Past Therapy History (use reverse side for additional space, if needed)

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Current Medications and Prescribing Physician

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Family of Origin: Who is in the family? Where did you grow up? What were/are the dynamics?_Write much or as little as you like.

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Significant Life Events (positive and negative):______

Administrative and Confidentiality Procedures

I adhere to all HIPAA laws concerning protection of your private health information. A summary of HIPAA regulations is on file in my office and you may ask to read it at any time. In addition, your signature on the Health Insurance Claim Form is a ‘Release of Information’ allowing me to send your insurance company the billing data and anything else they require for claims processing. A separate ‘Release of Information’ form will need to be signed by you, if you or your insurance company wishes for me to have contact with anyone else.

Your signature below indicates that you have read the above information as well as the handout given to you on ‘Office Policies and Procedures’ outlining: what to expect in therapy, confidentiality and its limits, appointments and cancellations, payment and insurance, no-show and late fees, my guidelines for individual, couples, group and telephone counseling, what to do upon arrive for a counseling session and my credentials, style and areas of expertise.

Printed Name______

Signature______Date______