INTAKE FORM FOR CLIENT NAME:__________________________________________________DATE:_______________________ ADDRESS:____________________________________________________________________________ CITY____________________________________________STATE________ ZIP CODE_____________ DATE OF BIRTH:______________________________ AGE: ______________ HOME PHONE:__________________________ CHILDS CELL:________________ (ok to use?__) CHILDS EMAIL_________________________(ok to use?__) PARENTS CELL________________________PARENTS EMAIL_________________________(ok to use?__) Work phone: _______________________________ (ok to use?__) Where did you hear about this Therapist?____________________________ Name of Physician__________________________________________ Phone:__________________ Clinic and Address: __________________________________________________________________ Medications prescribed/ reason for:________________________________________________________ ____________________________________________________________________________________ Major Medical conditions/past/present:_____________________________________________________ ___________________________________________________________________________________ INSURANCE: Primary Health insurance company_______________________________________________ Name of Insured______________________________________________________ Address of Insured if different from Child’s address___________________________ __________________________________________________________________________ Relationship to insured?______________________ Birth date of insured:_________ Insured Place of Employment____________________________________________ Insurance ID #:_____________________________ Group #_________________________________ Any other insurance held? Yes_______ No_______ If yes, please complete information below: Secondary Health insurance company_______________________________________________________ Name of Insured_____________________________ Birth date of insured________________ Insured Place of Employment_______________________________________________________ Policy Number________________________ Group Number______________________________ EMERGENCY INFORMATION AND RELEASE. Please list an emergency contact: Name: ______________________________________________ Relationship:___________________ Phone:__________________________ Please sign and date below to give consent to contact this person in the case of an emergency. This only gives consent for emergency contact. All other contact with this person needs to be expressed and specifically consented to in other signed documents. Sign Name:__________________________________________________ Date:_____________________ Please note: The Minnesota code of Agency Rules states that information may be disclosed to the family of a client, a potential victim, public authorities or appropriate professionals when that disclosure is necessary to protect against serious harm being inflicted on the client or another person. ASSIGNMENT OF BENEFITS I fully understand that my insurance coverage is a contract between my insurance company and myself and it is my responsibility to know my benefits. Your therapist will usually verify benefits as a courtesy, but it is not responsible for discrepancies between the information given and the actual coverage. I hereby authorize and request payment directly to NANCY E. WILSON, M.S., L.P., under the terms of my insurance policy and authorize the release of information needed to process claims. I understand that I am financially responsible for treatment charges not covered by my insurance benefits. Treatment co-pays are due at the time of the session. Any other arrangements must be discussed with your counselor. In the event of a default on payment, I will pay in addition to the amount due, collection costs and attorney fees as well as any service charges. I have read and understand the above policy and agree to its content. Signature of Parent___________________________________________Date________________ Nancy E. Wilson, M.S., Psychologist 14501 Granada Drive Suite 101 Apple Valley, MN 55124 Office Phone: 952-250-9952 FAX: 952-431-6448 Appointments Schedule times by calling 952-250-9952. The appointment time is reserved especially for you and we require at least 24 hour cancellation notice. If you do not cancel 24 hours in advance you may be charged for the time. If you miss an appointment, or cancel too late, you will be billed directly for the missed session as these charges cannot be submitted to insurance companies. I schedule all appointments in advance, and offer various times throughout the week. The “clinical hour” is 50 minutes in duration (less if you arrive late). Telephone Messages You may reach me by calling my office number at (952)250-9952. I work part time out of my clinical office and keep other office hours at home. If you do not reach immediately you may leave a message in my confidential voice mail. I check this several times a day and will return your call during my next available opportunity. My voice mail is not checked overnight, however, or during times that would be specified on my voice message. In the case of an emergency, there are several emergency services available in the Twin Cities. You can also call 911. Emergencies If this is a life or death issue, dial 911 or go to the hospital emergency room for evaluation. Do not leave a voice mail message for this type of message, especially if it is overnight. Below I have listed local services that provide 24 hours a day crisis lines: Dakota County Hennepin County Crisis Connection (952) 891-7171 (612) 374-3161 (612) 379-6363 (for all counties) Fees The fee for services is $100 an hour for counseling, and $160 an hour for Initial Intake appointments. If I am an in-network provider for your insurance, then I am contracted by them and I will submit all insurance forms necessary. I will also contact them to clarify your insurance coverage after our initial appointment is scheduled. All co-pays are required to be paid at the time of the appointment. Testing or consultation is made by arrangement. Insurance If you have a private insurance that I am not contracted with you might still be eligible for insurance reimbursement. While I will assist you in obtaining reimbursement, the ultimate responsibility for your bill is yours. I encourage you to obtain as much information as you can about the mental health benefits that your health insurance company provides for you. Ending Therapy Most often, we plan for ending therapy work during the last few sessions. If for some reason we have not done that and you decide to stop, please let me know. I believe it is helpful to be clear with each other about ending. Client fill this out on his or herself: Name: ________________________________________________Date:___________________ 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. Please circle specific problems if all of them in the line do not apply to you. ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 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 (cont.)Adult Checklist of Concerns (p. 2 of 2) ❑ 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: ❑_____________________________________________________________ ❑_____________________________________________________________ Please look back over the concerns you have checked off and choose the one that you most want help with. It is: ________________________________________________________________________ Please fill this out with basic significant information. We will discuss these things in our first session. Continue on back if you need to. Omit any items you do not know or are uncomfortable writing about. SIGNIFICANT INFORMATION Adult fill this out on Child Client: 1. Name of Adult filling out form:____________________________________________________ Name of Client:_________________________________________Date:________________________ D.O.B. ____________________Age__________ Grade and School attended:__________________________________________________________ Do you have a job?:__________________________________________________________ Medications used/ reason for:_____________________________________________________ Significant illnesses in immediate family______________________________________________ 2. Parents NAME LOCATION AGE OCCUPATION FATHER______________________________________________________________________ MOTHER______________________________________________________________________ 3.. Sisters and Brothers (list by birth order) NAME LOCATION AGE MARITAL ST. OCC. EDUC. 1. ____________________________________________________________________________ 2. ____________________________________________________________________________ 3. ____________________________________________________________________________ 4. ____________________________________________________________________________ 4.. History of therapy (Therapist, title, length, dates, type of therapy). Did you find it useful? 5. History of childhood, adolescence, father, mother, siblings, family. Also, any significant school/learning issues. 6. Describe what you want your child to get out of therapy. Consent to Treatment I do hereby seek and consent to take part in the treatment by Nancy E. Wilson, M.S.,L.P.. I understand that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. I am aware that I may stop my treatment with this therapist at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.) I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel and do not show up, I will be charged for that appointment. I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the therapist may stop my treatment. My signature below shows that I understand and agree with all of these statements. Signature of client (or person acting for client) ____________________________________Date_______________ Printed name ______________________________________________ Relationship to client (if necessary)_____________________________________ This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. **MY PRACTICE CONTINUES TO GROW THROUGH REFERRALS FROM MY CLIENTS, MANY SINCERE THANKS FOR YOUR TRUST AND CONFIDENCE! Child Checklist of Characteristics Name of client_____________________________: Date:_____________Age: ________ Person completing this form:___________________________________________________ Feel free to add any others at the end under “Any other characteristics.” ❑Affectionate ❑Argues, “talks back,” smart-alecky, defiant ❑Bullies/intimidates, teases, inflicts pain on others, is bossy to others, picks on, provokes ❑Cheats ❑Cruel to animals ❑Concern for others ❑Conflicts with parents over persistent rule breaking, money, chores, homework, grades, choices in music/clothes/hair/friends ❑Complains ❑Cries easily, feelings are easily hurt ❑Dawdles, procrastinates, wastes time ❑Difficulties with parent’s paramour/new marriage/new family ❑Dependent, immature ❑Developmental delays ❑Disrupts family activities ❑Disobedient, uncooperative, refuses, noncompliant, doesn’t follow rules ❑Distractible, inattentive, poor concentration, daydreams, slow to respond ❑Dropping out of school ❑Drug or alcohol use ❑Eating—poor manners, refuses, appetite increase or decrease, odd combinations, overeats ❑Exercise problems ❑Extracurricular activities interfere with academics ❑Failure in school ❑Fearful ❑Fighting, hitting, violent, aggressive, hostile, threatens, destructive ❑Fire setting ❑Friendly, outgoing, social ❑Hypochondriac, always complains of feeling sick ❑Immature, “clowns around,” has only younger playmates ❑Imaginary playmates, fantasy ❑Independent ❑Interrupts, talks out, yells ❑Lacks organization, unprepared ❑Lacks respect for authority, insults, dares, provokes, manipulates ❑Learning disability ❑Legal difficulties—truancy, loitering, panhandling, drinking, vandalism, stealing, fighting, drug sales ❑Likes to be alone, withdraws, isolates ❑Lying (cont.) Child Checklist of Characteristics (p. 2 of 2) ❑Low frustration tolerance, irritability ❑Mental retardation ❑Moody ❑Mute, refuses to speak ❑Nail biting ❑Nervous ❑Nightmares ❑Need for high degree of supervision at home over play/chores/schedule ❑Obedient ❑Obesity ❑Overactive, restless, hyperactive, overactive, out-of-seat behaviors, restlessness, fidgety, noisiness ❑Oppositional, resists, refuses, does not comply, negativism ❑Prejudiced, bigoted, insulting, name calling, intolerant ❑Pouts ❑Recent move, new school, loss of friends ❑Relationships with brothers/sisters or friends/peers are poor—competition, fights, teasing/provoking, assaults ❑Responsible ❑Rocking or other repetitive movements ❑Runs away ❑Sad, unhappy ❑Self-harming behaviors—biting or hitting self, head banging, scratching self ❑Speech difficulties ❑Sexual—sexual preoccupation, public masturbation, inappropriate sexual behaviors ❑Shy, timid ❑Stubborn ❑Suicide talk or attempt ❑Swearing, blasphemes, bathroom language, foul language ❑Temper tantrums, rages ❑Thumb sucking, finger sucking, hair chewing ❑Tics—involuntary rapid movements, noises, or word productions ❑Teased, picked on, victimized, bullied ❑Truant, school avoiding ❑Underactive, slow-moving or slow-responding, lethargic ❑Uncoordinated, accident-prone ❑Wetting or soiling the bed or clothes ❑Work problems, employment, workaholism/overworking, can’t keep a job Any other characteristics: ❑___________________________________________________________________ Please look back over the concerns you have checked off and choose the one that you most want your child to be helped with. Which is it?________________________________ This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.