New Horizons Counseling Intake Information

Date: ______

Please list client’s full name and names of family members living in the household –

NameDate of Birth

______

______

______

______

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Street Address:______

City: ______State:______Zip Code: ______

Telephone numbers: Home:______Cell: ______

Is it okay for our office to identify who we are, where we are calling from, and leave a message when we call these numbers?(please circle) Home: yes no Cell: yes no

Emergency Contact: Name:______Relationship:______Phone Number: ______

Yes, I do give permission for the above listed emergency contact to be contacted by New Horizons Counseling in case of an emergency. Signature: ______

Days and times you can best schedule appointments:______

Have you been to a therapist before: (please circle) YES NO

If yes, previous diagnosis: ______

How did you find out about New Horizons Counseling? (please circle all that apply)

Internet search Psychology Today Yellow Pages Word of Mouth Referral

Referred by:______

Medical Information

Reason for seeking therapy:

______

______

______

Who will be attending therapy?

______

List of medications for each person attending therapy:(if you need more space or do not have your entire list with you, please provide a separate completed medication list)

______

Primary Physician for each person attending therapy:

______

Psychiatrist for each person attending therapy:

______

Other MD for each person attending therapy:

______

Major medical problems or surgeries for each person attending therapy:

______

______

______

Client: ______Date: ______

Client: ______Date: ______

Therapist: ______Date: ______

Confidentiality

Duty to Warn

Although shared personal information is confidential, there are exceptions to these confidences set by my professional code of ethics and by the law:

  1. I must report what is mandated by law, such as child or elder abuse.
  2. I must report if there is a clear and present danger to a person or persons such as threat of suicide or homicide.
  3. I may disclose specific information if I have a signed waiver from each participant in therapy.
  4. I must disclose if I believe your mental/emotional condition makes you unable to take care of yourself or people for whom you are responsible.
  5. I must disclose if it is determined that you are in need of hospitalization.
  6. I must disclose if I am ordered by a court judge to do so.
  7. I may disclose information in order to defend myself against charges arising from therapy. I am subject to subpoena.
  8. I must disclose if you are using insurance to pay for your therapy.

The signature signifies that I have read and understand the above policies and that I give my informed consent for therapy.

Client: ______Date: ______

Client: ______Date: ______

Therapist: ______Date: ______

Fee Agreement

Service Fee

Intake Session$80

50 Minute Session$60

Session missed without 24 hour noticeFull session fee - $60

Phone calls (excluding scheduling)$30 per 15 minutes

Writing a letter$30

Client: ______Date: ______

Therapist: ______Date: ______

Your decision to enter into therapy was undoubtedly a serious one arrived at after considerable thought. Whether you were referred by your physician, urged to come by family or friends or have come because of problems and feelings only you know about, the decision to come here was yours.

My area of training is the systemic treatment of individuals, couples, and families. The systemic approach to therapy takes into consideration all immediate family members in family therapy sessions. I, along with you, will decide which family members (if any) need to be included in therapy. Various goals will be established together with you at the onset of therapy.

Therapy naturally involves activities such as identifying emotions and revealing secrets. There may be risks associated with our disclosures to other family members or other family members’ disclosures during the course of therapy, as well as exploration of issues. Decisions to disclose will be made by you except where mandated by law. It is expected that some uneasiness or painful emotions may occur as you are involved in therapy. Discussing painful issues will naturally create discomfort. Your participation in therapy is essential toward helping address your concerns. The Board of Examiners for the Licensure of Professional Counselors, Marriage and Family Therapists and Psychoeducational Specialists requires that all clients be informed that all forms of dual relationships such as business ventures and sexual intimacy are prohibited.

Please be aware that there is a higher incidence of divorce if only one partner in a relationship is involved in therapy. It is also important that you understand there is no guarantee all of your concerns, issues, or problems will be successfully resolved. I cannot guarantee outcomes. The outcomes may vary from your expectations. You may discontinue participation in therapy at any time. If at any time you are not satisfied with the course of the therapy, please discuss this concern with me.

Emergency Contact Information

If you call our office after hours, you may leave general messages which will be retrieved at the opening of the next business day. If you have an emergency situation you will need to call 911 or go to your nearest emergency room. Following are some emergency numbers for your reference:

Emergency Services / 911
SpartanburgRegionalMedicalCenter Emergency Room / 560-6222
The Mental Health Crisis Line / 585-0366
The Safe Homes Network / 583-9803
The 24-hour Child Abuse Line / 585-1445

It is important that you appreciate the fact that a block of time has been set aside just for you. Therefore, a twenty-four hour notice is required if you wish to cancel or reschedule your appointment, or you will be charged a fee for the missed appointment. On the occasion of sickness or emergency, it will be discussed if it would be appropriate for you to pay for a missed appointment.

New Horizons Counseling Intake 1