INTAKE FORMS
THESE FORMS ARE USED FOR YOUR INTAKE
SESSION. IF YOU WISH TO PRINT OUT AND
SIGN THESE FORMS PRIOR TO YOUR SESSION.
IT WILL REDUCE THE TIME WE SPEND ON
PAPERWORK AT YOUR FIRST SESSION.
IF YOU ARE NOT COMING TO THERAPY
FOR COUPLES THERAPY, YOU WILL JUST
NEED TO PRINT PAGES 1-16.
Best Life Counseling
10707 66th St. N. Ste. #6
Pinellas Park, FL 33782
GUIDELINES FOR TREATMENT FORM
Client Information and Consent
Therapist
The undersigned is a licensed Mental Health professional or chemical dependency counselor in private practice providing mental health care services to clients directly and as an independent contractor/provider for various managed care entities. In addition, the undersigned therapist provides all mental health services through Best Life Counseling.
Mental Health Services
While it may not be easy to seek help from a mental health professional, it is hoped that you will be better able to understand your situation and feelings and move forward resolving your difficulties. The therapist, using her knowledge of human development and behavior, will make observations about situations as well as suggestions for new ways to approach them. It will be important for you to explore your own feelings and thoughts and to try new approaches in order for change to occur. You may bring other family members to a therapy session if you feel it would be helpful or if this is recommended by your therapist.
Appointments
Appointments are made by calling (727) 546-6400 Monday through Friday between the hours of 9:00 a.m. and 5:00p.m. Please call to cancel or reschedule at least 24 hours in advance, or you will be charged for the missed appointment. Third-party payments will not usually cover or reimburse for missed appointments. The NO SHOW fee is $40.00. We request a credit card that will be billed if you do not show for your appointment. The therapist has set aside time to meet with you and if you do not show, the therapist is unable to meet with someone else who may need to be seen. Please be considerate of that.
Number of Visits
The number of sessions needed depends on many factors and will be discussed by the therapist.
Length of Visits
Therapy sessions are 45 minutes in length .The initial therapy session is 1 1/2 - 2 hours.
Relationship
Your relationship with the therapist is a professional and therapeutic relationship. In order to preserve this relationship, it is imperative that the therapist not have any other type of relationship with you.. Personal and/or business relationships undermine the effectiveness of the therapeutic relationship. The therapist cares about helping you but is not in a position to be your friend or to have a social or personal relationship with you.
Gifts, bartering and trading services are not appropriate and should not be shared between you and the therapist.
Cancellations
Cancellations must be received at least 24 hours before your scheduled appointment; otherwise YOU WILL BE CHARGED the customary fee of $40.00 for that missed appointment. You are responsible for calling to cancel or reschedule your appointment. We will give you 24 hours after the NO SHOW to call and give the reasoning for the NO SHOW before charging you.
Payment for Services
If you Self pay, the charge for your initial session is $125 and the charge for any subsequent session is $100.00. The undersigned therapist does accept assignment of insurance benefits. The undersigned therapist will look to you for full payment of your account and you will be responsible for payment of all charges. Different co-payments are required by various group coverage plans. Your co-payment is based on the mental health policy selected by your employer or purchased by you. In addition, the co-pay portion of the undersigned therapist's charges for services at the time of services are provided. It is recommended that you determine your co-payments before your first visit by calling your benefits office or insurance company.
Although it is the goal of the undersigned therapist to protect the confidentiality of your records, there may be times when disclosure of your records or testimony will be compelled by law. Confidentiality and exceptions to confidentiality are discussed below. In the event disclosure of your records or testimony is required by law, you will be responsible for and shall pay the costs involved in producing the records and the therapist's normal hourly rate for the time involved in preparing for and giving testimony. Such payments are to be made at the time or prior to the time the services are rendered by the therapist.
Confidentiality
Discussions between a therapist and a client are confidential. No information will be released without the client's written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations; Child abuse, abuse of the elderly or disabled, abuse of criminal prosecutions, child custody cases, suits in which the mental health of a party is in issue, situations where the therapist has a duty to disclose, or where, in the therapist's judgment, it is necessary to warn or disclose, fee disputes between the therapist and the client, a negligence suit brought by the client against the therapist, or the filing of a complaint with the licensing board. If you have any questions regarding confidentiality, you should bring them to the attention of the therapist when you and the therapist discuss this matter further. By signing this information and consent form, you are giving your consent to the undersigned therapist to share confidential information with all persons mandated by law and with the agency that referred you and the managed care company and/or insurance carrier responsible for providing your mental health care services and payment for those services, and you are also releasing and holding harmless the undersigned therapist from any departure from your right to confidentiality that may result. In couples or family therapy, confidentiality does not apply and the therapist will use there clinical judgment when sharing information.
You have the right to review your chart according to State Law.
If I see in the community, I will not approach you (as if could breach confidentiality). If you want to say hello, please feel free to approach me. However, please understand I will probably not be able to spend much time talking to you. Thanks for your consideration. In addition, you may bump into someone you know in the waiting room. This may be unavoidable. Please let me know if this occurs and how you feel about it.
If you cannot be reached, a message will be left, such as " This is Heather from Heather Pugh's office and I am calling for " Your Name". Please initial the circumstance under which you wish to be contacted.
___ Do not contact me under any circumstances
___ Yes, you may contact me as described above.
___ Yes, contact me, but only under these circumstances
Please describe conditions____________________________________________
I understand the above information
________________________________________________________
Signature of Patient/Parent Date
Duty to Warn
In the event that the undersigned therapist reasonable believes that I am a danger, physically or emotionally, to myself or another person, I specifically consent for the therapist to warn the person in danger and to contact6 the following persons, in addition to medical and law enforcement personnel:
NAME: TELEPHONE NUMBER
_______________________________________________________
_________________________________________________________
______________________________________________________________
I consent for the undersigned therapist to communicate with me by mail and by phone at the following addresses and phone numbers, and 1 will IMMEDIATELY advise the therapist in the event of any changes:
ADDRESS TELEPHONE NUMBER
__________________________________________________________
_________________________________________________________
____________________________________________________________
____________________________________________________________
Risks of Therapy
Therapy is the Greek word for change. You may learn things about yourself that you don't like. Often, growth cannot occur until you experience and confront issues that induce you to feel sadness, sorrow, anxiety or pain. The success of our work together depends on the quality of the efforts on both our parts and the realization that you are responsible for lifestyle choices/changes that may result from therapy. Specifically, one risk of martial therapy is the possibility of exercising the divorce option.
Completion of assignments/readings between therapy sessions will help therapy be more effective. In addition, within a reasonable period of time after beginning treatment,. I will discuss with you, my understanding of the problem, treatment. If you have any unanswered questions about any of the procedures used in the course of therapy, their possible risks, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that I do not provide, 1 have an ethical obligation to assist you in obtaining those treatments.
After the first couple meeting, I will assess if I can be of benefit to you. I do not accept clients who, in my opinion 1 cannot help. In such a case, I will give you a number of referrals that you can contact/ If at any point during psychotherapy, I assess that I am not being effective in helping you reach the therapeutic goals. I am obligated to discuss it with you and if appropriate to terminate treatment. In such a case, I will give you a number of referrals that may be of help to you. If you request it and authorize it in writing.
After-Hours Emergencies
A mental health professional or your therapist is on call when your therapist's office is closed, and can be reached for emergencies on a twenty-four hour, seven days per week basis, by calling (727) 743-8446. Emergencies are urgent issues requiring immediate action. Please call 911 or go to the Emergency Room if suicidal or homicidal.
If the therapist does need to return your phone call, and the call goes beyond 15 minutes, you will be billed for a therapy session. If it is not an emergency, you may email the owner, Heather Pugh CAP, SAP, LMHC at heatherpugh@counsellor.com
I acknowledge that, in the event that the understigned therapist becomes incapicitated or dies, it will become necessary for another therapist to take possession of my file and records. By signing this information and consent form, I give my consent to allowing another licensed mental health professional selected by the undersigned therapist to take possession of my file and records and provide me with copies upon request, or to deliver them to a therapist of my choice.
Disputes
AM disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be neutral party chosen by agreement of Heather Pugh, MA,CAP, LMHC/ Owner and client (s). The cost of mediation , if any, shall be split equally, unless otherwise agreed.
Consent to Treatment
I, voluntarily, agree to receive Mental Health/Drug and alcohol assessment, care, treatment or services and authorize the undersigned therapist to provide such care, treatment, or services as are considered necessary and advisable.
I understand and agree that I will participate in the planning of my care, treatment, or services, and that I may stop such care, treatment, or services that I receive through the undersigned therapist at any time.
By signing this Client Information and Consent Form, I the undersigned client, acknowledge that 1 have been both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.
______________________________________________________
Client/Parent Date
_______________________________________________________
Social Security Number and Address
As witnessed by:
_________________________________________________________
Therapist's Name Date
FORM 2
Financial Policy
Best Life Counseling Financial Policy
The therapist at the Best Life Counseling would like to welcome you to our Practice. We strive to provide you with excellent care and our goal is to make your visits as productive as possible.
By signing below you confirm that you have read this policy and understand that:
• It is your responsibility to inform our office of any address or telephone number changes.
• Your account is to be kept current - accordingly, all self-pay or insurance co-payments and deductibles will be collected at the TIME OF SERVICE. Payable by cash, check Visa, MasterCard, Discover or American Express.
• If you do not have your payment (s), your appointment may be rescheduled. NO SHOW FEES are $40.00.
• A returned check will result in a $25 service charge and ALL future payments being required in the form of cash or credit card and the payment of the monies owed. You may receive refunds if you have a credit balance.
• You will only be sent a statement, if you are owed money, Refunds will be issued within 4-6 weeks from the date requested, if there are no pending insurance claims.
• There is a $25 charge for the completion of paperwork (ex: disability, FMLA, etc.) This needs to be paid prior to paperwork being done.
• Any unpaid balances older than 30 days may be subject to 1.5
percent interest per month.
• If your account is turned over to a collection agency, you will be responsible for any costs incurred in collection of said balance, which may include collection agency fees up to 45 percent of your outstanding balance, court costs and attorney fees.
• If I need to go to court, the fee is $ 150, and may be billed at that rate as well. We require a retainer fee
of $100 up front.
•If phone calls beyond 15 minutes you will be billed for a therapy session.
If you have health insurance coverage:
We will submit your claims, however we must emphasize that as medical providers, our relationship is with
you, not your insurance company. Although we attempt to verify your benefits with your insurance policy,
please be advised this is only an estimate of your coverage based on the information given to us at the time of the
inquiry.
By signing below you confirm that you understand:
•It is your responsibility to inform us of any changes to your insurance policy so that your coverage can be re-verified prior to your appointment.
•If your insurance policy requires a referral from your primary care physician, it is your responsibility to have that referral faxed to our office prior to your appointment.
• Not all services are covered benefits with all insurance plans
and it is your responsibility to be aware of what service (s) is being provided to you and if it is a covered benefit.
We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we urge you to contact us promptly for assistance in the management of your account. If you have any questions about the above information, PLEASE do not hesitate to ask us. We are here to help you.
I have read and understand the above Financial Policy and agree to meet all financial obligations.
__________________________________________________
Patient Name(print) Patient Signature Date
_______________________________
Responsible Party Name (PRINT)
__________________________________________
Responsible Party Signature / Date
_________________________________________________________
Therapist Name (PRINT) Therapist Signature Date
FORM 3
BEST LIFE COUNSELING
10707 66th St. N, Ste. #6
Pinellas Park, FL 33782
I. THIS NOTICE DESCRIBES HOW MEDICAL
INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS
TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
II. IT IS MY LEGAL DUTY TO SAFEGUARD
YOUR PROTECTED HEALTH INFORMATION
(PHI). By law I am required to
insure your PHI is kept private.
The PHI constitutes information
created or noted by me that can be
used to identify you. It contains
data about your past, present, or
future health or condition, the
provision of health care services
to you, or the payment for such
healthcare. I am required to provide
you with the Notice about my privacy
procedures. This Notice must explain
when, why, and how I would use
and/or disclose you PHI. Use of PHI
means when I share, use, examine, or
analyze information within my
practice. PHI is disclosed when I
release, transfer, give, or
otherwise reveal it to a third
party outside my practice. With some
exceptions, I may not use, disclose
more of you PHI than is necessary
to accomplish the purpose for which
the use or disclosure is made;
however, I am always legally
required to follow the privacy
practices described in the Notice.
Please note that I reserve the right
to change the terms of this Notice
and my privacy policies at any time.
Any changes will apply to PHI already
on file with me. Before I make any
important changed to my policies, I
will immediately change this Notice
and post a new copy of it in my
office. You may also request a copy
of this Notice from me or can view a
copy in my office.
III. HOW I WILL USE AND DISCLOSe YOUR
PHI
I will use and disclose your PHI for
many different reasons. Some of the
uses or disclosures will require
your prior written authorization;
others, however, will not. Below
you will find the different
categories of my uses and
disclosures, with some examples.
A. Uses and Disclosures Related to
Treatment, Payment, or Health Care
Operations Do Not Require Your Prior
Written Consent. I may use and
disclose your PHI without your
consent for the following reasons:
1. For Treatment: I may disclose your
PHI to Physicians, psychiatrists,
psychologists, and other licensed
health care providers who provide
you with health care services or
are otherwise involved in your
care. Example: if a psychiatrist is
treating you, I may disclose you
PHI to him/her in order to
coordinate your care.
2. For health Care Operations: I may
disclose your PHI to facilitate the
efficient and correct operation of
my practice. Examples: quality
control-I might use your PHI in the
evaluation of the quality of health
care services that you have received
or to evaluate the performance of
healthcare professionals who provide
you with those services. I may also
provide your PHI to my attorneys,
accountants, consultants, and others
to make sure that I am in compliance
with applicable laws.
3. To Obtain Payment For Treatment: I
may use and disclose your PHI to
bill and collect payment for the
treatment and services I provided
you. Example: I might send your PHI
to your insurance company or health
plan in order to get payment for the
health care services that I have
provided to you. I could also
provide your PHI to business
associates, such as billing
companies, claims processing
companies and others that process
health care claims for my office.
At this time, I do my own billing
and do not use a billing company.
4. Other Disclosures: Examples: Your
consent isn’t required if you need
emergency treatment provided that I
attempt to get your consent after
treatment is rendered. In the event
that I try to get your consent but
you are unable to communicate with
me (For example, if you are
unconscious or in severe pain) but I
think that you would consent to such
treatment if you could, I may
disclose your PHI.
B. Certain Other Uses and Disclosures
Do Not Require Your Consent. I may
use and/or disclose your PHI
without your consent or
authorization for the following
reasons:
1. When disclosure is required by
federal, state, or local law;
2. If disclosure is compelled by a
party to a proceeding before a court
of an administrative agency pursuant
to its lawful authority.
3. If disclosure is required by a
search warrant lawfully issued to a
governmental law enforcement agency.
4. To avoid harm: I may provide PHI to
law enforcement personnel or persons
able to prevent or mitigate a
serious threat to the health or
safety of a person or the public. In
addition, if I am concerned you may
cause harm to yourself or someone
else, I can release PHI to those who
need it.
5. If I need to report suspected or
alleged abuse or neglect of a minor
or elder.
6. For Public health activities.
Example: In the event of your death,
if a disclosure is permitted or
compelled, I may need to give the
county coroner information about you.
7. For specific government functions:
Examples: I may disclose PHI of
military personnel and veterans
under certain circumstance. Also, I
may disclose PHI in the interests of
national security, such as
protecting the President of the
United States or assisting with
intelligence operations.
8. For research purposes: In certain
circumstances, I may provide PHI in
order to conduct medical research.
9. For Worker’s Compensation purposes:
I may provide PHI in order to comply
with Worker’s Compensation laws.
10. Appointment reminders and health
related benefits or services:
Examples: I may use PHI to provide
appointment reminders to you. I may
use PHI to give you information
about alternative treatment
options, or other health care
services or benefits I offer.
11. If an arbitrator or arbitration
panel compels disclosure: When
arbitration is lawfully requested
by either party, pursuant to a
subpoena for mental health records
or any other provision authorizing
disclosure in a proceeding before
an arbitrator or arbitration panel.
12. If disclosure is required or
permitted to a health oversight
agency for oversight activities
authorized by law. Example: When
compelled by U.S. Secretary of
Health and Human Services to
investigate to assess my compliance
with HIPPA regulations.
C. Certain Uses and Disclosures
require you to have the Opportunity
To Object.
1. Disclosures to family, friends, or
others. I may provide your PHI to
a family member, friend, or other
individual who you indicate is
involved in your care or
responsible for the payment from
your health care, unless you object
in whole or in part. Retroactive
consent may be obtained in
emergency situations.
D. Other Uses and Disclosures Require
Prior Written Authorization. In
any other situation not described
in Sections IIIA, IIIB, and IIIC
above. I will request your written
authorization before using or
disclosing any of your PHI. Even if
you have signed an authorization
to disclose your PHI, you may later
revoke that authorization, in
writing, to stop any future uses or
disclosures (assuming that I
haven’t taken action subsequent to
the original authorization) of your
PHI by me.
IV: WHAT RIGHTS YOU HAVE REGARDING
YOUR PHI
These are your rights with respect
to your PHI:
A. The Right to See and Get Copies of
your PHI. In general, you have the
right to see your PHI that is in
my possession or to get copies
of it; however, you must request
it in writing. If I do not have
your PHI, but know who does, I
will advise you how you can get
it. You will receive a response
from me within 30 days of my
receiving your written request.
Under certain circumstances, I
may feel I must deny your request,
but if I do, I will give you, in
writing, the reason for the
denial I will also explain your
right to have my denial reviewed.
If you ask for copies of your PHI,
I will charge you $.25 a page.
I may see fit to provide you with
a summary or explanation of the
PHI, but only if you agree to it,
as well as to the cost, in
advance.
B. The Right to Request Limits on Uses
and Disclosures of your PHI. You
have the right to ask that I limit
how I use and disclose your PHI.
While I will consider your request,
I am not legally bound to agree.
If I do agree to your request, I
will put those limits in writing
and abide by them except in
emergency situations. You do not
have the right to limit the uses
and disclosures that I am legally
required or permitted to make.
C. The Right to Choose How I Send
Your PHI to You. It is your right
to ask that your PHI be sent to you
at an alternative address (for
example, sending information to
your work address rather than your
home address or my an alternative
method (for example via e-mail
instead of regular mail). I am
obliged to agree to your request
providing that I can give you the
PHI, in the format you requested,
without undue inconvenience.
D. The Right to Get a List of the
Disclosures I Have Made. You are
entitled to a list of disclosures
of your PHI that I have made. The
list will not include uses or
disclosures to which you have
already consented, i.e., those for
treatment, payment, or health care
operations sent directly to you,
or your family; neither will the
list include disclosures made for
national security purposes, to
corrections or law enforcement
personnel, or disclosures made
before April 15, 2003. After
April 15, 2003, disclosure records
will be held for six years.
I will respond to your request for
an accounting of disclosures within
60 days of receiving your request.
The list I give you will include
disclosures made in the previous
six years. The list will include
the date of the disclosure, to whom
the PHI was disclosed (including
their address, if known), a
description of the information
disclosed, and the reason for the
disclosure. I will provide the list
to you at no cost, unless you make
more than one request in the same
year, in which case I will charge
you $25.
E. The Right to Amend your PHI. If you
believe that there is some error in
your PHI or that important has been
omitted, it is your right to request
that I correct the existing
information or add the missing
information. Your request and the
reason for the request must be made
in writing .You will receive a
response within 60 days of my
receipt of your request. I may deny
your request, in writing, if I find
the: the PHI is) a) correct and
complete,(b) forbidden to be
disclosed, (c) not part of my
records, or (d) written by someone
else than me. My denial must be in
writing and must state the reasons
for the denial. It must also
explain your right to file a written
statement objecting to the denial.
If you do not file a written
objection, you still have the right
to ask that your request and my
denial be attached to any future
disclosure of you PHI. If I approve
your request, I will make the
changes to your PHI. Additionally,
I will tell you that the changes
have been made and I will advise all
others who need to know about the
changes to your PHI.
F. The Right to get This Notice by
E-Mail and the right to request a
paper copy as well.
IV. HOW TO COMPLAIN ABOUT MY PRIVACY
PRACTICES
If in your opinion, I may have
violated your privacy rights, or
if you object to a decision I made
about access to your PHI, you are
entitled to file a complaint with
the Secretary of the Department
of Health and Human Services at:
200 Independence Avenue S.W.
Washington, D.C. 20201.
If you file a complaint about my
privacy practices, I will take no
retaliatory action against you.
V. EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on
April 14, 2003.
I acknowledge receipt of this notice
Patient Name____________________________Date________
Patient Name_____________________________Date_______
Therapist Name___________________________Date_________
BEST LIFE COUNSELING
10707 66th St. N. , Ste. #6
Pinellas Park, FL 33782
727-743-8446
www.bestlifecounseling.com
CLINICAL INTAKE INFORMATION
Today’s Date________________
How were you referred to us?_____________
Your Name_________________________
Phone Number:___________________
Cell Phone:_________________________
Work Phone:_____________________
E-Mail Address: __________________________
Address:__________________________
___________________________________
City: ______________ State: _________
Zip Code:________________________
Date of Birth:______________
Social Security Number:_____________________
Marital Status:
____Single ____Separated ____Married___Divorced
___Widowed ___Living Together ___Partner
Married or partner how long?_______
Your occupation_____________________
Employer_________________________
If a child or teen:
What grade is she/he in and have they ever repeated
a grade?________________________________________
Parents Names:___________________________________
Business Address: ______________________________________________
Business Phone: ___________________________
If applicable your partner’s
name___________________________________
Partner’s Date of Birth____________
Social Security Number_______________
Partner’s Occupation________________
Employer_________________________
Employer’s Phone________________
If applicable, your children or siblings:
Name M/F Age Living With You
___________________________________________________________
___________________________________________________________
____________________________________________________________
___________________________________________________
Emergency Contact___________________________
Relationship______________________
Phone Number_______________________
Have you ever received counseling before? ___Yes_____No
If yes, when / from whom?__________________________________________________________
__________________________________________________________
______________________
What made you come in for your appointment today?
____________________________________________________
_______________________________________________________
Have you ever been hospitalized?___Yes___No
If yes, When and where and for what reason?___________________________________________________________
____________________________________________________________
_________________________
Who do you turn to for support in your life?_____________
_________________________________________________________
Please list all the medications you are currently
taking (including over the counter) and
dosages____________________________________________________
___________________________________________________________
____________________________
Please list all known allergies to
medications_________________________________
Name of Primary Care
Physican__________________________________________________
Address and Phone
Number_____________________________________________________
___________________________________________________________
___________________________
Are you filing or planning to file for Social Security
Disability?___Yes___No
SYMPTOMS LIST
Do you (please check all that apply):
_____Smoke cigarettes (__packs a day)
_____Drink Caffeine( per day)
_____Drink alcohol beverages /How much and How often?___________________
_____Use of recreational drugs (marijuana, cocaine, etc.)
____ How often and drug of choice?
______Any prior treatment for drug and alcohol?
When and where?_________________________
_____Currently on a restricted diet?
____ Experience chronic physical pain
_____Have a physical injury or disability
_____Rely on medication to sleep
_____Are you pregnant
_____Do you exercise?
_____Any current or history of emotional eating/binge
purge cycle?
_____Prior or current legal charges?
What/were they?___________________
Has anyone in your family (including extended
relatives) ever suffered from depression, anxiety,
“nervous breakdown”, etc.?If so, who?
Has anyone in your family ever been hospitalized
for a mental condition?If so, who? Has anyone
ever suffered from: Bipolar Disorder or
Manic-Depression, Panic Disorder, Schizophrenia,
Alcoholism or Drug Addiction?
Have you aver been emotionally, verbally, physically
or sexually abused?
Do you (please check all that apply):
____fear you are going crazy
____have problems concentrating
____believe you can’t get better
____have problems sleeping
How many hours do you get a night?
____engage in ritualistic behaviors like
repetitive hand washing
____eating more or less than usual
____have disturbing thoughts
____have disturbing fears/thoughts
____have no willpower
____have low self-esteem
____have difficulty going to work
____have bursts of energy for more than 1 day
____anxiety
_____extreme sadness
Please list any additional symptoms:
>
FOR COUPLES ONLY
EACH PERSON IN THE COUPLE, PLEASE FILL
OUT AND BRING TO THE INITAL INTAKE
SESSION. THIS WILL BE HELPFUL TO THE
THERAPIST
Couple's Information Form
1) Name: ____________
2) Age:______
3) Date: _______
4) Address:
______________________________
City:___________State:_____
Zip: ___________
5) Briefly, what is your main
purpose in coming to
couple's counseling?
_______________________________________
Instructions: To assist us in helping
you, please fill out this
form as fully and openly as possible.
Your answers will help
plan a course of couple's therapy that
is most suitable for you and your
partner. Please do not exchange this
information with your partner at this
time. Several of your answers on this
form may be shared later with your
partner during joint therapy
sessions if you give us permission
to share this information.
For this reason you are advised to
respond honestly and carefully to
each item. If certain questions do
not apply to you or you do not want
to share this information, please
leave them blank.
6)Have you been married
before?
Yes ____ No___
If Yes, how many previous
marriages have you had?
7)How long have you and
your partner been in
this relationship?
8)Are you and your partner
presently living
together?
9)Are you and your partner
engaged to be married?
When? ________
10)Fill out the following
information for each child
of whom the natural parent
is both you and your
partner, children from
previous relationships,
and adopted children.
____ Neither of us has
children
(go to next page)
____ One or each of us has
children (continue)
*"Whose child?" answering
options:
B = Both of ours,
natural child
BA = Both of Ours,
adopted
M = My natural child
MA = My Child apopted
P = Partner's
natural child
PA = Partner's child,
adopted
Child's name Age Sex Whose child
and Lives with whom?
1) F M
2) F M
3) F M
4) F M
5) F M
6) F M
7) F M
8) F M
11) List five qualities that
initially attracted you to
your partner.
Does your partner still possess
this trait?
1) Yes No
2) Yes No
3) Yes No
4) Yes No
5) Yes No
12) List four negative concerns that
you initially had in the
relationship. Does your partner
still possess this trait?
1) Yes No
2) Yes No
3) Yes No
4) Yes No
13) List five present positive
attributes of your
partner. Do you often praise
your partner for these
traits?
1) Yes No Trait:
2) Yes No Trait:
3) Yes No Trait:
4) Yes No Trait:
5) Yes No Trait:
14) List five present negative
attributes of your partner.
Do you nag your partner about
these traits?
1) Yes No Trait:
2) Yes No Trait:
3) Yes No Trait:
4) Yes No Trait
5) Yes No Trait:
15) List five things you do (or could
do) to make the marriage more
fulfilling for your partner: Do
you often do this?
What do you do?
1) Yes No
2) Yes No
3) Yes No
4) Yes No
5) Yes No
16) List five things that your partner
does (or could do) to make the
marraige more fullfilling to you?
Does your partner often do these
things?
1) Yes No
2) Yes No
3) Yes No
4) Yes No
5) Yes No
17) List five expectations or dreams
you had about relationship before
you met your partner: Have they
come true or been met?
1) Yes No
2) Yes No
3) Yes No
4) Yes No
5) Yes No
19. What are the responsibilities that each person has in the relationship?For example, who does the laundry?,
Who fixes the car?____________________________________________________
____________________________________________________
____________________________________________________
20)If some of the following behaviors
take place only during MILD
arguments circle an "M" in the
appropriate blanks. If they take
place only during SEVERE arguments,
circle an "S." If they take place
during ALL arguments circle an "A."
Fill this out for you and your
impression of your partner. If
certain behaviors do not take place,
leave them blank. Circle the
Appropriate Response for Each:
(M = Mild arguments only
S = Severe arguments only
A = All arguments)
1) Apologize
M S A
2) Become silent
M S A
3) Bring up the past
M S A
4) Criticize
M S A
5) Cruel accusations
M S A
6) Cry
M S A
7) Destroy property
M S A
8) Leave the house
M S A
9) Make peace
M S A
10)Moodiness
M S A
11)Not listen
M S A
12)Physical abuse
M S A
13)Physical threats
M S A
14)Sarcasm
M S A
15)Scream
M S A
16)Slam doors
M S A
17)Speak irrationally
M S A
18)Speak rationally
M S A
19)Sulk
M S A
20)Swear
M S A
21)Threaten breaking up
M S A
22)Threaten to take kids
M S A
23)Throw things
M S A
24)Verbal abuse
M S A
25)Yell
M S A
21)How often do you have:
Mild arguments?
Severe arguments?
22)When a MILD argument is
over how do you usually feel?
23) When a SEVERE argument is
over how do you usually
feel?
24) Which of the following issues
or behaviors of you and/or
your partner may be
attributable to your
relationship or personal
conflicts? If an item
does not apply, leave
it blank. Circle the
Appropriate Responses
(M = My behavior
P = Partner's behavior
B = Both)
Alcohol consumption M P B
Perfectionist M P B
Childishness M P B
Possessive M P B
Controlling M P B
Spends too much M P B
Defensiveness M P B
Steals M P B
Degrading M P B
Stubbornness M P B
Demanding M P B
Uncaring M P B
Drugs M P B
Unstable M P B
Flirts with others M P B
Violent M P B
Gambling M P B
Withdrawn M P B
Irresponsibility M P B
Works too much M P B
Lies M P B
Other (specify)
Past marriage(s)
/relationship(s) M P B
M P B
Other's advice M P B
M P B
Outside interests M P B
Past failures M P B
25) In the remaining space please
provide additional information
that would be helpful:
I, , hereby
give my permission for this therapist
to share the information that
I, ,
provided on this form to
(partner) when it is deemed appropriate
by an agreement between me, my
partner,and our therapist.This sharing
of information may take place only
during a joint counseling session
(both partners present).
Client's signature:
Date:
PLEASE RETURN THIS AND OTHER INTAKE
MATERIALS TO THIS OFFICE AT THE
INITIAL APPOINTMENT.
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