Last Name:

First Name:

Date of Birth (MM/DD/YYYY):

Sex: Male     Female

Address:

Email Address:

Telephone/Cell Phone:

Living Arrangements:

Your main complaint/reason for initiating therapy/coaching:

Current Symptom List, Check all that apply:

Current Stresses in Life:

What areas of your life are affected by current stresses and symptoms, check all that apply:

Alcohol:

Type (beer, hard alcohol, mixed):

Frequency (times per week):

Amount per Occasion:

How long has this pattern continued?

Last drink was:

Any health related issues:

Drugs:

Type:

Frequency (times per week):

Amount per Occasion:

How long has this pattern continued?

Last use was:

Any health related issues:

Previous inpatient hospitalizations:

Previous outpatient counseling:

Previous psychotropic medication:

Current Medication:

When we call your home may we say who we are calling?
Yes No

When we call your work phone may we say who we are calling?
Yes No

When we call your cell/alternative phone may we say who we are calling?
Yes No

Close friend/relative we may contact in case of a true emergency and phone number:

Relationship to you:

Emergency Contact Number:

Emergency Contact - City/State/Zip:

I have read and understood by checking the following disclosures outlined on the disclaimer page of the website. Please make sure all the boxes are checked in order to continue:

Confidentiality: Ensuring complete confidentiality over the Internet/phone is not possible, since e-mails and other transmission can be intercepted by third parties.

Licensure/Certification: This therapist/coach adheres to the professional standards and guidelines of the American Association of Marriage and Family Therapists.

Age: The client must be 18 years or older to use this service.

Intake: Client must fill out an Intake questionnaire before counseling can begin and prior to the first session.

Exclusion: Online counseling is not a substitute for traditional face-to-face counseling. Certain types of presenting problems may not be appropriate for online counseling, such as sexual abuse, violent relationships, eating disorders, and psychiatric disorders involving distortions of reality.

Security: Intake information completed on the Internet is stored in a secure file and only the therapist/coach has access to the information, unless client signs a Release of Information to send records to third party.

Breach of confidentiality: Confidentially must be breached under the following conditions: if client reports feeling suicidal or homicidal, if the client reports instance of child or elder abuse. In such cases, police or child protective services (DCFS) or elder abuse hotline will be notified. Confidentiality may also be breached in cases of records being subpoenaed by court-order.

Emergency: In case of an emergency (suicidal or homicidal thoughts, intent, or plan), please call 911 or a local mental health emergency line in your area.

Technology Failure: In case we get disconnected during our session, I will make every effort to reconnect to you. If problems persist either on my end, or your end, you will only be charged for the time used (per minute). I will e-mail you or call you later to re-schedule this appointment.

E-mails are not continually monitored, but are checked frequently. You should receive a response to your email within 24 hours.

Time Zone: The appointment times are listed in Eastern Standard Time Zone. You must check prior to making an appointment, in which time zone you live in relation to the therapist's time zone.

Payment: All sessions are pre-paid prior to the actual appointment. If you cancel 24 hours prior to the appointment, your fee will be fully refunded. If you miss the appointment, you are responsible for 100% of the fee.

Telephone counseling: I will call you at the appointment time; therefore you will not have to pay any long distance charges. If you are using a cell phone, please make sure you have a strong signal, and are aware of how many minutes are included in your plan.

Your Digital Signature is required below, if you wish to make an appointment.

This is an e-signature form. By typing your name in the box it is the same as signing your signature and is legally binding.

Type Your Full Name:

Statement: I affirm that I am at least 18 years of age and have read and understand disclaimer, fees and policies listed on this website.

Signature:

I have read and agree to the terms of this disclosure:

Yes, I agree with the terms and conditions of the disclosure statement and agreement for services.

No, I do not agree with the terms and conditions of the disclosure statement and agreement for services.