New Client Intake Form

Please fill out this form before your first appointment

Basic Information

* Indicates required field

Name *

First

Last

Address *

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City

State

Zip Code

Country

Phone Number *

Email *

Date of Birth *

How did you hear about this site? *

Internet Search Psychology Today Friend Other

Financial Information

Credit Card Number *

Sessions will be charged to your credit card unless other arrangements are made. If there are issues with your credit card, you will be contacted by my office by telephone.

Expiration Date *

Verification Code on back of card. *

Billing Zip Code *

Emergency Contact

Who can I contact in case of an emergency?

Name *

First

Last

Address *

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City

State

Zip Code

Country

Phone Number *

Do I have permission to contact the above person regarding your therapy? *

Yes No

Please list any diagnoses or psychiatric medication you've taken in the past. *

List medications you are currently taking. *

Health History - Optional

Have you been in Therapy before? *

Yes No

Do you use alcohol? *

Yes No

Do you use Caffeine? *

Yes No

Do you use tobacco? *

Yes No

Do you have a history of illicit drug use? *

Yes No

List names and ages of those you live with. *

What's your highest level of education? *

Do you have a religious affiliation or spiritual practice? *

Does anyone in your family have a history of mental illness? *

Client Disclosure Statement

I am excited that you have selected me as your therapist to help you meet your need. This is to inform you of my background and of our client-therapist relationship. Your signature at the end of this document is required. Please review carefully.

Degree & Licensure

I hold a Bachelor of Arts in Psychology and Masters of Arts in Mental Health Counseling both from North Carolina Central University. I have been in private practice since 2012. I am licensed as a Professional Counselor (license #10155). Obtaining my license involved successfully completing a body of required coursework, passing nationally standardized licensing exams in addition to clinical internships, and hundreds of hours of supervised clinical practice. I continue to engage in education myself in the field of psychotherapy through workshops, webinars, & training.

Counseling Services Offered

I offer individual counseling to adults via teletherapy. My theoretical approach focuses on Cognitive Behavioral Therapy. I also utilize motivational interviewing, short term solution focused techniques, and mindfulness techniques to meet my clients needs. I treat diagnosis that include: Anxiety, Depression, Adjustment issues, PTSD, Schizophrenia, Bipolar Disorder, Schizoaffective Disorder, and Substance Use Disorders. I view therapy as a partnership between the Client and the Therapist to work towards the clients goals. I believe that the client is the expert on their experience and the Therapist works to facilitate insight and awareness.

Policies

After an evaluation period you can expect me to hold a regularly scheduled time(s) for you each week that we agree upon. My fee is $130.00 per initial 60-90 minute evaluation session & $80 per 45-60 minute Session there after. I ask that you give me 48 hours notice if you must cancel. I charge the full fee for missed sessions with the exception of illness or unavoidable emergencies. Be aware that there is great variability in insurance coverage. It will include a diagnosis which becomes part of your medical record. You are personally responsible for any fees incurred. Any information regarding your treatment is confidential and will not be released without your permission. Legal mandates give three exceptions to this policy; (1) if a client is believed to be harmful to himself/herself or others, or (2) situations where there is suspected child abuse, elder abuse, disabled adult abuse, and/or (3) by court order. I am legally bound to break confidentiality and report such instances.

Payment: At the end of each session, your credit card will be charged for the session. If you require a different card to be charged please notify me as soon as possible. In the even that your payment information changes, please notify me.

Remember there is a 48 hour requirement for canceled appointments.

If you believe you have been treated unethically or unfairly by me you may contact the North Carolina Board of Licensed Professional Counselors at PO. Box 7369, Garner, NC. 27529, (919) 667-0820 for clarification of client's rights as I've explained them or to lodge a complaint.

Signature *