Counseling Intake Form Please complete and submit this form prior to your first appointment. Any field marked with an asterisk ('*') is required. "*" indicates required fields 1Contact Information2Personal Information3Health Information4Disclosures5 Contact InformationFull Legal Name of the person being seen* First Last Email Address* Is this counseling for a minor? Yes No ConsentI attest that I am enrolling minor child in compliance with any court-mandated parenting agreements which may be in place to dictate the terms of parental responsibility. I take all responsibility for notifying any other parent or legal guardian of minor child of child’s enrollment in outpatient psychotherapy, in accordance with any court-mandated parenting agreement in place. I understand that Total Health Guidance may release minor child’s clinical records to any parent or legal guardian holding parental rights upon their request. I agree to the statement above.Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Sex* Male Female Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone / Mobile Phone*Work PhoneHome PhonePlease list an emergency contact:Emergency Contact* Phone*Relationship To You* Referral DetailHow did you hear about us? Are you coming in for a Court Ordered Evaluation / Assessment?* Yes No Please provide contact information for the third party requesting this assessment: Requestor Contact Relationship To You Firm / Organization / Entity PhoneEmail Insurance DetailInsurance Provider Group Number Member ID Primary Insured (Name, Date of Birth & Address) Personal InformationOccupation* Highest Level of Education*No Formal EducationPrimary EducationHigh School Diploma / GEDTechnical CertificationSome College / Accredited CourseworkAssociate DegreeBachelor's DegreeMaster's DegreeDoctorate DegreeProfessional DegreeRelationshipMarital Status* Single Married Partnered Divorced Separated Engaged How Long? Spouse / Partner Name Is spouse / partner supportive of this counseling? Yes No Please explain below:ChildrenNumber of Children*Ages of Children Please provide the name of any legal guardian(s) if other than your spouse/partner or yourself:Guardian Name PhoneRelationship To Child Guardian Name PhoneRelationship To Child MedicalAre you currently under medical care?* Yes No Please indicate the reason:Physician Name PhoneDo you take any prescription medications?*(If seeking marriage counseling, please combine your spouse/partner's response with your answer) Yes No Please list the medications:Please list any other significant medical history:CounselingHave you previously seen a counselor/therapist/psychologist/psychiatrist?* Yes No Please list them: Therapist Name Location Date MM slash DD slash YYYY Therapist Name Location Date MM slash DD slash YYYY WellnessOn a scale from 1 - 10 with 10 being 'excellent', how would you rate your current health in each of these areas:Relationally*Select10 (Excellent)987654321 (Terrible)Emotionally*Select10 (Excellent)987654321 (Terrible)Spiritually*Select10 (Excellent)987654321 (Terrible)Physically*Select10 (Excellent)987654321 (Terrible)Nutritionally*Select10 (Excellent)987654321 (Terrible)Financially*Select10 (Excellent)987654321 (Terrible)ConcernsHave you ever attempted suicide?* Yes No Have any family members attempted suicide?* Yes No In your own words, please explain why you are seeking counseling?*How long have these concerns been causing you distress?* How do you hope counseling will help?*What else do you feel is important for the counselor to know about you, your concerns, or your circumstances?*ServicesPlease select which service(s) you are interested in receiving information about: A/C & Heating (sales, service) Acupuncture Attorney - Business Law Attorney - Criminal Defense, Traffic Tickets Attorney - Family (divorce, custody, child support, etc.) Attorney - Immigration Auto Dealer & Repair Banker (personal, business) Business Consulting Business Marketing Caterer Chiropractor Counselor/Life Coach (individual, marriage, family, career) (Offered at Total Health Guidance) CPA (tax returns, audit representation, business start-up) Digital Marketing (SEO, website design, video, social media) Financial Planner (investments, IRA, 401k) Firearms Instructor Handyman / Lawn Maintenance Health Coaching (Offered at Total Health Guidance) Health Insurance (individual, group) Home Care Assistance Insurance (auto, home, business) Interior Design Legal Shield / Identity Theft Life Insurance Massage Therapy (Offered at Total Health Guidance) Merchant Services Movers (residential, commercial) Nutritional Counselor (Offered at Total Health Guidance) Office Supplies Office Furniture Payroll Services Photographer / Portrait Design Printing / Promotional Products Residential Cleaning Service Residential Mortgage (purchase, re-fi, construction, reverse) Residential or Commercial Estate Roofing Travel Agent Wedding / Event Planner Total Health Guidance, LLC - Disclosure Statement Thank you for deciding to seek out treatment at Total Health Guidance. We have listed below our various policies for your information. Please read through these, ask any questions, and sign at the bottom. You may call (321) 332-6984 regarding any questions you may have. All of the therapists at THG are licensed through the State of Florida and/or the Florida Association of Christian Counselors & Therapists. Total Health Guidance is not a 24 hour treatment center. In an emergency, please call 911. We have been trained in a variety of counseling techniques. We will work with you to verify which techniques might be most effective for your particular needs. You may, at any time, seek a second opinion from another therapist and/or you may terminate our services at any time without penalty. SESSIONS Sessions are typically scheduled for 50 minutes at a frequency to be determined by the counselor and client. PAYMENT POLICY We see clients on a fee-for-service basis only. The client/parent is responsible for payment in full at the time of each session. Additional time options and cost can be established with the therapist. Our policy is for each person to pay for services at the time they are rendered. Any other arrangements must be made in advance. A $25 administrative fee will be charged on all checks that are returned for non-sufficient funds. Payments can be made by cash, check or credit card. Charges for testing services are an additional fee. INSURANCE If you desire to use in-network benefits, confirmation of coverage must be completed prior to your appointment. We are not in-network with many insurance carriers. Until coverage is confirmed, you will be required to pay in-full for all appointments. If you desire to use out-of-network benefits, please direct questions about reimbursement amounts and timeliness to your insurance company. We can provide you with a receipt for the counseling service that may be used to submit for reimbursements if you choose. We do not complete any insurance paperwork for out-of-network benefits. If you elect to use your health insurance plan to assist in the payment of treatment then you understand that your insurance carrier and the National Information Center will have access to your diagnosis code and other pertinent data needed for processing. CANCELLATIONS We understand that it may, at times, be necessary to cancel an appointment. We require that changes / cancellations be made 24 hours in advance. Any changes, cancellations, or missed appointments within the 24 hour period will result in a $40 cancellation charge. CONFIDENTIALITY The confidentiality of the services provided by us is protected by law. Unless you grant us permission to do so in writing, we will neither inform anyone that you are a client, nor will we disclose the content of any session. The only circumstances under such professional confidentiality may be broken is if one or more of the following conditions apply: If you pose a serious physical danger to yourself or to another person. If you disclose that you or another person has physically or sexually abused or molested a child or an incompetent / disabled person. If you disclose that a child, an incompetent / disabled person is suffering because of neglect. If such abuse or neglect is disclosed, we are mandated by Florida law to report such information to an appropriate state agency. FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT*Total Health Guidance, LLC - Disclosure Statement Thank you for deciding to seek out treatment at Total Health Guidance. We have listed below our various policies for your information. Please read through these, ask any questions, and sign at the bottom. You may call (321) 332-6984 regarding any questions you may have. All of the therapists at THG are licensed through the State of Florida and/or the Florida Association of Christian Counselors & Therapists. Total Health Guidance is not a 24 hour treatment center. In an emergency, please call 911. We have been trained in a variety of counseling techniques. We will work with you to verify which techniques might be most effective for your particular needs. You may, at any time, seek a second opinion from another therapist and/or you may terminate our services at any time without penalty. SESSIONS: Sessions are typically scheduled for 50 minutes at a frequency to be determined by the counselor and client. PAYMENT POLICY: We see clients on a fee-for-service basis only. The client/parent is responsible for payment in full at the time of each session. Additional time options and cost can be established with the therapist. Our policy is for each person to pay for services at the time they are rendered. Any other arrangements must be made in advance. A $25 administrative fee will be charged on all checks that are returned for non-sufficient funds. Payments can be made by cash, check or credit card. Charges for testing services are an additional fee. INSURANCE: If you desire to use in-network benefits, confirmation of coverage must be completed prior to your appointment. Until coverage is confirmed, you will be required to pay in-full for all appointments. If you desire to use out-of-network benefits, please direct questions about reimbursement amounts and timeliness to your insurance company. We can provide you with a receipt for the counseling service that may be used to submit for reimbursements if you choose. We do not complete any insurance paperwork for out-of-network benefits. If you elect to use your health insurance plan to assist in the payment of treatment then you understand that your insurance carrier and the National Information Center will have access to your diagnosis code and other pertinent data needed for processing. CANCELLATIONS: We understand that it may, at times, be necessary to cancel an appointment. We require that changes / cancellations be made 24 hours in advance. Any changes, cancellations, or missed appointments within the 24 hour period will result in a $40 cancellation charge. CONFIDENTIALITY: The confidentiality of the services provided by us is protected by law. Unless you grant us permission to do so in writing, we will neither inform anyone that you are a client, nor will we disclose the content of any session. The only circumstances under such professional confidentiality may be broken is if one or more of the following conditions apply: If you pose a serious physical danger to yourself or to another person. If you disclose that you or another person has physically or sexually abused or molested a child or an incompetent / disabled person. If you disclose that a child, an incompetent / disabled person is suffering because of neglect. If such abuse or neglect is disclosed, we are mandated by Florida law to report such information to an appropriate state agency. I have read the preceding information and agree to it. I authorize treatment of the person named below and agree to pay all fees. I have received a copy of our HIPAA Notice of Privacy Rights.Electronic Signature of Client or Legal Guardian* Date* MM slash DD slash YYYY Electronic Signature of Spouse / Partner (when seeking joint therapy) Date MM slash DD slash YYYY Release of Information AuthorizationUse this form to authorize Total Health Guidance to share your information with others as may become necessary. Completion of this form is required for all clients.Please provide the names and contact information for the individuals with whom we may share your information:HiddenRecipient 1{Eval. Contact Name:45} (my {Eval. Contact Relation:56})HiddenRecipient 1{Insurance Provider:60} (my insurance provider)HiddenRecipient 1{Spouse / Partner Name:25} (my spouse/partner)Additional Recipient 1 First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information Types Attendance Diagnosis Records Treatment Plan Authorization I authorize the release of information from Total Health Guidance to the individual listed above and according to my selection(s) above.Additional Recipient 2 First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information Types Attendance Diagnosis Records Treatment Plan Authorization I authorize the release of information from Total Health Guidance to the individual listed above and according to my selection(s) above.Additional Recipient 3 First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information Types Attendance Diagnosis Records Treatment Plan Authorization I authorize the release of information from Total Health Guidance to the individual listed above and according to my selection(s) above.Signature* CommentsThis field is for validation purposes and should be left unchanged.
English
Spanish
