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 ADULT INTAKE FORM
Appointment Date: ____ / ____ / ____ *Section For Office Use Only* Time: ______________________
Diagnosis: ___________________
IP: ______________________________
Office: _____________________
Therapist: ____________________ Service Type Code: □ I □ C □ F □ G □ E
Copay/Fee: _________________
Payment: □ Insurance □ Private Important: Each person attending session should complete his/her OWN intake form. Parents should not complete their child’s form. Couples should use two intake forms. (PLEASE PRINT) Full Name: Date of Birth:
Social Security #: Gender: _________________________
____/____/____
__________________ _______ Address: _____________________________________________________________ City, State, ZIP: _______________________________________________________ Home Phone: ______________________
Work Phone:_____________________ Cell Phone:________________________
E­mail:__________________________ Marital / Relational Status: __ _____________________________________________ Would you like to receive our quarterly “Solutions Newsletter” with information about upcoming workshops, events and practical tips? □ E­mail □ Mail □ No, Thanks. How was your overall experience with the intake scheduling process? Comments : __________________________________________________________ Referral Source/ How did you find us? ______________________________________ Spiritual Concerns: Would you like your spiritual beliefs and values to be incorporated into therapy process? □ No □ Yes □ Not Sure Place of Worship (name/location)__________________________________________ Worship Leader’s Name ________________________________________________ Emergency Contact Information: Name: _____________________________
Phone:_____________________________
Relationship: ____________________ Religious Affiliation: □ Catholic □ Hindu □ Jewish □ Mormon □ Protestant □ Buddhist □ Muslim □ None □ Community Church □ Other ____________________ David C. Olsen, PhD., LCSW, LMFT | Executive Director 220 N. Ballston Ave., Scotia, New York 12302 | (518) 374-3514 | Fax (518) 374-9193 | samaritancounselingcenter.org Insurance Information Who is the primary person on the insurance plan? ____________________________ Insurance Company: __________________ Plan Name: _____________________ ID# / Member #: ______________________ Policy # / Group #:________________ Secondary Insurance: _________________ Plan Name: _____________________ ID# / Member #: ______________________ Policy # / Group #:________________ Children (or Siblings): Names:
Date of Birth: ________________________________ ____ / ____ / ____ ________________________________ ____ / ____ / ____ ________________________________ ____ / ____ / ____ ________________________________ ____ / ____ / ____ Pre­Session Evaluation: What is the primary concern that you would like to address in therapy?
How has this affected your functioning (relationally and/or vocationally)?
Is there now or has there been any substance abuse in your family? □ Yes □ No Relationship/s: _____________________________________________ Do you have concerns about abuse? ❑ Physical ❑ Sexual ❑ Emotional ❑ Substance Have you ever hurt yourself on purpose? □ Yes □ No Do you ever think of committing suicide? □ Yes □ No Have you ever attempted suicide? □ Yes □ No When? _____________ Do you presently have suicidal thoughts? □ Yes □ No Have you had previous therapy (here or elsewhere)? □ Yes □ No When? ____________________ Reason:_____________________________ Medical Information: Family Doctor: ________________________ Phone:_________________________ Address or Location: ___________________________________________________ Medications Taken: ____________________________________________________ Psychiatric Medication provider:___________________________________________ Allergies (other than seasonal):___________________________________________ Have you ever been hospitalized or had a major illness? □ Yes
□ No if Yes, When / For What? ___________________________________________ Do you drink alcohol? □ Yes, times per week? _____________ □ No Do you use drugs recreationally? □ Yes, times per week? _____________ □ No David C. Olsen, PhD., LCSW, LMFT | Executive Director 220 N. Ballston Ave., Scotia, New York 12302 | (518) 374-3514 | Fax (518) 374-9193 | samaritancounselingcenter.org ELECTRONIC COMMUNICATION AND SOCIAL MEDIA POLICY Contacting Therapist Between Appointments: You may contact your therapist via voicemail with any issues regarding scheduling appointments, policy, billing and other non­emergency or non­clinical concerns. In case of a life threatening emergency, call 911 or go to your nearest emergency room. We strive to respond to communications within 48 business hours if possible. E­Mail: Your therapist may use email in order to arrange appointments or address billing questions but will not respond to any clinical matters related to treatment via email. Please do not email content related to your therapy sessions, as email exchanged outside of our center is neither completely secure nor confidential. Electronic communications are not effective means for contacting your therapist in a clinical emergency. Social Media: We are committed to maintaining professional and ethical boundaries that include, but are not limited to, protecting the privacy and confidentiality of our therapeutic relationship. Therefore, your therapist will not accept “friend” or contact requests from current or former clients on any social networking site. Please do not attempt to contact your therapist by using networks such as Twitter, Facebook, or Linked­In. It is our practice not to respond to such contacts from clients. However, feel free to subscribe to posts on any of our Samaritan Centers public social network accounts. Legal: Any emails your therapist receives from you and any responses sent back to you become a part of your Legal Clinical Record. If you have questions or concerns about any of these policies regarding our potential interactions over the Internet, please bring them to your therapist’s attention. INSURANCE REIMBURSEMENT AND CASE CONSULT POLICY Client requests payment of authorized benefits to client or on client’s behalf for any service furnished by Samaritan Counseling Center, including physician services. Client authorizes the release of information necessary to process this claim through an insurance review including any periodic treatment review with the Managed Care Company. Client also authorizes Samaritan Counseling Center to consult with their physician and / or referring professional. Client agrees to pay any charges, copays or fees not covered by their insurance MISSED APPOINTMENT POLICY We ask that you give at least 24 hours notice of your decision to cancel a scheduled appointment. Other than in an emergency, you will be charged a fee of $50 for a canceled or missed appointment in which sufficient notice is not given. If you are using insurance, please be aware that your insurance does not cover missed appointments and you will be billed our fee per session. Missed appointments will be immediately charged to a credit/debit card account of your choosing. Please provide a copy of the debit/credit card which you would like us to use for missed appointment charges. No charge will be made to this account unless a missed appointment charge is incurred. Payment of any outstanding late cancel or missed appointment fees is required in order to schedule your next appointment. Client may grant consent to Samaritan Counseling Center for billing the credit/debit card account, of which client provided a photocopy. Please sign below to express you Acknowledge, Understand and Consent to Samaritan policies and have received a copy of Samaritan’s Notice of Privacy Practices: _______________________________
Print Name (Consenting adult)
____________________________ Date of Birth (must be over 18) _______________________________
Signature
____________________________ Date Indicate legal relationship to client on which consent is given: _________________________ David C. Olsen, PhD., LCSW, LMFT | Executive Director 220 N. Ballston Ave., Scotia, New York 12302 | (518) 374-3514 | Fax (518) 374-9193 | samaritancounselingcenter.org