Couples Client Intake Form

Couples Client Intake Form
Name

First Name Last Name
Age
Date of Birth

Month Day Year
Date
Address
Phone Number

Area Code Phone Number
May we leave a message?

yes no
May we text you?

yes no
Email
example@example.com
May we send you are Newsletter?

yes no
How did you hear about us?

Psychology Today Yelp Google
Relationship Information
Please indicate your relationship status: (check all that apply)

Married/Partnered Dating Separated Divorced Engaged In a relationship
Briefly tell us about the issues/concerns that have brought you here. Why are you seeking couples counseling at this time?
Have you been married or partnered before

Yes No
How long have you and your current partner been in this relationship?
Roughly what percentage are you committed to staying in the the relationship?
Roughly what percentage are you satisfied with the relationship?

On a scale from 0 to 6, how would you rate your current level of happiness in your relationship?

	0	1	2	3	4	5	6

0 is Extremely unhappy, 6 is Perfect

If neither you nor your partner has children, please move on to the next question. If either you or your partner have children, please fill out the following information for each child:

	Child's name	Age	Whose child?	Lives with whom?

Please check any topics that are areas of struggle within your relationship. If not applicable, leave blank.

Alcohol/substance use Flirting with others Perfectionism Anger Gambling Personality differences Apathy Getting engaged Physical attraction Commitment Honesty Fertility/Pregnancy Communication Housework/chores Sex life Conflict resolution Infidelity Social life Controllingness Intimacy/affection Spirituality/religion Criticism Irresponsible behavior Technology use Culture/Identity Jealousy Time together Defensiveness Love Trust Degrading comments Lying Violence Divorce Negativity Withdrawing Emotional closeness Outside interests Working too much Family responsibilities Parenting Finances Past relationships
Please check any behaviors that are present when you argue or engage in conflict. If not applicable, leave blank.

Becoming silent Moodiness Screaming Begging Name-calling Slamming doors Being mean Not apologizing Sulking Breaking things Not making peace Swearing Bringing up the past Not listening Threatening breaking up Criticizing Not speaking rationally Threatening taking the kids Cruel accusations Physical threats Throwing things Crying Leaving the home Sarcasm Withdrawing Yelling
Do you feel as though your temper adversely affects your relationship?

Yes No
...What about your partner's temper?

Yes No
Do you feel as though your mood adversely affects your relationship?

Yes No
...What about your partners mood?

Yes No
If you answered yes to either, which moods?
Have you ever been verbally abusive to your partner?

Yes No I don't know
Has your partner ever been verbally abusive to you?

Yes No I don't know
Have you every been physically abusive to your partner?

Yes No I don't know
Has your partner ever been physically abusive to you?

Yes No I don't know
It is our policy that if an affair or inappropriate outside relationship is revealed, that the individual will be expected to disclose this information during the course of couples counseling.
Have you ever had an affair (or inappropriate outside relationship) during your current relationship?

Yes No
...If yes, is the affair current?

Yes No
Has your partner ever had an affair (or inappropriate outside relationship) during your current relationship?

Yes No
...If yes, is the affair current?

Yes No
Have you ever been in couples therapy before?

Yes No
...If yes, What is the therapist name?

First Name Last Name
...What was the experience like
Individual Information
Briefly tell us about the issues/concerns that have brought you here:
What has you seeking therapy at this time?
Please check any current or past topics that are relevant to you:

Eating disorder/body image Academics or work Finances Outside interests (extracurricular) Perfectionism Technology use Stress/anxiety Phobias Sadness/Depression Chronic pain/illness Childhood abuse (i.e. physical, sexual, emotional) Sexual assault/rape Alcohol/problematic substance use Gambling Death of someone close Culture/identity Spirituality/religion Dating Trust Sexual health Coming out Transitioning Fertility/pregnancy Parenting Infidelity Domestic violence/abuse Family (i.e. divorce, alcoholism) Relationships Family Friend Parent Significant Roommate Coworker
Are you currently under the care of a primary care physician?

Yes No
If yes, what is your physician’s name?

First Name Last Name
Are there any physical health concerns of yours that may be relevant to couples counseling?
Current medications (all, including herbal):
Are you currently working with a psychiatrist?

Yes No
If yes, what is your psychiatrist’s name?

First Name Last Name
What is your psychiatrist’s phone number?

Area Code Phone Number
What is the psychiatrist treating you for?
Have you been on any medications in the past for mental health issues?

Yes No
If yes, please list:
Have you previously seen a therapist?

Yes No
If no, who/where?
For what types of issues?
How long ago?
Are you currently/recently seeing any kind of therapist/healer?

Yes No
Have you ever been hospitalized for physical or mental health issues?

Yes No
If yes, briefly describe
Have you had any previous suicide attempts?

Yes No
If yes briefly describe
Check all the apply

Difficulty concentrating Crying Missing work/class Feeling helpless Negativity Feeling uptight/tense Worrying Feeling hopeless Feeling afraid Lying to others feeling out of control feelings of self-doubt Injuring self Loneliness Nervousness around others Memory loss or blackouts Difficulty sleeping Stealing Anger Jealousy Eating binges Drinking heavily Problematic drug use Feelings of guilt Withdrawing socially Sexual preoccupation/obsessions Low sex drive Suicidal thoughts
Physical symptoms (i.e. headaches, digestive)
Any other unlisted symptoms?
Have you seen a health care provider for these?

Yes No
Is there anything else you’d like us to know about you?

Informed Consent

Confidentiality
All of our conversations, our work together, your records and any information that you give us are protected by client privilege. That means that the law protects you from having information about you given to anyone without your permission. Your privacy is respected, and we intend to honor your privilege. However, there are some limits to your privilege. Here are some exceptions you should understand before we start.

If your counselor believes that there is a risk that you might harm yourself or someone else, we may be required to contact the authorities or another person to give them the opportunity to protect you or the other person. If you report the abuse of children or elderly people, we are required by law to notify the authorities, so they can protect others from harm.

The financial part of our relationship also imposes some confidentiality limits. If you are using insurance or another third party payer, we must share certain information with them, including (but not necessarily limited to) your diagnosis and the times of your visits. If we submit claims to your managed care company, they may require us to provide additional information such as your symptoms and your progress. You should understand that insurance and managed care information is often stored in national computer databases for an undetermined amount of time.

As counselors, we specialize in treating general adult issues. If your counselor believes that your problems require knowledge that he or she does not have, you may be referred for a consultation with someone with specific training or experience. We will discuss any such referral with you before we act.

General Policies
Counseling sessions usually last 50-55 minutes, and we must end each session promptly. Payment is due at the end of your appointment. You will be charged a late cancellation fee if you do not cancel the appointment 24 hours in advance. Please keep in mind that if you are using insurance they will not cover missed appointments and therefore you will be responsible for the $80.00 fee. In addition, insurance will not cover the time missed if you run late for an appointment. Therefore you may be asked to pay for the missed portion of the session out of pocket.

We check messages throughout the day and whenever possible, we will return the call within the same day. However, if you have an emergency, please call 911 or go to your local emergency room. There may be extended periods of time when your counselor will be unreachable due to travel. During that time you may be given the number of another counseling professional to assist in your counselor’s absence.

This information is to help you understand some things about counseling and what you can expect from your time in treatment. If you have any questions or concerns before you begin or at any time, please don’t hesitate to ask so that your counselor can explain more fully.

I have read and understand:

·     The limitations to confidentiality

·     My HIPAA Rights and was provided with a copy of my rights

·     General office policies

·     I am aware that I can access all of these documents at any time online at www.therelationshipexperts.org
Signature

Clear
Name

First Name Last Name
Date

Month Day Year
Date

Relationship Counseling & Psychotherapy Services Financial Agreement

Thank you for choosing Relationship Counseling & Psychotherapy Services as your mental health care provider. Carefully review the following information, since your clear understanding of our financial policies is important to our
professional relationship. Please inquire if you have any questions about our fees, policies and/or your responsibilities.

• All payment is due in the form of cash, credit/debit, Paypal, or Zelle/Chase Quickpay, or any other electronic payment. This includes copays, co-insurance, deductible payments, and out of pocket fees. All fees must be paid in full at the time of service. We do not allow clients to carry balances. If you have outstanding unpaid fees, this may affect your ability to schedule future appointments.

• Missed appointments that are not canceled or rescheduled at least 24 hours in advance may be subject to a
late cancellation fee and will be charged to your card on file. The late cancellation fee is $80.00.

• If you are using an “in-network” insurance to pay for sessions, Relationship Counseling & Psychotherapy Services will file claims on your behalf. If you would like to submit claims to out of network insurance
providers, it is your responsibility to request a receipt of services from our office manager. Please be advised that your estimated eligibility and benefits are not a guarantee of coverage until the claim is processed. Any fees not covered by your insurance company are your responsibility.

• In the event that you have outstanding fees for services, these fees may be charged to the card listed below.
Charges will appear on your card from Relationship Counseling & Psychotherapy Services.

I authorize Relationship Counseling & Psychotherapy Services to charge the following card for payment of services
rendered under the above conditions.
Signature

Clear
Name (please also write name as listed on card if it differs from client name)

First Name Last Name

HIPAA Notice of Privacy Practices
HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability and Accountability Act (HIPAA) establishes patient rights and protections associated with the use of protected health information. HIPAA provides patient protections related to the electronic transmission of data (“the transaction rules”), the keeping and use of patient records (“privacy rules”), and storage and access to health care records (“the security rules”). HIPAA applies to all health care providers, including mental health care providers. Providers and health care agencies are required to provide patients a notification of their privacy rights as it relates to their health care records.

This Patient Notification of Privacy Rights informs you of your rights. Please carefully read this Patient Notification. It is important that you know and understand the patient protections HIPAA affords you as a patient.

In mental health care, confidentiality and privacy are central to the success of the therapeutic relationship; therefore, I will do all we can do to protect the privacy of your mental health records. If you have questions regarding matters discussed in this Patient Notification, please do not hesitate to ask.

I. Preamble
Records are kept documenting your care as required by law, professional standards, and other review procedures. HIPAA clearly defines what kind of information is to be included in your “designated medical record” or “case record” as well as some material, known as “Psychotherapy Notes” which is not accessible to insurance companies and other third-party reviewers. HIPAA provides privacy protections about your personal health information, which is called “protected health information (PHI)” which could personally identify you. PHI consists of three (3) components: treatment, payment, and health care operations.

Treatment refers to activities/sessions I provide, coordinate or manage your mental health care service or other services related to your health care. Examples include a counseling session or communication with your primary care physician about your medication or overall medical condition.

Payment is when Relationship Counseling & Psychotherapy Services obtains reimbursement for your mental health care or other services related to your health care.

Health care operations are activities related to my performance such as quality assurance. The use of your protected health information refers to activities my agency conducts for scheduling appointments, keeping records, and other tasks related to your care. Disclosures refer to activities you authorize such as the sending of your protected health information to other parties (i.e., your insurance company).

II. Uses and Disclosures of Protected Health Information Requiring Authorization
If you request Relationship Counseling & Psychotherapy Services to send any of your protected health information of any sort to anyone outside my office, you must first sign a specific authorization to release information to this outside party. A copy of that authorization form is available on the website and upon request. In recognition of the importance of the confidentiality of conversations between therapist and patients in treatment settings, HIPAA permits keeping “psychotherapy notes” separate from the overall “designated medical record”. “Psychotherapy notes” are the therapist’s notes “recorded in any medium by a mental health provider documenting and analyzing the contents of a conversation during a private, group, or joint family counseling session and that are separated from the rest of the individual’s medical record.” “Psychotherapy notes” are private and contain information about you and your treatment.

III. Uses and Disclosures Not Requiring Consent or Authorization
By law, protected health information may be released without your consent or authorization under the following conditions:

• Suspected or known child abuse or neglect

• Suspected or known sexual abuse of a child

• Adult and Domestic abuse

• Judicial or administrative proceedings (i.e. you are ordered here by the court)

• Serious threat to health or safety (i.e. “Duty to Warn” and Threat to National Security)

V. Patient’s Rights and Our Duties
You have a right to the following:

• The right to request restrictions on certain uses and disclosures of your protected health information which I may or may not agree to but if I do, such restrictions shall apply unless our agreement is changed in writing

• The right to receive confidential communications by alternative means and at alternative locations. For example, you may not want forms mailed to your home address so I will send them to another location of your choosing.

• The right to inspect and copy your protected health information in the designated record and any billing records for as long as protected health information is maintained in the record.

• The right to insert an amendment in your protected health information, although the therapist may deny an improper request and/or respond to any amendment(s) you make to your record of care.

• The right to an accounting of non-authorized disclosures of your protected health information.

• The right to a paper copy of notices/information from Relationship Counseling & Psychotherapy Services, even if you have previously requested electronic transmission of notices/information.

• The right to revoke your authorization of your protected health information except to the extent that action has already been taken.

For more information on how to exercise each of these aforementioned rights, please do not hesitate to ask for further assistance on these matters.

Relationship Counseling & Psychotherapy Services is required by law to maintain the privacy of your protected health information and to provide you with a notice of your Privacy Rights and our duties regarding your PHI. Relationship Counseling & Psychotherapy Services reserves the right to change its privacy policies and practices as needed with these current designated practices being applicable unless you receive a revision of these policies when you come for future appointment(s). Our duties in these matters include maintaining the privacy of your protected health information, to provide you with a notice of your rights and our privacy practices with respect to your PHI, and to abide by the terms of the notice unless it is changed and you are so notified.

VI. Complaints
· The right to have oral or written instructions for filing a grievance.

· The right to file a grievance is not time-limited. If you need assistance in filing a grievance or want further information, please For more information see:

https://www.hhs.gov/hipaa/for-individuals/notice-privacy-practices/index.html

Changes to the Terms of this Notice:

We can change the terms of this notice and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Signature

Clear
Name

First Name Last Name

Guidelines and Agreement for Couples Counseling

This document deals with issues specific to couples counseling. Please read the following information carefully and let your counselor know if you have any questions. When you sign this document, it will represent an agreement between all parties involved.

Confidentiality and Privacy Issues
Issues concerning privacy and confidentiality are somewhat complicated in couples counseling. In addition to the exceptions to confidentiality outlined in the informed consent, couples counseling may bring up additional compromises in privacy. For example, your counselor may require meeting with you and your partner individually as part of your work together. If these individual meetings were to occur, it would be an intentional decision made in advance by your counselor. During those individual meetings your counselor would encourage you to share with your partner anything that they deem appropriate. Although it is hoped that you would be completely honest with your counselor, you have the choice to not share certain information with your counselor if you are concerned about the possibility of your partner learning of it.

In the event that sensitive information (as listed below) is revealed to the counselor without the other partner being informed, the counselor may determine that this disclosure interferes with the goals of couples counseling. In this case, the information will be open to discussion during the future course of couples counseling work. This includes but is not limited to:

§   “Love” interest, affair, or emotional attachment to another, other than partner

§   Financial difficulties, debt, liabilities that may impact the partnership

§   Medical concerns such as sexually transmitted diseases

§   Legal problems such as court dates, DUI, etc.

§   Chronic alcohol and/or substance abuse, gambling, etc.

§   Any form or degree of physical contact during arguments or fights

Changes in Counseling Modality
In the event that couples counseling is terminated, the couple’s counselor cannot deliver individual counseling services to both partners. However, the couples counselor may be able to deliver individual counseling services to one of the partners involved if either or both of the following conditions have been met:

*It has been at least one year since the last attended couples counseling session

*The other partner provides direct consent to the counselor in favor of their partner pursuing individual counseling with the former couples counselor

Please note that in the event of this type of counseling modality change, couples counseling CANNOT be resumed.

Appointment Attendance
Unless it has been previously discussed and planned, both members of the partnership will attend scheduled appointments. If one member cannot attend, then the appointment must be rescheduled to allow both members to be present. Our 24-hour cancellation policy applies to avoid the late cancellation fee.

Legal Issues
In the event of a divorce or other custody-related legal proceedings, the parent/guardian will not request that their counselor or any staff member at Relationship Counseling & Psychotherapy Services takes part in any legal proceedings.

Communication
Electronic communication should be reserved for scheduling and administrative purposes – this is not an effective nor secure platform for clinical discussions. Unless communication with the counselor is strictly about scheduling, all partners must be included on all communication with the counselor. If this communication is through email or text message, all partners must be CC’d or added to the communication thread.

My signature indicates that I have read, fully understand, and fully agree to the Couples Counseling Contract of Relationship Counseling & Psychotherapy Services and understand the above information.
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Couples Client Intake Form

Relationship Information

Individual Information

Informed Consent

Relationship Counseling & Psychotherapy Services Financial Agreement

HIPAA Notice of Privacy Practices