Forms

Prior to our first session, please complete this form. This will help you share important details with me that you might have otherwise forgotten, and help our first meeting to occur more comfortably.

    Please click the links below to read and acknowledge the following forms:

    Informed Consent
    This form not only reiterates the important information we touched on in the consultation about confidentiality in more detail, it also explains my office policies and agreement to services. If you have questions, we can go over them in our first session so that you have a clear understanding about what you are reading.

    HIPPA
    I am required by law to provide you with a copy of the HIPAA Notice of Privacy Practices so you can understand your rights and protections related to the use and disclosure of your identifiable health care information.

    Social Media Policy
    This explains my policies as they relate to possible interactions on the internet. Please let me know if you have questions, concerns, or issues.

    Non-Violent Communication

    *Answer what you are comfortable with and we can talk about the rest*

    Acknowledgement (required)
    I have read and understand the Informed Consent, HIPPA, Social Media Policy, and Non-Violent Communication forms.


    Legal Name (required)

    Preferred Name (if different)

    Preferred Pronouns

    Address

    Phone

    Email (required)

    Preferred?

    In Case of Emergency Contact (please include phone, email, relationship type & length). If no ICE, please list your GP or simply state “none”

    Date / Place of Birth

    /

    Age

    Occupation / Employer

    /

    Will you be requesting a monthly Invoice?

    Do you understand I do not contract with any Insurance company?

    How did you hear about me?

    Demographic Info

    Race / Ethnicity

    Socioeconomic (Class) Status

    Current Sexual Identity / Orientation

    Gender Identity

    Any Chronic Mental and/or Physical Health Conditions or Learning Considerations?

    Religious affiliation / Spiritual practice

    Any other Identity related information you want me to know?

    Therapy Information

    Current reason(s) for seeking therapy

    Severity

    MildModerateSevereVery Severe

    Rate 1-5 if you’d like

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    If you have previously been in Therapy, when, and for what reasons?

    Was it helpful? If so, what specifically did you appreciate about former Therapy or Therapists?

    Were there any things you found unhelpful?

    Do you have any previous suicide attempts, self-destructive or violent behaviors? (Indicate age, circumstances, and whether it led to hospitalization)

    Are you having any self-destructive or self-harming impulses at this time?

    Please describe past/present drug/alcohol use. How did/do you feel about what/how much you used? How do you feel about what/how much you are currently using?

    Are you or have you ever been in a relationship of any kind with someone whose use of drugs/alcohol caused you regular anxiety or caused you to change your behaviors?

    Do other compulsive behaviors around gaming, sex, gambling, disordered eating , or spending play a big role in your life or the lives of people close to you, in your family of origin? If so, please explain how it has affected you and the relationship(s).

    Do you live with others? If so please state their names and relationship(s) to you?

    If you are in a current relationship with: Partner(s)/ Spouse (first name(s), occupation(s), how would you describe your relationship satisfaction?)

    Are there any other current relationships that are a significant focus in your life right now? Please describe. Are there animals in your life you feel especially close to? If not, do you wish that were different?

    How many people, if any, are there in your life that you can share emotional pain or personal successes/failures with somewhat comfortably?

    What are your worries/fears?

    What are your main strengths?

    What are your challenges?

    What are your most important intentions or dreams?

    Do you have specific goals for therapy at this time? Tangible results that would help you feel like your work has been a success? Or is part of the work you want to do discovering that very material?

    Do you have any requests of me that would make our work together more effective or more comfortable for you in some way?

    Please add any additional information that may be helpful to our work together

     

    Once you have read my Informed Consent and my Social Media Policy, and filled out the form above, please download, print and sign this form and bring it with you to the first session: Acknowledgement of Notifications

    This states that you have access to and have read and understood all forms. If you are having trouble accessing a computer and/or printer, please speak to me about this at least 48 hours before our first appointment and I will make arrangements.