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Tonja Roberts, LPC 008110
Licensed Counselor
Pawsitive Counseling Center
INTAKE QUESTIONAIRE
Name: ______Date of Intake: ______
LastFirstMI
Parent's Name (if applicable):______
Address: ______
City & State:______
Phone
(Work):______(Cell):______
(Home):______(other):______
Date of Birth:______Age:______SS#:______
Payor Source:______
Referral Source:______
NameOrganization
CURRENT PROBLEMS
What problems bring you here for this evaluation? ______
______
How and when did the problem begin? ______
______
Person completing this form:______
Tonja Roberts, LPC 008110
Licensed Professional Counselor
Pawsitive Counseling Center
326 Myrtle Crossing Drive, Suite 100
Statesboro, Georgia 30458
(912) 764-7001
INFORMED CONSENT TO TREATMENT
I am requesting services by Tonja Roberts, LPC and I apply for and consent to the prescribed counseling treatment. I understand that my record may be maintained in paper or electronic format, and may only be accessed by health care professionals and providers operating under the contractual authority of Tonja Roberts, LPC or as otherwise permitted or required under law. It has been explained to me that therapeutic treatment methods/services may include diagnostic assessment, individual, group, or family counseling, and crisis management services.
Counseling is a cooperative venture between therapist and client and if the client is a child, the legal guardian. All have responsibilities in the change process. Due to the cooperative nature of psychotherapy and counseling, no guarantee of a cure or positive resolution can be given. It is important to also note that when utilizing play therapy in treatment with children, touch is a natural part of the process. This not sexualized touch in any way, but may result in the therapist hugging or comforting a child. I am a Licensed Professional Counselor and I subscribe to the Code of Ethics and Standards of the practice of the American Counselor Association (ACA) and the Georgia Composite Board of Professional Counselors. As a Licensed Counselor, I am required to participate in ongoing continuing education. This is not only to maintain my license, but also to continue my growth as a counselor and for the benefit of my clients. In addition to continuing education, I am committed to seeking consultation and supervision in my practice as needed.
Confidentiality and privacy is maintained on all communication between the client and myself. I will not release clinical information about your treatment unless you give me written permission. However, there are circumstances where, by law, information must be revealed. Those instances are suspected or actual child abuse, the risk of imminent harm to self or others or the occurrence of such harm, disclosure of abuse or criminal activity, and a court order to disclose information outside of the scope of privileged communication. When counseling a minor, I ask that the legal guardian grant me permission to maintain confidentiality with the child. I will report to the guardian themes of the child’s play and such information that I believe to be in the best interest of the child and the overall healthy functioning of the family. Maintaining confidentiality with the child helps to build a trusting, therapeutic relationship between the client, child, and the therapist.
FEES
My fees are $110.00 for the initial visit and $90.00 for Individual and family follow up sessions. Sessions are 45 minutes. Payment is expected at the time that services are rendered unless arrangements have been discussed with the counselor. I acknowledge my financial obligation and ensure payment via the credit card information provided below.
SIGNATURE OF CLIENTDATE
Insurance coverage is the responsibility of the client. Please check with your provider regarding eligibility. Ultimately, payment is the responsibility of the client and the decision to use my counseling services constitutes an agreement to pay for services rendered. I agree to provide accurate and complete information to Tonja Roberts, LPC, to allow for thorough evaluation and appropriate planning of billing for my treatment/services, and agree to update this information as changes occur. I hereby assign and authorize payment to Tonja Roberts, LPC, all medical benefits, to which I am entitled under any insurance policy or policies, under any self-insurance program, or any other benefit plan. I authorize the release of any medical or other information necessary to process the claim unless otherwise indicated as a result of my approved request to restrict use or disclosure as outlined in the Notice of Privacy Practices.
CANCELLATION POLICY
If you are unable to attend a scheduled session, but do not cancel the session within 24 hours of your session, you will be charged $40 for the session.
I acknowledge my financial obligation and ensure payment via the credit card information provided below. I give Tonja Roberts permission to charge this credit card for any cancellations less than 24 hours prior to session or for any no shows:
Credit Card Number: ______
Expiration: ______Security Code: ______Zip code: ______
Office hours are Monday through Friday from 8:00 a.m. to 5:00 p.m. Please call my office, 912-764-7001 to schedule an appointment. If it is after normal business hours, please leave a confidential message with your name and phone number and I will return your call promptly. If it is an emergency please call 911 or go to the nearest hospital.
I cannot promise that I will be available at all times. Although I am usually in the office Monday through Friday, from 8:00 a.m. to 5:00 p.m., I usually do not take phone calls when I am with a client. You can always leave a voicemail message and I will return your call as soon as I can. Generally, I will return messages daily except on Saturdays, Sundays, and holidays.
If you have an emergency or crisis include the details in your message. If you have a behavioral or emotional crisis and cannot reach me, you or your family members should call one of the following community emergency agencies; Pineland Mental Health at (912) 764-5125, the crisis hotline at 1-800-766-6041, or go immediately to the local emergency room.
There may be instances when I need to contact a client. Please indicate below with a “yes” or “no” if I may contact you at these locations.
______Contact at home/cell______Contact at Work
______Leave a Message at Home/cell______Leave a Message at Work
I have been informed of my rights as a client and have been provided a copy of the Notice of Privacy Practices.
CLIENT’S NAME______
Consent:I have read the above professional policies and financial obligations and voluntarily request counseling services with Tonja Roberts, LPC, in accordance with the terms and conditions. For a child under the age of 18 the signature of a legal guardian is required.
SIGNATURE OF CLIENTDATE
SIGNATURE OF LEGAL GUARDIAN (IF MINOR)DATE
WITNESSDATE
Tonja Roberts, LPC
Licensed Professional Counselor
Pawsitive Counseling Center
326 Myrtle Crossing Drive, Suite 100
Statesboro, Georgia 30458
(912) 764-7001
SUMMARY OF CLIENT’S RIGHTS
When you receive services in mental health, your rights are protected by the Health Insurance Portability and Accountability Act (HIPPA). Listed below is a simplified outline of those rights. The Notice of Privacy Practices describe any limitation to these rights and other provisions that may apply and should be consulted when there is a dispute or questions arise regarding any of these rights.
Your rights include:
- The right to receive care suited to your needs.
- The right to receive services that respect your dignity, and protect your health and safety.
- The right to know the names and positions of those involved in services planning and implementation process
- The right to be informed of the benefits and risks of your treatment.
- The right to participate in planning your own program.
- The right to refuse service, unless a therapist feels that refusal would be unsafe for you or others.
- The right to receive a copy of the Notice of Privacy Practices.
- The right to inspect and copy your records.
- The right to request amendment to your records.
- The right to request restriction or limitation on the medical information we use or disclose about you.
- The right to request how and where you may be contacted.
- The right to request on accounting of all disclosures we make about you to other persons or agencies.
- The right to exercise all civil, political, personal, and property rights to which you are entitled s a citizen.
- The right to remain free from physical restraints or time-out procedures unless such measures are required for providing effective treatment, or protecting the safety of you or others.
- The right to be free from physical or verbal abuse.
- The right to file a complaint if you think any of these rights have been restricted or denied.
You must be provided with a Notice of Privacy Practices that provides detailed information regarding your rights under HIPPA.
The client has had an opportunity to read, or have read to him/her, the above form to ask questions regarding the data contained therein and has signed in this person’s presence.
______ ______
Client/Legal Representative Signature/Date Witness Signature/Date
Tonja Roberts, LPC008110
Licensed Counselor
Pawsitive Counseling Center
326 Myrtle Crossing Drive , Suite 100
Statesboro, GA 30458
(912) 764-7001
Notice of Privacy Practices Acknowledgement of Receipt
I have received and reviewed a copy of Tonja Roberts’ Notice of Privacy Practices.
Patient's Name:______
Relationship to Patient:□ Self
□ Spouse
□ Parent
□ Care Giver
Notice of Privacy Rights for E-communications Acknowledgement of Receipt
I have received and reviewed a copy of Tonja Roberts’
Notice of Privacy Rights for E-communications
E–MAILS, CELL PHONES, COMPUTERS, AND FAXES: It is very important to be aware that computers and unencrypted e-mail, texts, e-faxes, and fax communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all e-mails, texts and e-faxes that go through them. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. Unencrypted email or text provides as much privacy as a postcard. You should not communicate any information with your health care provider that you would not want to be included on a postcard that is sent through the Post Office. Tonja Robert’s laptop is equipped with a firewall, a virus protection and a password. Also, be aware that phone messages are documented as a part of your record. Please notify Tonja Roberts if you decide to avoid or limit, in any way, the use of e-mail, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted e-mail, texts or e-fax or via phone messages, Tonja Roberts will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and she will honor your desire to communicate on such matters. Please do not use texts, e-mail, voice mail, or faxes for emergencies.
______
Client/Legal Representative Signature Witness Signature
______
Date Date
ADULT INTAKE FORM
(Age 18 and over)
General Information
Patient Name ______Nickname (if any) ______
Street Address ______
City ______State ______Zip ______
Home Phone ______Cell Phone ______
Age ______Sex ______Date of Birth ______SS# ______
Employment or School______
Right Handed ______Left Handed ______Both ______
Do you wear glasses or contacts? ____ Do you wear hearing aid(s)?______
Marital Status: ______
Spouse or Next of Kin Information
Name ______Relationship______
Employment ______Employment Phone ______
INSURANCE
(Please furnish card to make a copy)
Primary Insurance: Insurance Name______
Insured’s Name (if different)______
Address ______
Phone Number (_____) ______Policy#______
Group#______Date of Birth ______SS#______
Deductible Amount ______Co-Payment ______
Secondary Insurance: Insurance Name______
Insured’s Name (if different)______
Address ______
Phone Number (_____) ______Policy#______
Group#______Date of Birth ______SS#______
Deductible Amount ______Co-Payment ______
* I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or the past to whom accepts assignments.
______
Signature of Patient
* I authorize payment of medical benefits to the undersigned physician or supplier for services received.
______
Signature of Patient
EDUCATION HISTORY
1. Last year completed in School? ______Present ______
2. Highest degree obtained? ______
3. Did you ever skip any grades? If yes, which? ______
4. Did you repeat or fail any grade(s)? If yes, which? ______
5. Did you have difficulty learning to speak, read, write, or spell? If yes, which?
______
6. Were you ever placed in any special education classes? If yes, which?
______
7. Were you ever told that you were hyperactive? If yes, by whom?
______
8. Were you ever told that you had Attention Deficit Disorder? If yes, by whom?
______
9. Were you ever told that you were Dyslexic? If yes, by whom?
______
10. Were you ever told that you had a learning disorder? If yes, by whom?
______
11. Were you ever suspended or expelled from high school for academic reasons?
If yes, when?______
12. Were you ever suspended or expelled from high school for disciplinary reasons? If yes, when? ______
13. Have you ever had your IQ tested? YES____ NO____ If yes, when and by whom?______
MEDICAL HISTORY
Medical Physician
Primary Care Physician’s Name ______
Address ______
City ______State ______Zip ______
Phone # ______Fax # ______
MEDICAL HISTORY
Allergies:______
Injuries:______Surgeries:______
Hospitalizations:______
MEDICATIONS THAT YOU ARE CURRENTLY TAKING
Medication StrengthTimes Per Day ForPhysician
1. ______
2. ______
3. ______
4. ______
5. ______
Medications (perception of efficacy) ______
List Other Medications that you take Occasionally
1. ______
2. ______
3. ______
Are you Allergic to any specific Medications? Be Specific!
1. ______
2. ______
3. ______
PSYCHIATRIC HISTORY
PREVIOUS TREATMENT HISTORY (Outpatient, inpatient, family hx)
Have you ever been treated for psychiatric reasons? YES _____ NO _____
If Yes, please complete the following:
Clinician’s Name ______
Clinician’s Credentials ______
Clinician’s Address ______
City ______State ______Zip ______
Referred By ______
Have you ever received psychological testing before: YES ____ NO ____ If yes, by whom and when? ______
Have you ever been hospitalized for psychiatric reasons? YES ____ NO ____ If yes, by whom and when? ______
Have you ever attempted suicide? YES ____ NO ____ If yes, how many times and when? ______
Is there a family history of any of the following psychiatric problems?
ProblemRelative
____Depression______
____Mania______
____Suicide or suicide attempts______
____Anxiety or panic attacks______
____Obsessive compulsive disorders______
____Eating disorders______
____Paranoia______
____Schizophrenia______
____Others (Be specific)______
FAMILY AND PSYCHOSOCIAL FACTORS
Early Birth and Developmental History: _Normal, _Abnormal, _ Happy, _Difficult, _Problematic
Family Constellation and Dynamics: _Close, _ Supportive, _ Estranged, _Difficult, _Complicated
Educational/Employment History:
Legal History:
Psychosexual/Social Development:
_Average, _Abnormal, _Problems with peers or family socialization/connections
Substance Use/Abuse:(individual or family members)
History of physical, sexual, and/or emotional abuse/trauma:
History of suicidal thoughts or attempts: _Yes, Thoughts, Plans, Intent, Means
Sleep:
_ Good _Fair _Poor _Problems going to sleep _Staying asleep _Nightmares ____Hours per night
Diet: _1 _2 _3 _ or more meals a day _ Good _Fair _Poor appetite
Exercise/Physical activity: _1-3x weekly _4-7x weekly _None
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ADULT CHECKLIST OF CONCERNS
Please mark all of the items below that apply, and feel free to add any others at the bottom under “Any other concerns or issues.” You may add a note or details in the space next to the concerns checked. (For a child, mark any of these and
then complete the “Child Checklist of Characteristics.”)
□ Abuse—physical, sexual, emotional, neglect (of children or elderly persons),
cruelty to animals
□ Aggression, violence
□ Alcohol use
□ Anger, hostility, arguing, irritability
□ Anxiety, nervousness
□ Attention, concentration, distractibility
□ Career concerns, goals, and choices
□ Childhood issues (your own childhood)
□ Codependence
□ Confusion
□ Compulsions
□ Custody of children
□ Decision making, indecision, mixed feelings, putting off decisions
□ Delusions (false ideas)
□ Dependence
□ Depression, low mood, sadness, crying
□ Divorce, separation
□ Drug use—prescription medications, over-the-counter medications, street
drugs
□ Eating problems—overeating, undereating, appetite, vomiting
(see also “Weight and diet issues”)
□ Emptiness
□ Failure
□ Fatigue, tiredness, low energy
□ Fears, phobias
□ Financial or money troubles, debt, impulsive spending, low income
□ Friendships
□ Gambling
□ Grieving, mourning, deaths, losses, divorce
□ Guilt
□ Headaches, other kinds of pains
□ Health, illness, medical concerns, physical problems
□ Housework/chores—quality, schedules, sharing duties
□ Inferiority feelings
□ Interpersonal conflicts
□ Impulsiveness, loss of control, outbursts
□ Irresponsibility
□ Judgment problems, risk taking
□ Legal matters, charges, suits
□ Loneliness
□ Marital conflict, distance/coldness, infidelity/affairs, remarriage, different
expectations, disappointments
□ Memory problems
□ Menstrual problems, PMS, menopause
□ Mood swings
□ Motivation, laziness
□ Nervousness, tension
□ Obsessions, compulsions (thoughts or actions that repeat themselves)
□ Oversensitivity to rejection
□ Panic or anxiety attacks
□ Parenting, child management, single parenthood
□ Perfectionism
□ Pessimism
□ Procrastination, work inhibitions, laziness
□ Relationship problems (with friends, with relatives, or at work)
□ School problems (see also “Career concerns . . . ”)
□ Self-centeredness
□ Self-esteem
□ Self-neglect, poor self-care
□ Sexual issues, dysfunctions, conflicts, desire differences, other (see also “Abuse”)
□ Shyness, oversensitivity to criticism
□ Sleep problems—too much, too little, insomnia, nightmares
□ Smoking and tobacco use
□ Spiritual, religious, moral, ethical issues
□ Stress, relaxation, stress management, stress disorders, tension
□ Suspiciousness
□ Suicidal thoughts
□ Temper problems, self-control, low frustration tolerance
□ Thought disorganization and confusion
□ Threats, violence
□ Weight and diet issues
□ Withdrawal, isolating
□ Work problems, employment, workaholism/overworking, can’t keep a job,
dissatisfaction, ambition
□ Any other concerns or issues:
□ I have no problem or concern bringing me here
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Pawsitive Counseling Center Location Code: 11
Tonja Roberts, LPC008110
Licensed Professional Counselor
326 Myrtle Crossing Drive, Suite 100
Statesboro, Georgia 30458
(912) 764-7001 FAX (912) 489-6864
Authorization to Use or Disclose Protected Health Information (PHI)
______
Patient NameDate of Birth
______
AddressSocial Security Number
______
City, State, Zip
I, ______, give my permission toTonja Roberts, LPC
toDISCLOSE TO AND/OR OBTAIN information from:
______
Name of RecipientPhone Number
______
AddressFax Number
______
City, State, Zip
Protected Health Information To Be Used or Disclosed
______
______
Expiration of Authorization providing consent to use/disclose protected health information:
___No more than 1 year from today______
___When the following happens:______
Your Rights
You can end this authorization to use or disclose information protected health information at any time by writing Tonja Roberts, LPC. If you make a request to end this authorization, it will not include information that has already been used or disclosed based on you previous permission. For more information about this and other rights, please see the applicable Notice of Privacy Practices.
You do not have to agree to this request to use or disclose your information.
Re-disclosure by Recipient